health assessment

1. Nursing Role in Health
Assessment
1

2. What are the roles of nurses?

3. Roles of the Professional Nurse
Nursing is the protection, promotion, and optimization of
health and abilities, prevention of illness and injury,
alleviation of suffering through the diagnosis and treatment
of human response, and advocacy in the care of individuals,
families, communities, and populations.

4. Four Main Goals of Nursing
1. Promote Health
2. Prevent Illness
3. Treat human responses to health or illness
4. Advocate for individuals, families, communities,
and populations

5. Nursing and Health Promotion
• Health behaviors are influenced by one’s beliefs,
cultures, and perception
• Health beliefs and experiences determine who is
likely to practice healthy behaviors and why.

6. WELLNESS and ILLNESS
• Wellness is an integrated method of functioning
oriented toward maximizing the potential of the
individual.
• Illnesses are separate short or long events that may
challenge a person’s desire for health. Health is
more than merely the absence of illness.

7. Health Assessment
• gathering information about the health status of
the patient, analyzing and synthesizing those
data, making judgments about nursing
interventions based on the findings, and
evaluating patient care outcome
• includes both a health history and physical
assessment.

8. NURSING PROCESS
• a systematic problem-solving approach
• Serves as a framework
• Focuses on solving problems and enhancing strengths
• Applicable to patients in all stages of the lifespan and in all
settings.
• Central to all nursing care
• Encompasses all steps taken by the nurse in caring for a
patient

9. Characteristics of the Nursing Process
• Within the legal scope of nursing
• Based on knowledge-requiring critical thinking
• Planned-organized and systematic
• Client-centered
• Goal-directed
• Prioritized
• Dynamic

10. Benefits of the Nursing Process
• Provides an orderly & systematic method for planning &
providing care
• Enhances nursing efficiency by standardizing nursing
practice
• Facilitates documentation of care
• Provides unity of language for the nursing profession
• Is economical
• Stresses the independent function of nurses
• Increases care quality through the use of deliberate
actions

11. Responsibilities as a Nurse?
• Recognize health problems.
• Anticipate complications.
• Initiate actions to ensure appropriate and timely
treatment.
• Begin to think CRITICALLY!

14. Nursing Assessment
 The first phase of the nursing process, called assessment,
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, and other
health team members.

15. Assessment
 using the nurse's five senses
 critical thinking skills
 good clinical judgment as to what seems to be the
priority problem
 taken thru observation, interview, physical
examination

16. Nursing Diagnosis
 The second step in the nursing process involves further
analysis (breaking the whole down into parts that can be
examined) and synthesis (putting data together in a new
way) of the data that have been collected.

17. Nursing Diagnosis
 Sort, cluster, and analyze information
 Identify potential problems and strengths
 Write a statement of problem or strength
 Example of a nursing diagnosis:
 Risk of infection related to compromised nutrition

18. Purposes of Nursing Diagnosis:
 Nursing diagnosis is unique in that it focuses on a
client’s response to a health problem, rather than
on the problem itself, and it provides the
structure through which nursing care can be
delivered.
 Nursing diagnosis also provides a means for
effective communication.

19. According to the North American Nursing
Diagnosis Association (NANDA) a nursing diagnosis
is a clinical judgment about individual, family, or
community responses to actual or potential
health problems/life processes.
Nursing diagnoses provide the basis for the
selection of nursing interventions to achieve
outcomes for which the nurse is accountable.

20. NANDA International (NANDA-I)
 earlier known as the North American Nursing
Diagnosis Association (NANDA) is the principal
organization for defining, distributing, and
integration of standardized nursing diagnoses
worldwide.

21. Components of a Nursing Diagnosis
A nursing diagnosis has typically three components:
(1) the problem and its definition,
(2) the etiology, and
(3) the defining characteristics.

