HEALTH ASSESSMENT

LECTURE (Chapter 1)
Nurse’s Role in Health ● The first and most critical phase of the nursing
process
Assessment: Collecting and ● Ongoing and continuous throughout all phase of the
nursing process
Analyzing Data

Nursing PHASES OF NURSING PROCESS

- the protection, promotion and optimization of I. ASSESSMENT
health and abilities, prevention of illness and injury,  Collecting subjective and objective data
alleviation of suffering through the diagnosis and II. DIAGNOSES
treatment of human responses and advocacy in the  Analyzing subjective and objective data to
care of individuals, families, community and make a professional nursing judgment
populations. (nursing diagnosis, collaborative problem or
- collects comprehensive data pertinent to the referral)
patient’s health or situation. III. PLANNING
 Determining outcome criteria and developing a
THE NURSES: (TO ACCOMPLSIH PERTINENT AND
plan
COMPREHENSIVE DATA COLLECTION)
IV. IMPLEMENTATION
1. Collects data in a systematic and ongoing process  Carrying out the plan
2. Involves the patient, family, other health care V. EVALUATION
providers and environment, as appropriate in holistic  Assessing whether outcome criteria have been
data collection met and revising the plan as necessary
3. Prioritizes data collection activities based on the NURSING ASSESSMENT
patient’s immediate condition, or anticipated needs of  Collective subjective and objective data to
the patient or situation. determining a client’s overall level of
4. Uses appropriate evidence-based assessment functioning in order to make a professional
techniques and instruments in collecting pertinent clinical judgement
data.
5. Uses analytical models and problem-solving tools
6. Synthesizes available data, information and MEDICAL ASSESSMENT
knowledge relevant to the situation to identify patterns  Focuses primarily on the client’s physiologic
and variances development status
7. Documents relevant data in a retrievable format .
TYPES OF HEALTH ASSESSMENT
TO ACCOMPLISH THIS, THIS REGISTERED NURSE:
1. Derives the diagnoses or issues based on TYPE DESCRIPTION
assessment data
2. Validates the diagnoses or issues with the 1. Initial  Family history - record of
client, family and other healthcare provider Comprehen health information about a
when possible and appropriate sive person and his or her close
3. Documents diagnoses or issues in a manner Assessment relatives. Inlcudes
that facilitates the determination of the information from three
generations of relatives,
expected outcomes and plan
including children, brothers
and sisters, parents, aunts
and uncles, nieces and
nephews, grandparents and
cousin .
ASSESSMENT  Lifestyle and health practices
 To establish a baseline data

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 which future health status documentation of inaccurate
changes can be measured data.
and compared.
4 sections asked in each physical 4. Documenti  Thorough and accurate
systems: ng Data documentation is vital to
 Collection of subjective ensure that valid conclusions
data are made
 History of present health
concern
 Past medical history
ANALYSIS PHASE OF NURSING PROCESS
 Identify abnormal data and strengths
2. Ongoing  Consist of data collection
or Partial that occurs after the  Cluster the data
Assessment comprehensive data base is  Draw inferences and identify problems.
established  Propose possible nursing diagnoses.
 Check for defining characteristics of those
3. Focused  Consists of a thorough diagnoses.
or problem- assessment of a particular  Confirm or rule out nursing diagnoses
oriented client problem and does not  Document conclusions.
Assessment cover areas not related to
the problem
Evolution of the Nurse’s Role in Health
4. Emergen  Very rapid assessment Assessment: Past
cy performed in life-threatening
Assessment situations.  Physical assessment integral part of
nursing
 Nurses relied on natural senses
STEPS OF HEALTH ASSESSMENT  Palpation
 Movement of health care from acute care
TYPE DESCRIPTION setting to community care and proliferation
of baccalaureate and education
1. Collection  Biographical Information  Advanced practice nurses
of subjective  Physical symptoms related
Data to each body parts or system
 Past health history
 Family history
 Health and lifestyle practices

2. Collection  Physical characteristics

of Objective  Body Function
Data  Appearance
 Behavior
 Measurements
 Results of laboratory testing

3. Validating  Crucial part of assessment

Data that often occurs along with
Assessment collection of subjective and
objective
 Serves to ensure that the
assessment process is not
ended before all relevant
data have been collected
and helps to prevent

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