Unit 1A: Nurse's Role in Health Assessment: Collecting & Analyzing Data

Main Topics: (1) Four Basic Types of Assessment (2) Overview of the Steps of Health Assessment (3) Evolution of the Nurse's Role in Health Assessment

Assessment

1st and most critical step of the nursing process and accuracy of assessment of data

Assessment, Diagnosis, Planning, Intervention, Evaluation (ADPIE)

Nursing Process

Assessment

1st and most critical step of the nursing process and accuracy of assessment of data

Assessment, Diagnosis, Planning, Intervention, Evaluation (ADPIE)

Nursing Process

Assessment

One of the components of the nursing process

Collecting data that is subjective (from the patient) and objective (like lab results)

Diagnosis

One of the components of the nursing process

Analyzing subjective and objective data to make a professional judgement

Planning

One of the components of the nursing process

Determining outcome criteria and develop a plan

Implementation

One of the components of the nursing process

Carrying out the plan

Evaluation

One of the components of the nursing process

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

Objective (because it is from the S.O. not patient)

Is this subjective or objective data?

A daughter says, “Mom said that her head is aching.”

Assessment

Gathering of information about a patient’s physiological, psychological, sociocultural, development and spiritual status

Collect subjective and objective data to determine client overall

What is the purpose of assessment?

1. Initial Comprehensive

2. Ongoing/Partial

3. Emergency

4. Focus/Problem-Oriented

4 Basic Types of Assessment

Initial Comprehensive Assessment

One of the basic types of assessment

• Collection of subjective data about client’s perception of all body parts or systems

• Gathering of objective data during a step by step physical exam

Ongoing/Partial Assessment

One of the basic types of assessment

• Data collection after comprehensive assessment

• Any problems initially detected in the client’s body system are reassessed in less depth

Focus/Problem Oriented Assessment

One of the basic types of assessment

Through assessment of a particular client problem and doesn’t cover unrelated areas

Emergency Assessment

One of the basic types of assessment

• Very rapid assessment performed in life-threatening situations

• An immediate diagnosis is needed to provide prompt treatment

Airflow, Breathing, Circulation

An example of Emergency Assessment is the assessment of ABC’s. What does “ABC” stand for?

1. Collection of subjective data

2. Collection of objective data

3. Validation of data

4. Documentation of data

4 Major Steps of Health Assessment

Op Ed, As In

Acronym to remember the ways to prepare for the assessment

1. Keep an Open mind

2. Educate yourself about the client’s medical diagnosis

3. Obtain and organize materials needed for Assessment

4. Gathering Information (like sex, age, religion, etc) before actually meeting the client

Ways to prepare for the assessment

1. Collecting of Subjective Data

One of the major steps for Health Assessment

• data that includes sensation or symptoms, feelings, perception, desires, preferences, beliefs, values, and personal information that can be elicited and verified only by the client

• interview used to collect the data

Interview

What is the method used to collect the subjective data?

1. Biographical information

2. Physical symptoms related to each body part or system

3. Past health history

4. Family history

5. Health and lifestyle practices

What are the 5 major areas of subjective data?

2. Collecting Objective Data

One of the major steps for Health Assessment

• Includes data directly obtained, physical exam, observed

1. Physical characteristics

2. Body functions

3. Appearance

4. Behavior

5. Measurement

6. Lab Results

What are the 6 major areas of objective data?

3. Validation of Data

One of the major steps for Health Assessment

• Process of confirming or verifying that the subjective and objective data you have gathered are reliable and accurate as well

• 4 methods of this

1. Recheck your own data

2. Clarify data with the client

3. Verify with another health care professional

4. Compare objective from subjective findings

What are the 4 methods of validation of data?

4. Documentation of Data

One of the major steps for Health Assessment

• Primary reason for this is to provide the health care team with a data base that becomes the foundation of the care of the patient

• Helps to identify health problems, formulate nursing diagnosis and plan

Nightingale

Evolution of the Nurse’s Role in Health Assessment:

In the past, assessment was an integral part of nursing ever since the days of ___.

natural senses

Evolution of the Nurse’s Role in Health Assessment:

In the past, nurses relied on their ___ ___.

nurses

Evolution of the Nurse’s Role in Health Assessment:

In the present, the role of ___ in health assessment is more prevalent today.

technology

Evolution of the Nurse’s Role in Health Assessment:

In the present, the depth and scope of nursing assessment has expanded due to the advancement of ___

specialization; diversity

Evolution of the Nurse’s Role in Health Assessment:

In the future, there may be increased ___ and ___ of assessment skills

assessment; client teaching

Evolution of the Nurse’s Role in Health Assessment:

In the future, it’s the nurse’s role to vastly grow with nurses who have strong ___ and ___ ___ abilities.