HEALTH-ASSESSMENT-module-1.

 1. HEALTH ASSESSMENT

.2. •In humans, it is the ability of individuals and communities to

adapt and self- manage when facing physical, mental or social
changes.

3.•A state of complete physical, mental and social well-being and

not merely the absence of disease or infirmity- WHO, 1947

 4. ASSESSMENT: •A systematic, dynamic process by which the

nurse through interaction with client, significant others and
healthcare providers, collects and analyze data about the client -
American Nurses Association

 5. • an organized systematic assessment of human body which

involves the use of one’s senses to determine the general physical
and mental conditions of the body by collecting both subjective and
objective data. Indications: On admission Health camps On
discharge Before and after diagnostic procedure On follow ups

 8. • Establish a database for the clients normal abilities, risk

factors, and any current alterations in functions.

 • To get a clear picture of a client’s health status and health related

problems.

 • To identify cause and extend of disease.

 • To identify the problem at early stage.

 • To determine the nature of treatment required for the patient.

 • To get a holistic view of the client.

 in medical research.

 • To identify client’s strength, weakness, knowledge, attitude,

motivation, support systems and coping skills. • To build rapport
with patient and family. • To identify need for health teaching. • To
compare clients’ health status with an ideal status.

 11. NURSING PROCESS The cornerstone of the Nursing

profession • Defined as a systematic problem-solving approach
towards giving individualized nursing care. OR • Is a systematic
method that directs the nurse and patient as together they
accomplish the following: (1) Assess the patient to determine the
need for nursing care; (2) determine nursing diagnosis for actual
 and potential health problems; (3) identify expected outcomes and
plan care; (4) implement the care; and (5) evaluate the results.

 13. NURSING PROCESS - THE ESSENTIAL CORE OF PRACTICE FOR

THE NURSE TO DELIVER HOLISTIC, PATIENT-FOCUSED CARE.

 Assessment (gather subjective and objective data, family history,

surgical history, medical history, medication history, psychosocial
history) Analysis or diagnosis (formulate a nursing diagnosis by
using clinical judgment; what is wrong with the patient) Planning
(develop a care plan which incorporates goals, potential outcomes,
interventions) Implementation (perform the task or intervention)
Evaluation (was the intervention successful or unsuccessful)

 14. • Systematic: nursing process has an ordered sequence of

precise and accurate activities. Preceding activities influence
activities following them. • Dynamic: provides active interaction and
integration among activities. Current activity is necessary to
influence future activities. • Interpersonal: ensures that nurses are
client-centered rather than task-oriented. The nursing process
encouraged nurses to work and help clients use their strength to
meet their own needs. • Goal-directed: Np is a means for nurses and
clients to work together in order to identify specific goals related to
wellness promotion, disease and illness prevention, health
restoration, and coping with altered functioning. • Universally-
applicable: allows nurses to practice nursing with well or sick
people, young or old, regardless of race, creed or religion.

 15. NURSING ASSESSMENT- (what data is collected?) • Is the

collection of data for nursing purposes. Information is collected
using the skills of observation, interviewing, physical examination,
and intuition and from many sources, including clients, their family
members or significant others, health records, other health team
members.

 16. TYPES OF ASSESSMENT 1. Initial Assessment: Aim: initial

identification of normal function, functional status, and collection of
data concerning actual or potential dysfunction. Baseline for
reference and future comparison. Time Frame: within the specified
time frame after admission to a hospital, nursing home, ambulatory
health center. E.g.: admission assessment 2. Comprehensive Health
Assessment: includes

 17. 3. Focus Assessment or Ongoing Assessment: Aim: status

determination of a specific problem identified during previous
assessment. To identify new or overlooked problems. Time Frame:
 ongoing process, integrated with nursing care, a few minutes to a
few hours between assessments. E.g.: Hourly fluid input and output
assessment

 18. 4. Time-Lapsed Reassessment: Aim: comparison of client’s

current status to baseline obtained previously, detection of changes
in all functional health patterns after an extended period of time has
passed. Time Frame: several months (3,6,9 months or more)
between assessment. E.g.: Reassessment clients’ functional health
patterns in home care or OPD setting 5. Emergency Assessment:
Aim: identification of life-threatening situation Time Frame: at
anytime E.g.: ABC assessment in Cardiac Arrest Assessment of
suicidal attempt on violence

 19. ASSESSMENT SKILLS 1- OBSERVATION comprises more

than the nurse’s ability to see the client, nurses also use the senses
of smell, hearing, touch, and rarely, the sense of taste. Observation
includes looking, watching, examining. Observation begins the
moment the nurse meets the client. It is a conscious, deliberate skill
that is developed through efforts and with an organized approach. 2
Aspects: a. noticing the data b.selecting, organizing, and
interpreting the

 20. 2- INTERVIEW a planned communication or a conversation

with a purpose, for example to get or give information, identify
problems of mutual concern, evaluate change, teach, provide
support. 3- Physical Examination Technique a systematic data
collection method that uses the senses of sight, hearing, smell, and
touch to detect health problems.

