Ncm 101 Health Assessment Handouts 1.docx

1

INTRODUCTION TO HEALTH ASSESSMENT The Nurse’s Role in Health Assessment: Collecting and Analyzing Data

-Nursing Scope and Standards of Practice Standard 2 – The RN analyses the assessment data to determine the diagnosis or issues. To accomplish this, the RN: o

Case Study Mrs. Gutierrez, age 52, arrives at the clinic for diabetic teaching. She appears distracted and sad, uninterested in the teaching. She is unable to focus, and paces back and forth in the clinic wringing her hands. What should the nurse suspect of Mrs. Gutierrez? -A professional nurse should constantly observe situations and collect information to make nursing judgements. It can occur no matter what the setting: hospital, clinic, home, community or long-term care. Introduction to Health Assessment in Nursing Nursing – the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals, families, communities and populations. (Nursing: Scope and Standards of Nursing Practice (American Nurses Association (ANA), 2010)

-Nursing Scope and Standards of Practice Standard 1 – The RN collects comprehensive data pertinent to the patient’s health or situation. (ANA p.21)

o

o

EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT Physical assessment has been an integral part of nursing since the days of Florence Nightingale. Late 1800s – Early 1900s -

-

-

- To accomplish this pertinent and comprehensive data collection, the nurse: o o

o

o

o o

o

Collects data in a systematic and ongoing process Involves the patient, family, other health care providers, and environment, as appropriate, in holistic data collection. Prioritizes data collection activities based on the patient’s immediate condition, or anticipated needs of the patient or situation. Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data. Uses analytical models and problem-solving tools Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances. Documents relevant data in an retrievable format (ANA 2010, p.21)

Dianna Rose O. Belen, RN, LPT

Derives the diagnosis or issues based on assessment data Validates the diagnosis or issues with the client, family, and other healthcare providers when possible and appropriate. Documents diagnoses or issues in a manner that facilitates the determination of the expected outcomes and plan (ANA, 2010, p.22)

Nurses relied on their natural senses; the client’s face and body would be observed for “changes in color, temperature, muscle strength, use of lims, body output and degrees of nutrition, and hydration. Palpation was used to measure pulse rate and quality to locate the fundus of the puerperal woman. Examples of independent nursing practice using inspection, palpation, and auscultation have been recorded in nursing journals since 1901. Some examples reported include gastrointestinal palpation, testing eighth cranial nerve function, and examination of children in school systems.

1930 – 1949 -

-

The American Journal of Public Health documents routine client and home inspection by public health nurses in the 1930s. This role of case finding, prevention of communicable diseases, and routine use of assessment skills in poor inner-city areas was performed through the Frontier Nursing Service and the Red Cross.

1950 – 1969 -

Nurses were hired to conduct pre-employment health stories and physical examinations for major

NCM 101 HEALTH ASSESSMENT

2018

2

companies, such as New York Telephone, form 1953 through 1960 1970 – 1989 -

-

-

organizations (HMOs) and preferred provider organizations (PPOs).

Assessment: Step One of the Nursing Process

The early 1970s prompted nurses to develop an active role in the provision of primary health services and expanded the professional nurse role in conducting health histories and physical and psychological assessments Joint statements of the American Nurses Association and the American Academy of Pediatrics agreed that in-depth client assessments and on-the-spot diagnostic judgments would enhance the productivity of nurses and the health care of clients. Acute care nurses in the 1980s employed the “primary care” method of delivery of care. Each nurse was autonomous in making comprehensive initial assessments from which individualized plans of care were established.

-

-

Assessment is the first and most critical phase of the nursing process. Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ongoing and continuous throughout all phases of the nursing process. The nursing process should be thought of as circular, not linear.

Phases of the Nursing Process Phase I

Title Assessment

II

Diagnosis

III

Planning

IV V

Implementation Evaluation

1990 – present -

-

-

-

-

Over the last 20 years, the movement of health care from the acute care setting to the community and the proliferation of baccalaureate and graduate education solidified the nurses’ role in holistic assessment. Downsizing, budget cuts, and restructuring were the priorities of the 1990s. In turn, there was a demand for documentation of client assessments by all health care providers to justify health care services. In the 1990s, critical pathways or care maps guided the client’s progression, with each stage based on specific protocols that the nurse was responsible for assessing and validating. Advanced practice nurses have been increasingly used in the hospital as clinical nurse specialists and in the community as nurse practitioners. While state legislators and the American Medical Association struggled with issues of reimbursement and prescriptive services by nurses, government and societal recognition of the need for greater cost accountability in the health care industry launched the advent of diagnosisrelated groups (DRGs) and promotion of health care coverage plans such as health maintenance

