Chapter 1: INTRODUCTION TO HEALTH ASSESSMENT

A. Overview of the NURSING PROCESS (ADPIE)

 cyclic and dynamic in nature
 client centered
 focuses on problem solving and decision making
 it's interpersonal and collaborative style
 universal applicability
 in all phases, it uses critical thinking

1. assessment
- is the first and the most critical phase of the nursing process.
- if data collection is inadequate or inaccurate incorrect, nursing judgments may be made
which will affect the kind of care that your patients will be receiving and it will affect the
different phases of the nursing process.
- assessment is ongoing and it is continuous throughout the phases of the nursing process
- health assessment is more than just gathering information about the health status of your
patient
- it also involves analyzing the data that you gathered, synthesizing that data making
judgments about the effectiveness of nursing interventions and evaluating client care
outcomes.
2. Nursing diagnosis
3. Planning
4. Implementation
5. Evaluation

4 MAJOR STEPS IN HEALTH ASSESSMENT

1. collection of subjective and objective data

2. organization of data
3. validation of data
- This refers to the act of "double-checking" data to confirm that it is accurate and factual
4. documentation of data

SUBJECTIVE DATA
- are symptoms or convert data, apparent only to the person affected, can be described only
by the person affected
- these are verbalizations what the patient has told you about how he's feeling
1. sensations or symptoms
- like pain or the feeling of hunger feelings such as happiness sadness you have
2. perceptions
3. desires
4. preferences
5. beliefs
6. ideas
7. values
8. personal information

Major Areas Of Subjective Data:

1. biographical information
- this refers to the name, age, religion, occupation, of the client
 2. physical symptoms related to each body part or system
- example: eyes, ears, abdomen
3. past health history
4. health and lifestyle practices
- examples would be health practices that would put your patient’s life or health at risk
nutrition activity relationships
5. family history
- what are the herd of familial diseases in the family like asthma hypertension diabetes
OBJECTIVE DATA
- is a type of data obtained by general observation by using your physical examination
techniques (like inspection palpation precaution and auscultation)
- is directly observed by the examiners
- these are signs or convert or overt data and can be seen heard felt or smelled
- this is obtained through observation or physical examination
- these data would include:
 physical characteristics (like skin color, posture)
 body functions (like heart rate respiratory)
 appearance (like how your patient dresses up or the hygiene of your pt. measurements
(like bp, temperature, height, and weight)
 results of laboratory testing (like results of your analysis platelet count, x-ray findings)
PHASES OF NURSING PROCESS

- steps the nurse takes to provide nursing care

- The determining factor in the revision of the nursing care plan is the EFFECTIVENESS OF THE
INTERVENTIONS
- to utilize the nursing process, the nurse must first obtain information about the client

1. ASSESSING OR ASSESSMENT
- During the assessment phase of the nursing process, the nurse should VALIDATE DATA
- involves collecting, organizing, validating, and documenting client data
- the purpose of assessment or assessing is to establish a database about the client's
response to health concerns or illness and the ability to manage health care needs
- activities involved in this phase:
1. obtaining nursing health history
2. conducting physical assessment
3. reviewing clients records (like a client's or patient's chart)
4. review nursing literature consult
5. support persons and members of the healthcare team
2. DIAGNOSING
- may also be referred to as ANALYSIS
- The nursing diagnosis represents CLIENT'S HEALTH PROBLEMS
- is analyzing and synthesizing data
- purpose: identify your client’s strengths and health problems that can be prevented and
resolved by collaborative and independent nursing interventions
- activities involved:
compare data against standards or cluster group data
identify gaps and inconsistencies
determine the client's strengths, risk, diagnosis, and problems
- formulate nursing diagnosis and collaborative problem statements
- need to document nursing diagnosis on the care plan

3. PLANNING
- Writing nursing orders and nursing care plans are part of which phase of the nursing process
- is determining how to prevent or reduce or resolve the identified client problem
- determine how to support the client's strengths
- how to implement nursing interventions in an organized individualized and goal-directed
manner
- purpose: to develop an individualized care plan that is specific to the client that the goals
and the desired outcomes is specific to the needs or the identified problem of the client;
- activities here would be:
setting priorities and goals or outcomes
writing goals and desired outcomes
select nursing strategies and interventions
- you can also consult other health care professionals and you must write the nursing orders
or making of the nursing care plan