 21. 4- INTUITION -use of insight, instinct, and clinical experience

to make clinical judgements about the client. Intuition plays a role in
the nurse’s ability to analyze cues rapidly, make clinical decisions,
and implement nursing actions even though assessment data may
be incomplete or ambiguous. It is a process based on knowledge
and care experience and has a place beside research-based
evidence. Nurses integrate both analysis and synthesis of intuition
alongside objective data when making decisions. Nurses

 23. ASSESSMENT ACTIVITIES 1. Collect Data: process of

compiling information about the client, begins with the first client
contact. 2. Validate Data: referred to as double checking the
information at hand, is the process of confirming the accuracy of
assessment data collected. Validation assists in verifying and
clarifying cues and inference. 3. Organize Data: clusters the
 information together in order to identify areas of strength and
weaknesses. 4. Documenting Data: accurate documentation is
essential which include all data collected about client’s health
status. Record in a FACTUAL manner NOT interpretation. e.g.-
Recording the breakfast intake as- “ate 2 pcs of bread

 24. 1. Primary Source---PATIENT- Alert, oriented patient is most

reliable source. 2. Secondary Source—family members, significant
others, other health professionals medical records and reports,
laboratory and diagnostic procedures analyses, and relevant
literatures are secondary source or indirect sources.

 25. -SUBJECTIVE DATA also known as symptoms or covert cues

include the client’s feeling and statement about his or her health
problems and are best recorded as direct quotations from the client,
such as “ Every time I move, I feel nauseated.” Information
perceived only by the affected person. - OBJECTIVE DATA also known
as signs or overt cues, are observable and measurable
(quantitative) that are obtained through observation, standard
assessment techniques performed during the PE, laboratory and
diagnostic testing.

 26. Let’s review! SUBJECTIVE or OBJECTIVE??? 1. Headache 2.

Temp. 37.9 3. RR: 20 br/min 4. Toothache 5. Client states, “ I haven’t
moved my bowel since Friday (3 days) 6. Cyanosis 7. Urine output:
60 ml 8. Ate only half of the food served

 27. • O = Onset what you were doing when the pain started? was
the onset sudden or gradual? • P = Provokes what causes pain?
what makes it better? what makes it worse? • Q = Quality what
does it feel like? Is it sharp, dull, stabbing, burning, crushing? (try to
let patient describe the pain) • R = Radiates where does the pain
radiates? Is it in one place? Does it goes anywhere else? Did it start
elsewhere and now localized to one spot?

 28. • S = Severity how severe is the pain on a scale of 1-10 • T =

Time -time pain started? How long did it last?

 30. • A process which results to a diagnostic statement Nursing

Diagnosis. It is the clinical act of identifying problems. • to diagnose
in nursing, it means to analyze assessment information and derive
meaning from this analysis. • Statement of patient’s potential or
actual alteration of health status. It uses the critical-thinking skills of
analysis and synthesis. Format use in diagnosing: P = problem P =
problem R = related factors E = etiology S = signs and symptoms S
= signs and
 31. HTTPS://NURSESLABS.COM/NURSING- DIAGNOSIS/

 32. • Example: 1. Anxiety related to insufficient knowledge

regarding surgical experience. 2. Ineffective airway clearance
related to tracheobronchial infection as manifested by weak cough,
adventitious breath sounds, and copious green sputum production.
Exercises: Correct or incorrect Nursing Diagnosis??? Acute pain
related to physical exertion. Acute pain related to myocardial
infarction. Ineffective breathing pattern related to pneumonia.
Ineffective breathing pattern related to increased airway secretions.