Dianna Rose O. Belen, RN, LPT

NCM 101 HEALTH ASSESSMENT

Description Collecting subjective and objective data Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral) Determining outcome criteria and developing a plan Carrying out the plan Assessing whether outcome criteria have been met and revising the plan as necessary

2018

3

FOCUS OF HEALTH ASSESSMENT IN NURSING -

-

The purpose of a nursing health assessment is to collect holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment. In contrast to a physician performing a medical assessment, its focus is only client’s physiologic status.

o

The Health Promotion Model -

FRAMEWORK FOR HEALTH ASSESSMENT IN NURSING -

-

-

A nursing framework helps to organize information and promotes the collection of holistic data. Head – to – toe assessment The questions asked in each physical systems focus on that particular body system and are broken down into four sections: o History of Present Health Concern o Personal Health History o Family History o Lifestyle and Health Practices The end result of a nursing assessment is the formulation of nursing diagnoses to know: o nursing care o identify collaborative problems requiring interdisciplinary care o identify medical problems that require immediate referral o client teaching for health promotion.

-

There are many models used to analyze health promotion and disease prevention. Two of the major models are: o The Health Belief Model (Becker & Rosenstock) o The Health Promotion Model (Pender)

-

-

based on three concepts: o the existence of sufficient motivation; o the belief that one is susceptible or vulnerable to a serious problem;

Dianna Rose O. Belen, RN, LPT

Initial comprehensive assessment Ongoing or partial assessment Focused or problem-oriented assessment Emergency assessment

1. Initial Comprehensive Assessment -

-

involves collection of subjective data about the client’s perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client’s overall function) as well as objective data gathered during a step-by-step physical examination. a total health assessment (subjective and objective data regarding functional health and body systems) is needed when the client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared.

2. Ongoing or Partial Assessment -

The Health Belief Model

also focused on behavioral outcomes. Pender proposes that individual characteristics and experiences (prior related behavior and personal biologic, psychological, and cultural factors) affect behavior-specific cognitions and affect (perceptions of benefit, barriers, self-efficacy, and activity-related affect; as well as interpersonal and situational influencers), which in turn yield the level of commitment to a plan.

TYPES OF HEALTH ASSESSMENT

USING EVIDENCE TO PROMOTE HEALTH AND PREVENT DISEASE -

the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost.

-

consists of data collection that occurs after the comprehensive database is established. consists of a mini-overview of the client’s body systems and holistic health patterns as a follow-up on health status. Any problems that were initially detected in the client’s body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data.

NCM 101 HEALTH ASSESSMENT

2018

4

-

-

usually performed whenever the nurse or another health care professional has an encounter with the client. Ex. a client admitted to the hospital with lung cancer requires frequent assessment of lung sounds.

-

3. Focused or Problem-Oriented Assessment -

-

-

does not replace the comprehensive health assessment. performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem. Ex. if your client, John P., tells you that he has pain you would ask him questions about the character and location of pain, onset, relieving and aggravating factors, and associated symptoms.

4. Emergency Assessment -

a very rapid assessment performed in lifethreatening situations. Ex. choking, cardiac arrest, drowning Check for ABCs.

STEPS OF HEALTH ASSESSMENT Four major steps: 1. Collection of subjective data 2. Collection of objective data 3. Validation of data 4. Documentation of data Preparing For The Assessment - Before actually meeting the client it is helpful to review the client’s medical record. - After reviewing the record or discussing the client’s status with others, remember to keep an open mind and to avoid premature judgments that may alter your ability to collect accurate data. - Use this time to educate yourself about the client’s diagnoses or tests performed. - Consult the necessary resources (laboratory manual, textbook, or electronic reference resource,

Dianna Rose O. Belen, RN, LPT

-

such as a smart phone application) to learn about the test and the implications of its findings. Once you have gathered basic data about the client, take a minute to reflect on your own feelings regarding your initial encounter with the client. Remember to obtain and organize materials that you will need for the assessment.

