1 - NURSE’S ROLE IN HEALTH ASSESSMENT

Nursing health assessment

differs in purpose, framework, and the end result from all types of professional health care assessment.

Assessment

is the first and most critical step of the nursing process, and the accuracy of assessment data affects all other phases of the nursing process

Collection of data

is in a systematic and ongoing process.

1. Collection of data

2. Involves the patient, family, other health care providers, and environment

3. Prioritization of data collection activities

4. Appropriate evidence-based assessment

5. Analytical models and problem-solving tools usage.

6. Synthesize available data, information, and knowledge

KEY CONSIDERATIONS FOR PERTINENT AND COMPREHENSIVE DATA COLLECTION

Involves the patient, family, other health care providers, and environment

as appropriate in holistic data collection

Prioritization of data collection activities

based on the patient’s immediate condition, or anticipated needs of the patient, or situation

Appropriate evidence-based assessment techniques and instruments

collecting pertinent data

Analytical models and problem-solving tools usage

KEY CONSIDERATION FOR PERTINENT AND COMPREHENSIVE DATA COLLECTION: (ANA)

Synthesize available data, information, and knowledge

relevant to the situation to identify patterns and variances.

1. Collection of holistic subjective and objective data

2. Mind, body, and spirit

3. Assessing how clients interact within their family and community

4. Assessing how family and community affect the individual

FOCUS OF HEALTH ASSESSMENT

Collection of holistic subjective and objective data

to determine a client’s overall level of functioning in order to make a professional clinical judgment.

Mind, body, and spirit

are considered to be interdependent factors that affect a person’s level of health, focusing on how a client’s health status affects the activities of daily living (ADL) and how those ADL affect the client’s health.

activities of daily living

ADL

affects the family and the community

Assessing how clients interact within their family and community, and how the client’s health status

client’s health status.

Assessing how family and community affect the individual

the client’s physiologic status, psychological, sociocultural, or spiritual well-being

the physician performing a medical assessment focuses primarily on

Nursing framework

helps to organize information and promotes the collection of holistic data which provides clues that help to determine human responses.

is used or applied for organizing data through comprehensive health assessment procedures.

end result of a nursing assessment

is the formulation of nursing diagnoses that require nursing care, identification of collaborative problems requiring interdisciplinary care, identification of medical problems requiring immediate referral, and client teaching for health promotion

nursing care

nursing diagnoses that require

interdisciplinary care

identification of collaborative problems requiring

immediate referral

identification of medical problems requiring

client teaching

for health promotion

- Health Belief Model

- Health Promotion Model

2 Major Models applied to analyze health promotion and disease prevention

Irwin Rosenstock

Health Belief Model

Nola Pender

Health Promotion Model

1. Existence of sufficient motivation.

2. Belief that one is susceptible.

3. Belief that changes following a health recommendation would be beneficial to the individual at a level of acceptable cost.

Health Belief Model

Based on three concepts:

1. Individual characteristics and experiences

2. Behavior-specific cognition and affect

3. Behavioral outcomes

three concepts of Health Promotion Model:

Health Promotion Model

proposes that each person has unique characteristics and experiences that affect the subsequent actions.

1. Culture, family, community, and spirituality

2. Healthcare providers

FACTORS AFFECTING HEALTH ASSESSMENT

Culture, family, community, and spirituality

may all affect a client’s health status affecting client's health

Healthcare providers

must be aware of any perceived notions they have about the client’s culture, family, spirituality, community, and family context.

Focus

should include the emphasis on the need to consider the client in the context of best practice in health assessment.

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

PHASES OF THE NURSING PROCESS

Assessment

Subjective and Objective data collection

Diagnosis

Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral)

Nursing diagnosis

refers to the clinical judgment concerning a human response to health conditions or life processes, or a vulnerability for that response, by an individual, family, group, or community

Nursing diagnosis

provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.

Collaborative problems

refer to certain physiological complications that nurses monitor to detect their onset or changes in status.

Referrals

occur since nurses assess the “whole” client often identifying problems that require the assistance of other health care professionals

Planning

Determining the outcome criteria and developing a plan.

Implementation

Carrying out the plan.

Evaluation

Assessing whether the outcome criteria have been met and revisiting the plan as necessary

1. Initial Comprehensive Assessment

2. Ongoing Comprehensive Assessment

3. Focused Assessment

4. Emergency Assessment

Four Basic Types of Health Assessment

Initial Comprehensive Assessment

Involves the 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 as well as objective data gathering during a step-by-step physical examination.

triage, to determine the origin and nature of the problem and to use that information to prepare for the next assessment stages

total health assessment

● Regardless of who collects the data, a _______________________ is needed when the client first enters a healthcare system and periodically thereafter to establish baseline data against which future health nurses can be measured or compared.

Age, Risk factors, Health status, Health promotion practices, Lifestyle

Assessment frequency considerations: (ar)

Determined by the acuity of the client.

Assessment frequency consideration

Ongoing / Partial Comprehensive Assessment

Occurs after the comprehensive database is established, consisting minor 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 systems or holistic health patterns are reassessed to determine any changes in terms of deterioration or improvement from the baseline data.

