Nursing Roles & Health Assessment (NUR 319)

Weeks 1: Chapters 1

4 Goals of the Professional Nurse

1.) To promote health

2.) To prevent illness

3.) To treat human responses to health/illness

4.) To advocate

Primary Prevention

Strategies aimed at preventing problems

Secondary Prevention

Early diagnoses, prompt treatment

Tertiary Prevention

Preventing complications of existing disease, promoting highest possible level of health

4 Aspects of Health Assessment

1.) Assess

2.) Diagnose

3.) Identify outcomes

4.) Plan care

Diagnostic Reasoning

Gathering/clustering of data to draw inferences and propose diagnoses or hypotheses, based on critical thinking

7 Steps of Diagnostic Reasoning

1.) Identify strengths and abnormal data

2.) Cluster data

3.) Draw inferences

4.) Propose nursing diagnoses

5.) Check for defining characteristics

6.) Confirm or remove nursing diagnosis

7.) Document conclusions

Clinical Judgement

Nursing Process + Critical Thinking + Diagnostic Reasoning

3 Common Types of Nursing Assessments

1.) Emergency

2.) Comprehensive

3.) Focused

Emergency Assessment

Life-threatening or unstable situation (A, B, C, D, E)

Comprehensive Assessment

Complete health history and physical examination (annual outpatient & new admission)

Focused Assessment

Smaller scope but increased depth for specific issues

First-Level Priority

Emergent and life-threatening issue requiring immediate intervention

Second-Level Priority

Urgent issue requiring prompt intervention

Third-Level Priority

Important issue but can be attended after urgent issues

Health Assessment (Purpose)

Collect family/personal histories of risk factors and past issues

3 Major Health Assessment Frameworks

1.) Functional (ADLs)

2.) Head-to-Toe (Most organized)

3.) Body systems (Organizational for documentation/communication)

Maslow’s Hierarchy of Needs

P hysiological

S afety

L ove & belonging

S elf-esteem

S elf-actualization

5 Determinants of Health

1.) Environment

2.) Access to healthcare

3.) Community

4.) Education

5.) Economic stability