Chapter 001 Power Wilson
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Why Learn Health Assessment? Chapter 1
Copyright © 2005, Mosby, Inc. All rights reserved.
Why Learn Health Assessment? • • • • •
Every interaction initiates nursing process Nursing process (six steps) First step: assessment ANA definition Assessment process – Two components • Data collection • Interpretation/analysis of data
– Different nurses use differently Copyright © 2005, Mosby, Inc. All rights reserved.
Components of Health Assessment • Systematic method of data collection to identify client’s health characteristics • Data collected: client’s health compared with ideal—accounting for client’s traits • Collection/analysis of data lead to identify problems – Guide nurse in developing care plan – Assist client to maximize health potential Copyright © 2005, Mosby, Inc. All rights reserved.
Components of Health Assessment • Two primary components: history (subjective data) and examination (objective data) • Interchangeable with signs/symptoms – Sign: clinical finding (objective) – Symptom: what client feels/communicates (subjective) • Clinical manifestations: signs/symptoms experienced by client Copyright © 2005, Mosby, Inc. All rights reserved.
Application of Health Assessment • Setting/reason for seeking health care determines type of assessment performed • Different types: screening, focused/ problem based, episodic, comprehensive • Setting/expertise of nurse: factor determining type
Copyright © 2005, Mosby, Inc. All rights reserved.
Documentation of Data • Data documented for use by all health care team members • Complete, accurate, descriptive data improves effectiveness of health care team • Prevents repetition • Legal document and permanent record • Baseline for evaluation of changes/care • Outline/notes facilitate documentation, ↑ accuracy • Recorded concisely, accurately, legibly without bias or opinion Copyright © 2005, Mosby, Inc. All rights reserved.
What Do You Do with All These Data? • Assessment data lead to portrait of client’s health characteristics and health problems • Subjective and objective data analyzed by nurse to initiate nursing care plan – Data clustered (framework) • Body systems (incomplete) • Functional health patterns: Gordon • NANDA Copyright © 2005, Mosby, Inc. All rights reserved.
Health Promotion/Health Protection • Central component of nursing—health • Health assessment—data to identify client’s health status, practices, risk factors • Interpretation of data allows nurse to target health promotion needs – Promotion: behavior motivated by desire to increase well-being/actualize health potential – Protection: behavior motivated by desire to avoid illness, detect early, maintain functioning if/when ill Copyright © 2005, Mosby, Inc. All rights reserved.
Health Promotion/Health Protection • Three levels of health promotion – Primary: preventing disease from developing; promoting healthy lifestyle – Secondary: screening to find early indicators of disease – Minimizing disability from acute/chronic illness/ injury: productive life within limitations
• Nurses educate/care to help meet health promotion needs Copyright © 2005, Mosby, Inc. All rights reserved.
Health Promotion/Health Protection • Framework for promotion: Healthy People 2010: Understanding and Improving Health (DHSS) – National health objectives that address most significant preventable threats to health/goals to reduce threats – Two overarching goals: (1) increase years of healthy life; (2) eliminate health care disparities Copyright © 2005, Mosby, Inc. All rights reserved.
Health Promotion/Health Protection • Knowledge of health assessment necessary for: – Comprehensive health data collection for (1) clinical decision making; (2) developing interventions to improve client’s health
• Foundation for art and science of professional nursing Copyright © 2005, Mosby, Inc. All rights reserved.
Copyright © 2005, Mosby, Inc. All rights reserved.
Why Learn Health Assessment? • • • • •
Every interaction initiates nursing process Nursing process (six steps) First step: assessment ANA definition Assessment process – Two components • Data collection • Interpretation/analysis of data
– Different nurses use differently Copyright © 2005, Mosby, Inc. All rights reserved.
Components of Health Assessment • Systematic method of data collection to identify client’s health characteristics • Data collected: client’s health compared with ideal—accounting for client’s traits • Collection/analysis of data lead to identify problems – Guide nurse in developing care plan – Assist client to maximize health potential Copyright © 2005, Mosby, Inc. All rights reserved.
Components of Health Assessment • Two primary components: history (subjective data) and examination (objective data) • Interchangeable with signs/symptoms – Sign: clinical finding (objective) – Symptom: what client feels/communicates (subjective) • Clinical manifestations: signs/symptoms experienced by client Copyright © 2005, Mosby, Inc. All rights reserved.
Application of Health Assessment • Setting/reason for seeking health care determines type of assessment performed • Different types: screening, focused/ problem based, episodic, comprehensive • Setting/expertise of nurse: factor determining type
Copyright © 2005, Mosby, Inc. All rights reserved.
Documentation of Data • Data documented for use by all health care team members • Complete, accurate, descriptive data improves effectiveness of health care team • Prevents repetition • Legal document and permanent record • Baseline for evaluation of changes/care • Outline/notes facilitate documentation, ↑ accuracy • Recorded concisely, accurately, legibly without bias or opinion Copyright © 2005, Mosby, Inc. All rights reserved.
What Do You Do with All These Data? • Assessment data lead to portrait of client’s health characteristics and health problems • Subjective and objective data analyzed by nurse to initiate nursing care plan – Data clustered (framework) • Body systems (incomplete) • Functional health patterns: Gordon • NANDA Copyright © 2005, Mosby, Inc. All rights reserved.
Health Promotion/Health Protection • Central component of nursing—health • Health assessment—data to identify client’s health status, practices, risk factors • Interpretation of data allows nurse to target health promotion needs – Promotion: behavior motivated by desire to increase well-being/actualize health potential – Protection: behavior motivated by desire to avoid illness, detect early, maintain functioning if/when ill Copyright © 2005, Mosby, Inc. All rights reserved.
Health Promotion/Health Protection • Three levels of health promotion – Primary: preventing disease from developing; promoting healthy lifestyle – Secondary: screening to find early indicators of disease – Minimizing disability from acute/chronic illness/ injury: productive life within limitations
• Nurses educate/care to help meet health promotion needs Copyright © 2005, Mosby, Inc. All rights reserved.
Health Promotion/Health Protection • Framework for promotion: Healthy People 2010: Understanding and Improving Health (DHSS) – National health objectives that address most significant preventable threats to health/goals to reduce threats – Two overarching goals: (1) increase years of healthy life; (2) eliminate health care disparities Copyright © 2005, Mosby, Inc. All rights reserved.
Health Promotion/Health Protection • Knowledge of health assessment necessary for: – Comprehensive health data collection for (1) clinical decision making; (2) developing interventions to improve client’s health
• Foundation for art and science of professional nursing Copyright © 2005, Mosby, Inc. All rights reserved.
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