Focused / Problem-Oriented Assessment

Performed when a comprehensive database exists for a client who comes to the healthcare agency with specific health concerns. This type of assessment consists of a thorough assessment of a particular client's problem and does not address areas not related to the problem

This type of assessment does not replace the comprehensive health assessment

Emergency Assessment

Rapid assessment performed in life-threatening situations as an immediate assessment is needed to provide prompt treatment.

The major and only concern during this type of assessment is to determine the status of the client’s life-sustaining physical functions.

1. Initial step

2. Subjective data collection

3. Objective data collection

4.Data validation

5. Data documentation

STEPS OF HEALTH ASSESSMENT

Initial step

(preparatory works for the assessment)

Initial step

● Review the client’s record

● Review the client’s status with other healthcare team members

● Educate about the client’s diagnosis and tests performed

Subjective data collection

Data referring to sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.

Biographical information

- History of present health concern

- Personal health history

- Family history

- Health and lifestyle practices

- Review of systems

Major areas of subjective data

Objective data collection

Data obtained by general observation and by using the four (4) physical examination techniques: inspection, palpation, percussion, and auscultation.

client’s medical/health records

Another source of objective data is the ___________________________- (document that contains information about what other health care professionals observed about the client.

May also be observations noted by the family or significant others about the client.

SUBJECTIVE

Data elicited and verified by the client

Sources are client, client records, other healthcare professionals

obtained from Client interview

Interview and therapeutic communication (communication skills), caring ability, empathy and listening skills

OBJECTIVE

Data directly observed through measurement

Observation and physical assessment findings of the health care team members.

Observation and physical examination

Inspection, palpation, percussion, and auscultation

SUBJECTIVE DATA

“I have a headache” “It frightens me” “I am not hungry”

OBJECTIVE DATA

Respiration 16 per minute

BP 180/100

Apical pulse 80 and irregular

X-ray film reveals a fractured pelvis

Data validation

Crucial part of the assessment that often occurs along with the collection of subjective and objective data

Serves to ensure that the assessment process is not to be ended before all relevant data have been collected and helps to prevent documentation of inaccurate data.

- Identification of areas where data are missing.

- Type of assessment data that should be validated.

- Means to validate data.

Key process considerations on Data validation

Data documentation

Forms the database for the entire nursing process and provides data for all members of the health care team.

Thorough and accurate documentation

is vital to ensure that valid conclusions are made when data are analyzed in the second step of the nursing process

PAST

●Physical assessment integral part of nursing

●Nurses relied on natural senses

●Movement of health care from acute care setting to community care and proliferation of baccalaureate and graduate education

●Advanced practice nurses

PRESENT

● Managed care and internal case management has impact on the assessment role of the nurses:

Acute care nurses

Focused assessment with the incorporation of assessment findings to a multidisciplinary team for the development of a comprehensive plan of care.

Critical care outreach nurses

Enhanced assessment skills to safely assess critically ill clients outside the structured intensive care environment.

Ambulatory care nurses

Assessment and screening of clients to determine the need for physician referrals.

Home health nurses

Independent nursing diagnosis and referrals for collaborative problems as needed.

Public health nurses

Assessment for the need of the communities

School and hospice nurses

Monitoring the health and the growth of children for school nurses, and hospice nurse for terminally ill clients and their families

FUTURE

●Rising educational cost

●Increasing complexity of acute care

●Growing aging population with complex comorbidities

●Expanding healthcare needs of single parents

●Increasing impact of children and homeless

●Intensifying mental health issues

●Expanding health services network

●Increasing reimbursement for health promotion and preventive care services

●Limited number of medical students pursuing practice in primary care settings

●Aging of the baby boomer generation

Late 1800s - early 1900’s

• Nurse relied on natural senses alone.

• Palpation was used to measure pulse rate and quality and to locate the fundus of the puerperal woman.

• Records for independent nursing inspections by palpation and auscultation were noted as early as 1901 (gastrointestinal palpation, eight cranial nerve function tests, and examination of children in school systems)

1930-1949

• Routine client and home inspections by public health nurses.

• Frontier Nursing Service and Red Cross lead role in the case finding, prevention of communicable diseases, and routine use of assessment skills in poor inner-city areas.

1950-1969

Conduct pre-employment health stories and physical examinations involving hired nurses from major companies.

1970-1989

• Active role of nurses in the provision of primary health services.

• Expansion of the professional nurse role in conducting health histories, and physical and psychological assessments.

• Productivity enhancement of nurses and the health care of clients occurred through in-depth client assessments and on-the-spot diagnostic judgments.

• Acute care nurses began to employ the “Primary care” Method of Delivery.

• Individualized plans of care were established and nurses became autonomous in making comprehensive initial assessments.

1990-PRESENT

• Use of Advanced Practice Nurses increased in the community as Nurse Practitioners and as Clinical Nurse Specialists within the hospital setting.

• Nurses became responsible for assessing and validating specific protocols through the use of critical pathways and care maps as referential guides related to the client progression.

• Increase in demand for documentation as justification for health care services provided by health care practitioners.

• Increased nurse’s role in the holistic assessment solidified due to the proliferation of graduate and baccalaureate education, and the movement of the acute care setting to the community.

• Government and society recognized the need for greater cost accountability in the healthcare industry resulting to the launching of Diagnosis-Related Groups (DRG’s), and for the promotion of health care coverage plans, the Health Maintenance Organizations (HMO’s) and Preferred Provider Organizations (PPO’s).