Chapter One: Health Assessment

What is the role of the professional nurse?

The professional nurse has a multifaceted role based on education in the biological and physical sciences, humanities, and social sciences. Nurses provide care, educate patients, promote health, prevent illness, use evidence to guide practice, and participate in assessment and clinical decision-making.

Nurse as a Teacher

A nurse who helps patients gain the knowledge needed to maintain or improve health, prevent illness or injury, manage therapies, and make informed decisions about health and treatment.

Nurse as a Caregiver

The traditional nursing role involving the provision of care to patients.

What does a nurse researcher do?

A nurse researcher identifies problems related to patient care, designs research studies, develops research tools, contributes to nursing knowledge, guides future research, and works to improve patient care.

Nurse Practitioner (NP)

An advanced-practice nurse with an advanced degree and certification who may practice independently in primary or acute care settings. NPs combine expertise in diagnosing and treating illness with nursing knowledge of health promotion and prevention.

Certified Registered Nurse Anesthetist (CRNA)

An advanced-practice nurse who completes an accredited nurse-anesthesia program and national certification examination and provides anesthesia services in collaboration with other healthcare providers.

Certified Nurse Midwife (CNM)

A registered nurse with graduate-level education and certification who provides general healthcare, gynecologic care, family planning, pregnancy/labor/birth care, and menopause care.

Clinical Nurse Specialist (CNS)

An advanced-practice nurse educated in a specific patient population and/or area of nursing practice who provides direct care, teaches healthcare team members, and conducts nursing research.

Nurse Administrator

A nurse, usually with an advanced degree, responsible for areas such as complex patient-care management, staffing, budgets, organizational performance, consulting, and achieving agency goals.

Nurse Educator

A nurse with an advanced degree who teaches nursing in settings such as universities, community colleges, hospitals, or healthcare agencies. Responsibilities include didactic and clinical teaching, curriculum development, clinical placement, and evaluating learning.

Evidence-Based Practice (EBP)

A focused problem-solving approach to clinical decision-making that incorporates evidence from scientific research, practical research, and best practices to provide safe, effective, and competent care.

Why is evidence-based practice important in nursing?

It helps nurses make informed clinical decisions and provide safe, effective, competent care based on scientific evidence and best practices.

What is the purpose of the EBP movement?

The EBP movement aims to improve healthcare outcomes through the development and use of best-practice policies and clinical guidelines.

Agency for Healthcare Research and Quality (AHRQ)

An organization that supports healthcare improvement through research on quality of services and patient outcomes. Its Evidence-based Practice Centers review scientific literature and produce evidence reports and technology assessments.

What types of information does AHRQ's Evidence-based Practice Centers review?

Scientific literature concerning clinical, behavioral, organizational, and financial healthcare topics.

Nursing Process

A systematic, rational, dynamic, and cyclic process nurses use to assess, plan, implement, and evaluate patient care.

What are the major steps of the nursing process?

Assessment → Diagnosis → Planning → Implementation → Evaluation

Why does the nursing process begin with assessment?

It begins with a comprehensive and systematic assessment so that nursing care can be comprehensive, evidence-based, and appropriate for the patient.

Assessment

The collection, organization, and validation of subjective and objective information about a patient.

What is the purpose of assessment?

To gather complete, accurate, and relevant information about the patient that can be used to identify problems, plan care, and establish a comprehensive patient database.

Subjective Data

Information that the patient tells the nurse.

What are examples of subjective data?

• Patient's perception of health

• Pain level

• Health and illness history

• Allergies

• Food eaten

• Medications being taken

Objective Data

Information that the nurse measures or observes about the patient.

What are examples of objective data?

• Physical examination findings

• Laboratory values

• Information in the patient's chart

• Growth and development findings

• Anything observed or measured by the nurse

What is the difference between subjective and objective data?

Subjective is what the patient says/experiences while Objective is what the nurse observes/measures.

Nursing Diagnosis

A clinical determination based on comparison of subjective and objective data with expected/normative values and standards. It identifies patient problems that will be the focus of nursing care.

What happens during the diagnosis phase?

The nurse compares subjective and objective data with expected values and standards and considers all data to determine areas where nursing intervention can support or improve health and wellness.

Planning

The nursing-process phase in which the nurse identifies measurable patient goals/outcomes, establishes priorities, and selects evidence-based nursing interventions.