STEP 1 COLLECTING SUBJECTIVE DATA -

Subjective - sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. - For accurate subjective data, learn to use effective interviewing skills with a variety of clients in different settings. o Biographical information (name, age, religion, occupation) o History of present health concern: Physical symptoms related to each body part or system (e.g., eyes and ears, abdomen) o Personal health history o Family history o Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity, relationships, cultural beliefs or practices, family structure and function, community environment) Case Study As the assessment progresses, the nurse learns through the interview with Mrs. Gutierrez that she has no appetite and no energy. She feels as though she wants to stay in bed all day. She misses her sisters in Mexico, and cannot do her normal housekeeping or cooking. The nurse thinks that Mrs. Gutierrez is probably suffering from depression. But when the nurse asks Mrs. Gutierrez what she believes is causing her lack of appetite and low energy, Mrs. Gutierrez says she was shocked when her husband was hit by a car. He could not work for a month.

NCM 101 HEALTH ASSESSMENT

2018

5

STEP 2 COLLECTING OBJECTIVE DATA - This type of data is obtained by general observation and by using the four physical examination techniques: - Inspection - Palpation - Percussion - Auscultation. - Another source of objective data is the client’s medical/health record, which is the document that contains information about what other health care professionals. - Objective data may also be observations noted by the family or significant others about the client. STEP 3 VALIDATING ASSESSMENT DATA - crucial part of assessment that often occurs along with collection of subjective and objective data. - It serves to ensure that the assessment process is not ended before all relevant data have been collected, and helps to prevent documentation of inaccurate data. STEP 4 DOCUMENTING DATA - Documentation of assessment data is an important step of assessment because it 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 analyzed in the second step of the nursing process.

Analysis of Assessment Data/ Nursing Diagnosis: Step Two of the Nursing Process -

-

Analysis of data (often called nursing diagnosis) is the second phase of the nursing process. During this phase, you analyze and synthesize data to determine whether the data reveal a nursing concern (nursing diagnosis), a collaborative concern (collaborative problem), or a concern that needs to be referred to another discipline (referral).

Dianna Rose O. Belen, RN, LPT

-

Nursing Diagnosis - “a clinical judgment about individuals, family or community responses to actual and potential health problems and life processes. A nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.” (North American Nursing Diagnosis Association (NANDA, 2012–2014)

-

-

Collaborative Problem - “physiological complications that nurses monitor to detect their onset or changes in status. Nurses manage collaborative problems by implementing both physician- and nurseprescribed interventions to reduce further complications. Referrals - occur because nurses assess the “whole” (physical, psychological, social, cultural, and spiritual) client, often identifying problems that require the assistance of other health care professionals.

PROCESS OF DATA ANALYSIS - This process requires diagnostic reasoning skills, often called critical thinking. The process can be divided into seven major steps: 1. Identify abnormal data and strengths 2. Cluster the data. 3. Draw inferences and identify problems. 4. Propose possible nursing diagnoses. 5. Check for defining characteristics of those diagnoses. 6. Confirm or rule out nursing diagnoses. 7. Document conclusions. Case Study Consider Mrs. Gutierrez, introduced at the beginning of the chapter, to help illustrate the reason for seeing the client in context. The nurse continues to listen to Mrs. Gutierrez and learns that she is also suffering from “susto.” Mrs. Gutierrez states that a few days in bed will help her recover her soul and her health. The nurse decides to reschedule the diabetic teaching for a

NCM 101 HEALTH ASSESSMENT

2018

6

later time and provide only essential information to Mrs. Gutierrez at this visit. Questions: 1. The nursing process is utilized to: a. Provide a systemic, organized and comprehensive approach to meeting the needs of clients. b. Encourage the family to make decisions regarding patient's care. c. Increase involvement of allied healthcare professionals in decision-making d. None of the above 2. a. b. c. d.

c. "Is it possible that your child might be taking drugs?" d. "Independence is really important for this age group. Try to be extra attentive when your child does spend time at home."

Objective data might include: Chest pain. An evaluation of BP Complaint of dizziness None of the above

3. The following is the most important purpose of documentation except a. For Communication b. For Reimbursement c. For Quality assurance d. To provide comfort 4. a. b. c. d.

Subjective data might include: Heart rate Oral temperature of 37.7 C Pain Scale of 4/10 Poor hygiene

5. A teenage girl spends most of her free time with friends or at school. Sharing their concerns about this behaviour with the school nurse, the parents are worried about their child seeming to draw away from them. The nurse's best reply is: a. "You should really keep better track of your child. It's hard to tell what kinds of trouble they may be getting into. b. "Use stricter guidelines for curfew and punishment if curfew is broken." Dianna Rose O. Belen, RN, LPT

NCM 101 HEALTH ASSESSMENT

2018