Health Relative state in which a person is able to live to his or her potential Includes the “7 Facets” Is not solely the absence of disease or eating right
Health Assessment #1 Definition: The processes used to evaluate the health status of a person Asking pertinent questions to gather data Consists of: o Comprehensive health history o Complete physical examination
Health History Past medical history Past physical issues Past psychological issues Social history Cultural history Spiritual beliefs Environmental influences Developmental level
Physical Examination Structured head-to-toe examination Identify changes in patient’s body systems Unusual or abnormal findings may support history data or trigger new questions Document all findings in a clear, concise manner Collate all information with medical records
“The Nursing Process” The overall goals: o Extrapolate the findings o Prioritize the findings o Formulate the plan of care o Implement the plan of care
Purpose of Health Assessment Determine a patient’s health status Determine the patient’s risk factors Determine the need for health education Develop a nursing plan of care
Health Assessment #2 Every person needs to have a complete assessment Ideally done on admission Circumstances may delay the completion; should be completed once situation allows o A critically ill patient coming into the ER—wait until patient is stable to complete o A patient with a professional relationship with the nurse—just need updates o A patient with dementia may require supplementation from family
Question #1 Is the following statement True or False? The nursing health assessment is not a requirement for successfully caring for the patient. A. True B. False
Answer to Question #1 Is the following statement True or False? The nursing health assessment is not a requirement for successfully caring for the patient. B. False The nursing health assessment is important for developing the nursing care plan to ensure each patient receives the care they need.
Nursing vs. Medical Assessments Nursing Medical o Focus on diagnoses o Focus is on the and treatment of diagnoses and the actual or treatments of the potential human disease responses o Identifies many contributing factors to the individual’s health and wellness
Health Assessment #3 Nurse detects areas of concern requiring immediate attention Nurse uses findings to decide the areas that take precedence Health promotion and disease prevention are essential areas of patient education
Healthy People 2020 Framework that identifies risk factors, health issues, and diseases of concern in the United States Goals and objectives serve to improve the health of individuals and communities Overall goal is to increase quality of life by creating guidelines for healthy lifestyle Promotes health and disease prevention as it impacts the quality and length of a person’s life Data provided by U.S. Department of Health and Human Services (www.healthypeople.gov)
Question #2 Healthy People 2020 is based on which components? (Select all that apply) A. Results of Healthy People 2010 B. Current data C. New developments D. Emerging challenges in the United States
Answer to Question #2 Healthy People 2020 is based on which of the following: A, B, C, D The national health objectives determined by Healthy People 2020 are broad and take into consideration the results of the Healthy People 2010 outcomes of the past. These are based on current data, new developments, and challenges that are prevalent, or emerging in the United States. The U.S. Department of Health and Human Services provided this data online and invited health care leaders and the community to voice their opinions regarding the focus for this next decade.
Role of the Nurse #2 Use findings and decide in which areas patient needs the most care Deliver care across the lifespan Promote health and prevent disease Educate and counsel individuals, families, groups, and communities Determine what affects the patient’s health Focus on health and goals of the patient
Role of the Nurse #3 Oversee the holistic care of each patient Collect data Make judgments that will impact patient safety and quality of care Identify what is important on a daily basis for each patient Carefully watch and listen to the patient to determine what additional questions to ask Watch for subtle changes in the patient
Role of the Nurse #4 Rely on assessment skills Use the “7 Facets” to assess the patient Use information detected in assessment to work with the patient to enhance quality of life Learn to detect a change in patient to enable providing best care Take advantage of teaching opportunities that present with the patient and family Continually reassess the patient for changes in order to achieve the best results
Answer to Question #3 Which of the following is NOT one of the “7 Facets”? D. Education The “7 Facets” consist of the patient’s physical, emotional, social, cultural, developmental, and spiritual aspects. The patient’s health status is the sum of these facets and not solely the absence of disease or eating right. The nursing health assessment should include information in all seven of these categories.