4. IMPLEMENTING
- is carrying out of the planned nursing interventions
- what you have planned or written in your ncp, you will now put the interventions into action
- purpose: to assist the client to meet desired goals or outcomes; promote wellness prevent
illness and disease;
- and restore the health of your client so activities here would be:
1. reassess the client to update the database;
2. determine the need for nursing assistance;
3. perform planned nursing interventions and;
4. communicate what nursing interventions were implemented

5. EVALUATION OR EVALUATING
- is measuring the degree to which the goals and outcomes have been achieved
- is identifying factors that positively or negatively influence the goal achievement
- purpose: to determine whether to continue or if is there need to modify or to terminate the
plan of care
- the activities here would be to collaborate with a client and:
1. collect data related to the desired outcomes to judge whether goals and outcomes have
been achieved
2. comparing data with desired outcomes
3. relate nursing actions/activities to client outcomes
4. drawing conclusion or make decisions about problem status
5. review and modify the care plan as indicated or terminate at the nursing care
B. Health Assessment in Nursing Practice
4 Types Of Assessment
1. initial comprehensive assessment
- involves collection of subjective data about the client's perception of his or her health. you
will be gathering data:
health of all body parts or systems
past health history
family history
lifestyle and even the health practices of the client

- total health assessment subjective or objective data regarding functional health and body
systems is needed when the patient enters the health care facility and periodically
thereafter to establish baseline data
- frequency of the comprehensive assessment again depends on the age of the patient, risk
factors, health status, and health promotion practices

2. ongoing or partial assessment

- is data collection that occurs after the comprehensive data is established and this consists
of:
mini overview of the client's body systems
holistic health patterns as a follow-up on the health status

- any problems which were initially detected are being reassessed so that's why it's ongoing
like if your patient complained of pain and whenever you get to interact with the patient you
have to go back and reassess do you still feel pain a few a few minutes ago you measured
your level of pain to be eight after taking the medication how is the level of pain now so that
one so there is a need to really
- reassess or if your patient is complaining of difficulty in breathing you have to go back to
your patient from time to time and check if he is still experiencing that symptom

3. Focus or problem-oriented assessment

- is performed when a comprehensive database is already existing for a client who comes to
the hospital, that of consists:
thorough assessment of a particular client problem
does not cover areas not related to the problem

- if your patient is complaining of pain your focus in your assessment would be about pain
 - if your patient is complaining about difficulty in breathing then your focus would be on the
respiratory system of your of your client or what factors are causing him to experience
difficulty in breathing

4. emergency assessment
- a very rapid assessment that is performed in life threatening situations (like choking and
cardiac arrest, drowning), immediate assessment is needed to provide in order for you to provide
treatment
- example: a patient is brought to the hospital you will have to check on the AIRWAY,
BREATHING, and CIRCULATION (or ABCs) of your patient like you suspect that your
patient is who has come to the emergency room for consult, there's a possibility or the way
you see it the patient might have cardiac arrest so you have to check on the ABCs of the
patient first in order for you to determine what type of care you are going to give him.

C. NURSE’S ROLE IN HEALTH ASSESSMENT

what do you think our roles are as nurses in health assessment?
1. collects data in a systematic and ongoing process
- you collect data you have to follow steps not just move from one system to another there
are steps that need to be followed

2. involve the patient family and other healthcare providers and environment as
appropriate in holistic data collection
- it is not only the patient that is involved there's also the family and the significant others

3. prioritize data collection activities based on the client's immediate response immediate
condition or anticipated needs of the patient or situation
- so when you when you handle a patient always learn how to prioritize the needs which is
more important

4. use appropriate evidence-based assessment techniques and in collecting pertinent data

5. use analytical models and problem-solving tools
6. synthesize available data information and knowledge that is relevant to the condition of your
patient
7. the most important part that sometimes may be forgotten is the documentation always
document in whenever you collect data. take note, bring an outlook with you and put down the
significant data that you gathered that you will not forget.

NURSES’ ROLE IN THE ANALYSIS OF DATA. when we analyze after we gather the data we have
to analyze the data that we gathered

1. derive the diagnosis

- so after gathering data identify the nursing diagnosis

2. validate the diagnosis or issues with the client so when your source of the data are secondary
sources
like the chart significant others family members
 - there is a need for you to make sure that that data that you gathered is accurate that it is
reliable and for you to determine that there is a need for you to go to the patient and check
for the validity of the information gathered

3. document the diagnosis and issues in a manner that facilitates the determination of expected
outcomes and plan

Among the methods used in data collection, interviewing is NOT the major method used in physical health
assessment.
All data gathered from the client require validation

To build an accurate database, nurses must validate assumptions regarding the client's physical or
emotional behavior