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Health Assessment: An: Diana Rose D. Emerenciana, RN., Man
Health Assessment: An: Diana Rose D. Emerenciana, RN., Man
Health Assessment: An: Diana Rose D. Emerenciana, RN., Man
OVERVIEW
DIANA ROSE D. EMERENCIANA, RN., MAN
PURPOSE OF NURSING HEALTH
ASSESSMENT
To collect subjective & objective data to
determine a client’s overall level of functioning
in order to make a professional clinical
judgement
the mind, body and spirit are interdependent
factors that affect a persons level of health
(Holistic)
THE PERSON
(Therapeutic The Disease
Use of Self- (Pathological
Aspect of and Sciences
Nursing “The “ The Cure”
Core”
THE BODY
“The Care”
PROCESS
Step 2: Diagnosis
Potential Problems?
Step 5:
Top 2 Priorities?
Evaluation
Two Measurable Outcomes?
Make a Difference?
Modify Plan?
Accomplish
Outcomes?
Step 3: Planning
What Shall I do?
Interdisciplinary?
Resources and Timeline?
Not Just Technical Care
Step 4: Implementation Involve Patient and Family?
Am I Being Effective? Efficient?
Have I Delegated Properly?
Assessment
Activities During Assessment
1. Collecting Data- This involves gathering information
about the patient, considering the physical, psychological,
emotional, cultural and spiritual factors that may affect his
her health status.
Types of Data
a. Subjective data (Symptoms)
b. Objective data (Signs)
Assessment
Methods of Collection of Data
A. Interview – it is planned, purposeful conversation
Examples: Collection of data for health history
Admission of patient to a health care facility.
B. Observation
Examples: Use of senses (vision, hearing, touch, smell)
Use of units of measure
Physical examination (IPPA)
inspection,palpation, percussion, auscultation
Interpretation of lab results ( urinalysis, RBC,WBC,PUS
and bacteria)
Assessment
Sources of Data
PROCESS
Step 2: Diagnosis
Potential Problems?
Step 5:
Top 2 Priorities?
Evaluation
Two Measurable Outcomes?
Make a Difference?
Modify Plan?
Accomplish
Outcomes?
Step 3: Planning
What Shall I do?
Interdisciplinary?
Resources and Timeline?
Not Just Technical Care
Step 4: Implementation Involve Patient and Family?
Am I Being Effective? Efficient?
Have I Delegated Properly?
2. Diagnosing
Purpose – To identify the patients health care needs and to
prepare diagnostic statements.
CORRECT INCORRECT
PROCESS
Step 2: Diagnosis
Potential Problems?
Step 5:
Top 2 Priorities?
Evaluation
Two Measurable Outcomes?
Make a Difference?
Modify Plan?
Accomplish
Outcomes?
Step 3: Planning
What Shall I do?
Interdisciplinary?
Resources and Timeline?
Not Just Technical Care
Step 4: Implementation Involve Patient and Family?
Am I Being Effective? Efficient?
Have I Delegated Properly?
Outcome Identification
PLANNING
PURPOSES
1. To identify the patient's goals and appropriate
nursing intervention
2. To direct patient care activities
3. To promote continuity of care.
4. To focus charting requirements
5. To allow for delegation of specific activities.
3. PLANNING
PROCESS
Step 2: Diagnosis
Potential Problems?
Step 5:
Top 2 Priorities?
Evaluation
Two Measurable Outcomes?
Make a Difference?
Modify Plan?
Accomplish
Outcomes?
Step 3: Planning
What Shall I do?
Interdisciplinary?
Resources and Timeline?
Not Just Technical Care
Step 4: Implementation Involve Patient and Family?
Am I Being Effective? Efficient?
Have I Delegated Properly?
4. IMPLEMENTATION
Requirement of Implementation
1. Knowledge
2. Technical skills
3. Communication skills
4. Therapeutic use of self
THE 5 STEP Step 1: Assessment
Complete data? Lab & x-ray?
Multidisciplinary? What is going on?
NURSING What are my patient’s Learning
needs?