22.  Physical nursing diagnoses include those that pertain to
physical processes, such as circulation (ineffective renal
Tissue Perfusion), ventilation (impaired Gas Exchange),
and elimination (Constipation).
 Psychosocial nursing diagnoses include those that
pertain to the mind (acute Confusion), emotions (Fear),
or lifestyle and relationships (ineffective Role
Performance).
Types of Diagnosis

23. Differentiating Nursing Diagnosis vs
Medical Diagnosis
Nursing Diagnosis Medical Diagnosis
focus on unhealthy
responses to health and
illness.
identify diseases
describe problems treated by
nurses within the scope of
independent nursing practice.
describe problems for which
the physician directs the
primary treatment .
may change from day to day
as the patient’s responses
change
remains the same for as long
as the disease is present

25. Planning
 The process of prioritizing nursing diagnoses and
collaborative problems, identifying measurable goals or
outcomes, selecting appropriate interventions, and
documenting the plan of care.
 The nurse consults with the client while developing and
revising the plan.

26. Setting Priorities
 Determine problems that require immediate action
 Maslow’s Hierarchy of Human Needs

29. Functional Health Patterns
1.Health Perception – Health Management Pattern
⮚ describes the client’s perceived pattern of health and well-
being and how health is managed.
2. Nutritional – Metabolic Pattern
⮚ describes the pattern of food and fluid consumption
relative to metabolic needs and pattern indicators of local
nutrient supply.

30. 3. Elimination Pattern
⮚ describes the pattern of excretory function (bowel,
bladder)
4. Activity – Exercise Pattern
⮚ describes the pattern of exercise, activity, leisure, and
recreation.
5. Cognitive–Perceptual Pattern
⮚ describes the sensory, perceptual, and cognitive pattern

31. 6. Sleep – Rest Pattern
⮚ describes patterns of sleep, rest, and relaxation.
7. Self-perception – Self-concept Pattern
⮚ describes self-concept and perceptions of self (body
comfort, image, feeling state)
8. Role – Relationship Pattern
⮚ describes a pattern of role engagements and
relationships.

32. 9. Sexuality – Reproductive Pattern
⮚ describes client’s pattern of satisfaction and
dissatisfaction with sexuality pattern, describes
reproductive patterns.
10. Coping – Stress Tolerance Pattern
⮚describes general coping patterns and the effectiveness
of the pattern in terms of stress tolerance.
11. Value – Belief Pattern
⮚describes the pattern of values and beliefs, including
spiritual and /or goals that guide choices or decisions.

33. GOAL:
 A general statement of purpose.
 end towards which all efforts are directed.
OBJECTIVES:
 more specific statements.
 step-by-step family responses toward the attainment
of the goal

34. Nursing Interventions
✔ Road maps directing the best ways to provide nursing
care.
✔ Evidence-based nursing.
1. Monitor health status.
2. Minimize risks.
3. Resolve or control a problem.
4. Assist with ADLs.
5. Promote optimum health and independence.
✔ must be based on the perceived diagnosis and objectives
✔ must be RATIONAL enough; realistic

35. Types of Interventions:
 Direct interventions:
- actions performed through interaction with clients.
 Indirect interventions:
- actions performed away from the client, on behalf of a
client or group of clients.
 Independent
 Dependent
 Collaborative/interdependent

36. Evaluation
1. Determining outcome achievement (met or unmet)
2. Identifying the variables affecting outcome achievement
3. Deciding whether to continue, modify or terminate the
plan
– must be in the present or past tense
– nursing interventions can be modified at this stage.

37. Determining Outcome Achievement
 Must be aware of outcomes set for the client.
 Must be sure the patient is ready for evaluation.
 Is the patient able to meet outcome criteria?
 Is it:
Completely met?
Partially met?
Not met at all?
 Record in progress in notes.
 Update care plan.

38. Documenting the Plan of Care
 To ensure continuity of care, the plan must be
written and shared with all healthcare personnel
caring for the client.
 Consists of:
1. Prioritized nursing diagnostic statements.
2. Outcomes.
3. Interventions.

