Ncm 101 Health Assessment Ppt 1.pptx

NCM 101 HEALTH ASSESSMENT DIANNA ROSE BELEN, RN, LPT

INTRODUCTION TO HEALTH ASSESSMENT • 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?

• 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) • -Nursing Scope and Standards of Practice Standard 2 – The RN analyses the assessment data to determine the diagnosis or issues.

ASSESSMENT: STEP ONE OF THE NURSING PROCESS

•Assessment is the first and most critical phase of the nursing process.

PHASES OF THE NURSING PROCESS Phase

Title

I

Assessment

II

Diagnosis

III

Planning

IV

Implementation

V

Evaluation

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

FRAMEWORK FOR HEALTH ASSESSMENT IN NURSING • A nursing framework helps to organize information and promotes the collection of holistic data. • The questions asked in each physical systems focus on that particular body system and are broken down into four sections: • • • •

History of Present Health Concern Personal Health History Family History Lifestyle and Health Practices

• The end result of a nursing assessment is the formulation of nursing diagnoses to know: • nursing care • identify collaborative problems requiring interdisciplinary care • identify medical problems that require immediate referral • client teaching for health promotion.

USING EVIDENCE TO PROMOTE HEALTH AND PREVENT DISEASE

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

THE HEALTH BELIEF MODEL

• based on three concepts: • the existence of sufficient motivation; • the belief that one is susceptible or vulnerable to a serious problem; • the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost.

THE HEALTH PROMOTION 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, selfefficacy, 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

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

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 • review the client’s medical record. • keep an open mind and to avoid premature judgments • Use this time to educate yourself about the client’s diagnoses or tests performed. • (laboratory manual, textbook, or electronic reference resource, such as a smart phone application)

• 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.

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.

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

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.

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 later time and provide only essential information to Mrs. Gutierrez at this visit.

QUESTIONS • 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

• Objective data might include: A.Chest pain. B.An evaluation of BP C.Complaint of dizziness D.None of the above

• The following is the most important purpose of documentation except A.For Communication B. For Reimbursement C.For Quality assurance D.To provide comfort

• Subjective data might include: A.Heart rate B.Oral temperature of 37.7 C C.Pain Scale of 4/10 D.Poor hygiene

• 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." 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."