What characteristics should a nursing goal have?

A nursing goal should be:

• Specific

• Measurable

• Attainable

• Relevant

• Include a time element

Why must nursing goals be measurable?

So the nurse can later determine whether the patient actually achieved the expected outcome during evaluation.

Implementation

The phase in which the nurse carries out the specific nursing interventions selected during planning to achieve the patient's goals.

What happens during implementation?

The nurse performs the planned, relevant, evidence-based interventions designed to help the patient achieve established goals.

Evaluation

The nursing-process phase in which the nurse determines the degree to which the patient has achieved the identified goals or outcomes.

What can happen if a patient does not meet a goal?

The nurse may revise the care plan by adding, changing, or discontinuing nursing diagnoses or interventions.

Is the nursing process a one-time process?

No. It is dynamic and cyclic, meaning evaluation can lead to changes in the care plan and another cycle of assessment, diagnosis, planning, implementation, and evaluation.

Health Assessment

A systematic process used by the nurse to collect subjective and objective information about a patient and create a comprehensive database for planning care.

What are the purposes of health assessment?

Health assessment can be used to:

• Determine the patient's current or ongoing health status

• Predict risks to health and well-being

• Identify health-promoting activities

What types of information are collected during a health assessment?

• Physical

• Social

• Cultural

• Environmental

• Emotional

• Wellness behaviors

• Signs and symptoms of illness

• Patient strengths and weaknesses

• Risk factors

Primary Source of Information

The patient, who is the primary source of subjective information during the health assessment.

Secondary Source of Information

Family members or caregivers who provide information when appropriate.

What is the purpose of the health history?

To obtain information about the patient's health in the patient's own words and according to the patient's own perception.

How does the health history help the nurse?

It provides cues about the patient's health and guides additional data collection during the focused interview.

Focused Interview

The portion of the interview in which the nurse asks questions to clarify information, obtain missing information, and further explain information identified in the health history.

What is the purpose of a focused interview?

To expand the subjective database and obtain enough reliable information to help the nurse make judgments and plan care.

Physical Assessment

The collection of objective data through observation, measurement, a general survey, and examination of body systems.

What are the components of the physical assessment?

• General survey

• Examination of body systems

How does physical assessment contribute to the patient's database?

Objective findings from the physical assessment are combined with other reliable information to create the comprehensive database used for care planning.

Documentation

The accurate and complete recording of subjective and objective data collected during the interview and physical examination.

Why is the patient's medical record important?

It is a legal document used to:

• Plan care

• Communicate information

• Monitor quality of care

• Support reimbursement

• Provide data for research

HIPAA

The Health Insurance Portability and Accountability Act, which includes federal regulations requiring confidentiality and protection of medical records and individually identifiable health information.

What information does HIPAA protect?

Medical records and other individually identifiable health information communicated in written, oral, or electronic forms.

What is individually identifiable health information?

Health information, including demographic information, that could be used to identify an individual.

Critical Thinking in Nursing

A cognitive process involving purposeful and rational analysis of information to support clinical reasoning, judgment, and decision-making.

Is critical thinking simply problem-solving?

No critical thinking is more than problem solving.

How does critical thinking relate to the nursing process?

The critical-thinking process parallels the nursing process and supports clinical reasoning, judgment, and decision-making throughout patient care.

Health

A holistic concept that includes physical, psychosocial, and spiritual components.

Wellness

A state of being that is balanced, personally satisfying, and characterized by the ability to adapt and participate in activities that enhance quality of life.

What is the difference between health and wellness?

Health is viewed holistically through physical, psychosocial, and spiritual components. Wellness describes a balanced, personally satisfying state involving adaptation and participation in activities that improve quality of life.

Health Disparities

Differences in health outcomes and conditions in which certain groups are affected in uneven ways.

Why should nurses recognize health disparities?

Nurses need to recognize social determinants that can affect the health outcomes of specific populations.

What social determinants are identified in the slideshow as affecting health outcomes?

• Race

• Ethnicity

• Gender

• Sexual identity

• Age

• Disability

• Socioeconomic status

• Geographical location

What are the Elements of Critical Thinking

Evaluation, Collection of Information, Analysis of Situation, Generation of Alternatives, Selection of Alternatives