39. Documentation
 Clear and concise
 Appropriate terminology
 Physical assessment
- Usually by Review of Systems
 Overview of symptoms
 Diet
 Each body system

40. Documentation
✔ Use patient’s own words in subjective data –
enclose in “ ___” (quotation marks)
✔ Avoid generalizations – be specific

41. Types of Nursing Assessment
1. Initial Comprehensive assessment
2. On-going assessment
3. Focused or problem-oriented assessment
4. Emergency assessment

42. 1. Initial Comprehensive Assessment
✔ involves the collection of subjective data about the
client’s perception of her health of all body parts or
systems, past health history, family history, and lifestyle
and health practices as well as objective data gathered
during a step-by-step physical examination.
✔ The nurse typically collects subjective data, especially
those related to the client’s overall function.

43. 2. Ongoing or Partial Assessment
✔ consists of data collection that occurs after the
comprehensive database is established.
✔ a mini-overview of the client’s body systems and holistic
health patterns as a follow-up on his health
✔ Problems that were initially detected in the are reassessed
✔ Usually performed whenever the nurse or another health
care professional has an encounter with the client.

44. 3. Focused or Problem-Oriented Assessment
✔ it does not take the place of 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.

45. 4. Emergency Assessment
✔ A very rapid assessment performed in life-threatening
situations.
✔ Example: the evaluation of the client’s airway, breathing,
and circulation (known as the ABCs) when cardiac arrest is
suspected.
✔ The major and only concern during this type of assessment
is to determine the status of the client’s life-sustaining
physical functions.

46. - To establish baseline information on the client
- To determine the client’s normal function
- To determine the client’s risk for dysfunction
- To determine the client’s strengths
- To provide data for the diagnosis phase
Reasons for doing assessment:

47. Communication
⮚ a process of sharing information and meaning, of
sending and receiving messages.

48. Essential Parts of Communication
⮚ Sender
⮚ Message
⮚ Receiver
⮚ Feedback

49. Importance of Good Communication
1. Enhances good rapport.
2. Builds a trusting relationship with the patient and
client.
3. Aids in obtaining accurate data necessary for
formulating a good plan of care.
4. Helps ensure that the message you want to send is
the one your patient actually receives.

50. Types of Communication
1. Verbal
2. Non - verbal

51. NON - VERBAL
COMMUNICATION

52. Nonverbal Communication includes:
1. Appearance
2. Demeanor
3. Facial Expression
4. Attitude
5. Silence
6. Listening

53. 1. Appearance
✔ Ensure that your appearance is professional.
✔ Wear comfortable clothes.
✔ Make yourself presentable.
✔ Keep yourself clean.

54. 2. Demeanor
✔ Demeanor should also be professional.
✔ Display poise.
✔ Make yourself known.
✔ Don't be snobbish but don't be overly friendly or
touchy.

55. 3. Facial Expression
✔ Often shows what you are truly thinking.
✔ Keep a close check on your facial expression.
✔ Keep your expression neutral and friendly.

56. 4. Attitude
✔ One of the most important nonverbal skills
- nonjudgmental attitude.
✔ Keep in mind that ALL clients should be accepted,
regardless of beliefs, ethnicity, lifestyle, and health care
practices.
✔ Do not act superior to the client or appear shocked,
disgusted, or surprised at what you are told.

57. 5. Silence
✔ Periods of silence allow you and the client to reflect and
organize thoughts, which facilitates more accurate
reporting and data collection.

58. 6. Listening
✔ Most important skill
✔ Becoming an effective listener takes concentration and
practice.
✔ How?
- Maintain good eye contact
- Smile or display an open, appropriate facial expression
- Maintain an open body position (open arms and hands and
lean forward).
✔ Avoid preconceived ideas or biases; keep an open mind.