PROCESS
Step 2: Diagnosis
Potential Problems?
Step 5:
Top 2 Priorities?
Evaluation
Two Measurable Outcomes?
Make a Difference?
Modify Plan?
Accomplish
Outcomes?
Step 3: Planning
What Shall I do?
Interdisciplinary?
Resources and Timeline?
Not Just Technical Care
Step 4: Implementation Involve Patient and Family?
Am I Being Effective? Efficient?
Have I Delegated Properly?
5. EVALUATION
Assessing the patients response to nursing
interventions and then comparing the response
to predetermined standards of outcome criteria
Purpose:
To appraise the extent to which goals and
outcome criteria of nursing care have been
achieved
5. EVALUATION
Activities
1. Collect the data about the clients response.
2. Compare the patients response to goals and
outcome criteria.
3. Possible judgement
Characteristics of the Nursing Process
1. Problem oriented
2. Goal oriented
3. Systematics
4. Open to accepting new information
5. Interpersonal
6. Permits creativity
7. Cyclical
8. Universal
Benefits of Nursing Process to the Patients
Understanding selves
Weight Loss
Weight 155 lbs (69.8 kg), height 5’9 (175.3cm) Hemoglobin 13.6mg/ml
Triceps skinfold thickness 12.1mm Hematrocrit 40%
Hemoglobin 120g/dl
)
Nursing Diagnosis
1. Knowledge deficit concerning principles of
sound nutrition and meal preparations
2. Ineffective coping with lifestyle changes
and career demands.
3. Alteration in nutrition: less than body
requirements.
4. Ineffective rest/activity pattern related to
excessive work hours and emotional upset over
divorce.
FRAMEWORK FOR HEALTH ASSESSMENT
IN NURSING
HEAD – TO – TOE FRAMEWORK
END RESULT OF NURSING ASSESSMENT
Nursing diagnosis (wellness, risk or actual
problem) that require nursing care,
the identification of collaborative
problems that require interdisciplinary
care,
identification of medical problems that
require immediate referral
4 BASIC TYPES OF ASSESSMENT
SUBJECTIVE OBJECTIVE
Methods Client interview Observation & Physical
used to Examination
obtain data
Skills needed Interview & Inspection
to obtain therapeutic Palpation
data communication skills; Percussion
Caring ability & Auscultation
empathy;
Listening skills
Validating Assessment Data
Ensure that the assessment process is not
ended before all relevant data have been
collected
Helps to prevent documentation of
inaccurate data
Documenting Data
Forms the database for the entire nursing
process and provides data for all other
members of the health care team
Thorough and accurate documentation
is vital to ensure that valid conclusions are
made when the data are analysed in the
second step of the nursing process
Analysis of Assessment Data/ Nursing
Diagnosis
second phase of the nursing process
the nurse analyse & synthesize data to
determine whether the data reveal a
nursing concern(nursing diagnosis);
collaborative concern (collaborative
problem); concern that needs to be
referred to other discipline)
Nursing Diagnosis (North American
Nursing Diagnosis Association)
a clinical judgement concerning human
response to health conditions/ life
processes, or a vulnerability to a response,
by an individual, family, group or
community
provides a basis for selecting nursing
interventions to achieve outcomes for
which the nurse is accountable
Collaborative Problems
1.Culture
2.Family
3.Community
4.Spirituality
Formulate Nursing Diagnosis
1. Problem: Weight Loss
2. Subjective Data: Severe Diarrhea (up to 8
episodes /day, including some passage of some
blood in stools for past 4 days, anorexic for past 2
months, resulting in decreased intake, weight loss
of 25lb (11.3kg) over past 2 months, Worried over
loss of school time (college freshmen) also worried
about academic standing, because it affects his
scholarship, complains of fatigue, doesn’t have
the energy to wash or cook, preillness weight 163
lb(73.4kg)
Formulate Nursing Diagnosis
3. Objective Data: Weight 138 (62.1kg), height
5’11” (180.3cm), arm circumference 21.3cm,
Hemoglobin 100mg/dl, hematocrit 34%.
Thank You!!!