 33. NURSING DIAGNOSIS • Statement of nursing judgement that

made by nurse base on education, experience, expertise and license
to treat. • Describes human response to an illness or a health
problem. • May change when client’s responses changes. •
Independent nursing function (areas of health care that are unique
to nursing, separate and distinct from medical management.
MEDICAL DIAGNOSIS • Made by a physician • Refers to disease
processes • A client’s medical diagnosis remains the same as long
as long as the disease process is present. • Dependent nursing
function (physician-prescribed therapies and treatments)

 36. • Involves decision making and problem solving • It is the

process of formulating client goals and designing the nursing
interventions required to prevent, reduce, or eliminate the client’s
health problem. TYPES: 1. Initial planning: done after the initial
assessment 2. Ongoing planning: a continuous planning 3.
Discharge planning: planning for needs after discharge

 37. a) Setting priorities deciding which nursing diagnosis

requires attention first. The nurse usually uses Maslow’s Hierarchy
of Needs when setting priorities.

 38. b) Establishing client goals/desired outcomes - the nurse set

goals for each nursing diagnosis. Goals maybe short term or long
term. Short-term goal – a statement distinguishing a shift in
behavior that can be completed immediately, usually within a few
hours or days. Long-term goal – indicates an objective to be
completed over a longer period, usually over weeks or months. c)
Selecting nursing interventions and activities. d) Writing
individualized nursing interventions on care plans. Nursing
Intervention is any treatment that a nurse performs to improve
patients’ health. Types: Independent: are activities that nurses are
licensed to initiate on the basis of their knowledge and skills.
Dependent: carried out under the orders or supervision of licensed
 physician. Collaborative: actions the nurse carries out in
collaboration with

 41. CHARACTERISTICS OF NURSING PROCESS  Problem-oriented

 Goal-oriented  Orderly, planned, step by step (systematic)  Open
to accepting new information during its application. It is flexible to
meet the unique needs of client, family, group or community. 
Interpersonal. It requires that the nurse communicates directly and
consistently with the patient.  Permits creativity among nurses and
patients in devising ways to solve the health problems.  Cyclical.
Steps may overlap because they are interrelated.  Universal. It is
applicable to all individuals, families and communities.

 42. BENEFITS of NURSING PROCESS PATIENTS:  Quality patient

care. It meets standard of care.  Continuity of care  Participation
by the patients in their health care. This reflects respect for human
dignity. NURSES:  Consistent and systematic nursing education. 
Job satisfaction  Professional growth  Avoidance of legal action.

 43. Critical Thinking- in nursing:  Entails purposeful, outcome-

directed (result-oriented) thinking  Driven by patient, family, and
community needs  Based on the nursing process, evidenced-based
thinking, and the scientific method.  Requires specific knowledge,
skills and experience  Guided by professional standards and code
of ethics.  Constantly reevaluating, self-correcting, and striving to
improve.

 44. TYPES OF NURSING ASSESSMENT 1. EMERGENCY AND

URGENT ASSESSMENT Involves a life-threatening or unstable
situation, such as a patient who has experienced a critical traumatic
injury. Staff members use triage to determine the level of urgency
by considering assessments based on the mnemonics o A – Airway o
B – Breathing – rate, depth, use accessory muscles o C – Circulation
– pulse rate and rhythm. Skin color o D – Disability – level of
consciousness, pupils, movement o E – Exposure

 47. 2. COMPREHENSIVE ASSESSMENT  Includes a complete

health history and physical assessment. In the clinic, the history
may be obtained by having the patient initially fill out a written form
with family history of illness, personal illness, and medical treatment
or surgeries.  A comprehensive history also includes a patient’s
perception health, strengths to build upon, risk factors for illness,
functional abilities, methods of coping, and support system.  A
comprehensive physical examination includes all body systems and
areas usually in a head-to-toe format.
 48. 3. FOCUSED ASSESSMENT Based on the patient’s health
issues. This type of assessment occurs in all setting. It usually
involves one or two body systems and is smaller in scope than the
comprehensive assessment, but more in depth on the specific issue
or issues. Example: A patient who presents to the clinic with a
cough. The health history focuses on the duration of the cough,
associated symptoms such as wheezing or shortness of breath, and
factors that relieve or worsen the cough. The physical assessment
includes an evaluation of the nose and throat, auscultation of the
lungs, and inspection of sputum.

 49. FRAMEWORKS FOR HEALTH ASSESSMENT

1. Functional Assessment Focuses on the functional patterns that all

humans share: health perception and health management, activity
and exercise, nutrition and metabolism, elimination, rest and sleep,
cognition and perception, self- perception and self-concept, roles
and relationships, coping and stress tolerance, sexuality and
reproduction, and values and beliefs (Gordon, 1993). 2. Head – to –
Toe assessment Most organized system for gathering
comprehensive physical data. 3. Body System Approach A logical
tool for organizing data when documenting and communicating
findings. This method promotes critical thinking and allows you to
analyze findings as you cluster similar data.