59. VERBAL
COMMUNICATION

60. Verbal Communication Techniques:
1. Open-ended questions
2. Close-ended questions
3. Laundry list
4. Rephrasing
5. Well-placed phrases
6. Inferring information
7. Providing Information

61. 1. Open-ended questions
✔ elicit the client’s feelings and perceptions.
✔ Begin with the words “how” or “what.”
✔ Requires more than a one-word response from the client.
Thus, helps reveal significant data about the client’s
health status.
Example:
“How have you been feeling lately?”

62. 2. Closed-ended questions
✔ obtain facts focusing on specific information.
✔ typically begin with the words “when” or “did.”
✔ Clarifies information disclosed in response to open-ended
questions.
Example:
In response to the open-ended question “How have you been
feeling lately?” the client says, “Well, I’ve been feeling really
sick in my stomach and I don’t feel like eating because of it.”
You may be able to follow up and learn more about the
client’s symptoms with a closed-ended question such as
“When did the nausea start?”

63. 3. Laundry List
✔ Providing the client with a choice of words to choose
from in describing symptoms, conditions, or feelings.
✔ Helps you obtain specific answers and reduces the
likelihood of the client’s perceiving or providing an
expected answer.
Example:
“Is the pain severe, dull, sharp, mild, cutting, or piercing?”
“Does the pain occur once every year, day, month, or
hour?”
* Repeat choices as necessary.

64. 4. Rephrasing
✔ Helps you to clarify information the client has stated; it
also enables you and the client to reflect on what was
said.
Example:
Mr. G., tells you that he has been really tired and nauseated
for 2 months and that he is scared because he fears that he
has some horrible disease.
You might rephrase the information by saying, “You are
thinking that you have a serious illness?”

65. 5. Well-placed phrases
✔ Encourages client verbalization.
✔ If the client is in the middle of explaining a symptom or
feeling and believes that you are not paying attention,
you may fail to get all the necessary information.
✔ Listen closely to the client during his or her description
and use phrases such as “um-hum,” “yes,” or “I agree” to
encourage the client to continue.

66. 6. Inferring information
✔ Inferring information from what the client tells you and
what you observe in the client’s behavior may elicit more
data or verify existing data.
Example:
Your client, Mrs. J., tells you that she has bad pain. You ask
where the pain is, and she says, “My stomach.” You notice
the client has a hand on the right side of her lower abdomen
and seems to favor her entire right side.
You say, “It seems you have more difficulty with the right
side of your stomach” (use the word “stomach” because that
is the term the client used to describe the abdomen).

67. 7. Providing Information
✔ Another important thing to consider.
✔ Make sure you answer every question as well as you can.
If you do not know the answer, explain that you will find
out for the client.
✔ The more clients know about their own health, the
more likely they are to become equal participants in
caring for their health.

68. Therapeutic
vs.
Non-therapeutic
Communication

69. Therapeutic Communication
 a process in which the healthcare professional consciously
uses specific techniques to help patients better understand
their condition or situation. At the same time, they also
encourage patients to freely express their ideas and
feelings in a relationship of mutual respect and acceptance

70. Non-Therapeutic Communication
 An interaction that hinders good nurse-patient
relationship

71. Phases of Interview
1. Pre-introductory phase
2. Introductory phase
3. Working phase
4. Summary / Closing phase

72. Phases of Interview
1. Pre-introductory phase - reviewing the medical record
2. Introductory phase - introduction of self, explain the
purpose, discuss types of questions, explain the need of
taking notes, ensure confidentiality
3. Working phase - eliciting client's comments on
biographic data, past health history, etc.
4. Summary / Closing phase - summarizing and validating
data; identifying and discussing a plan of care; asking
patient about any concern

73. Communication During the Interview
 Verbal - its goal is to elicit as much information about the
client's health status as possible.
 Non-verbal - your appearance, demeanor, posture, facial
expressions, and attitude.

74. COMPONENTS OF A NURSING HEALTH HISTORY
⮚ Biographic data
⮚ Reason for seeking health care/ chief complaint.
⮚ History of present Illness
⮚ Past health history
⮚ Family history
⮚ Review of systems
⮚ Lifestyle
⮚ Socio-cultural History
⮚ Psychological History
⮚ Occupational and environmental History

75. Biographic data
Personal data including name, address, age and date
of birth, gender, religion, race / ethnic origin, bed
number, ward, medical diagnosis, surgery (if
performed), occupation, education, and type of
health plan/insurance.

76. Reason for seeking health care / chief
complaint.
• It should be written in the client’s statement.
• In case of multiple problems, ask the client to
indicate the priority of the complaint.
• Avoid using medical terminology.
• Write problems in chronological order.

77. History of Present Illness
 Expansion of Chief of Complaints
 Chronological order
 Location, quality, quantity, chronology, setting,
exaggerating and relieving factors, associated symptoms,
effect on sleep, and daily activities.

78. Past Health History
• Allergies
• Medical diseases such as Hypertension, Diabetes, TB,
Anemia, Seizures, Arthritis, Heart Disease, Glaucoma etc.
• Trauma, Injury: Fracture, abdominal trauma, burns,
blunt/penetrating injury, altered consciousness level.
• Hospitalization
• Childhood disease and immunization
• Obstetric History
• Drug history

79. FAMILY HISTORY- Family Health History
The family history should include causes and age of death
of parents, details about the health of siblings and
children, and information about heart diseases,
hypertension, diabetes, asthma, allergies & ethnic origin.

80. Review of Systems (ROS)
A brief account from the client of any recent signs or
symptoms associated with any of the body systems.

81. Respiratory History
• Presenting Problem / Complaint: Cough, Sputum,
Hemoptysis, Wheeze, Chest Pain, Shortness of breath,
Systematic symptoms,
• Drug History: Allergies, inhalers, nebulizer, home
oxygen
• Social History: Smoking history measured in pack-
years Contact with animals/pets Presence of stairs in
or leading into flat/house Hobbies.
• Family History: e.g. asthma/hay fever

82. Cardiovascular History
• 4 main cardiovascular symptoms: Chest pain, Shortness
of breath, Presence, and extent of edema, Palpitations
• Main risk factors for Ischemic Heart Disease:
Smoking, Hypertension, Diabetes mellitus,
Hyperlipidemia, Family history
• Past Medical History: e.g. angina, myocardial
infarction, bypass operation, rheumatic fever, stroke
• Social History: Smoking, alcohol, etc.
• Family History
• Drug History: Allergies

83. LOCOMOTOR HISTORY
• Evolution of condition - Acute or chronic,
Associated events and Response to treatment
• Current symptoms - Pain, Stiffness, Swelling,
Pattern of joint involvement
• Involvement of other symptoms – Skin, lung,
eye, or kidney symptoms, malaise, weight
loss, fevers, or night sweats
• Impact of lifestyle - Patient’s needs/ aspirations, Ability
to adapt to functional loss
• Pain History: PQRST
• Use of medication for pain relief

84. Personal Data / Life Style
• Habit
• Diet
• Elimination pattern
• Sleep and rest pattern
• Activity and exercise pattern

85. Obstetric History
• Menstrual Pattern – regular/irregular
• History of pregnancy, labor, puerperium, and
complications if any

86. Socio-Cultural History
• Home environment
• Family situation
• Client’s role in the family

87. Psychosocial History
• Psychosocial history refers to an assessment of dimensions
such as self-concept and self-esteem as well as usual
sources of stress and the client’s ability to cope.
• Sources of support for clients in crisis, such as family,
significant others, religion, or support groups, should be
explored

88. Occupational and Environmental History
• It includes collecting data regarding the client’s
occupation, lifestyle in the job, working environment, etc.
• Collecting information includes designation, location of
work, exposure to hazardous material, residing near mines,
farms, factories, or shipyards, congestion, and
overcrowding, which may spread communicable diseases.