Health Assessment Overview

INTRODUCTION TO HEALTH ASSESSMENT

  • Course Code: N347

  • Facilitator: Bailey Stiff, RN, MSN/ED.

  • Institution: University of Louisville

EVIDENCE-BASED ASSESSMENT

Chapter 1 Overview

  • Focuses on the principles and applications of evidence-based assessment in health care.

STEPS OF EVIDENCE-BASED PRACTICE

Overview of the Evidence-Based Practice Process

  1. Develop a Clinical Question

    • Importance of formulating a clear, answerable question to guide the search for evidence.

  2. Search for the Best Available Evidence

    • Utilize databases and current literature to find applicable studies and articles.

  3. Appraise the Evidence

    • Critically evaluate the evidence for its validity, impact, and applicability.

  4. Apply the Best Available Evidence

    • Implement findings into patient care and decision-making processes.

  5. Evaluate the Outcomes

    • Assess the effects of the applied evidence on patient outcomes and revise practices accordingly.

HEALTH ASSESSMENT: DATA COLLECTION

Types of Data Collected

  • Subjective Data: Information gathered from the patient’s personal experience and feelings (e.g., symptoms).

  • Objective Data: Information obtained through physical examinations, tests, and observations (e.g., vital signs).

Assessment Process

  • Assessment: Involves both subjective and objective data to provide a comprehensive health evaluation.

CLINICAL REASONING MODELS

Assessment Includes:

  • Data Collection Methods:

    • Review of clinical records

    • Patient interview

    • Health history documentation

    • Physical examination

    • Functional assessment (ADLs)

    • Consultation with colleagues or specialists

    • Review of relevant literature.

  • Diagnostic Reasoning: Utilizes critical thinking to interpret data and identify health issues.

EVALUATION PHASE

  1. Refer to Established Outcomes:

    • Comparison of individual’s actual condition with the expected outcomes.

  2. Summarize Evaluation Results:

    • Document findings and any adjustments needed in the patient’s care plan based on evaluation.

  3. Corrective Action:

    • Modify the care plan if expected outcomes were not met.

  4. Documentation:

    • Record evaluation results and any modifications made to the plan of care.

IMPLEMENTATION PHASE

  1. Planned Interventions:

    • Review and prepare interventions according to the care plan.

  2. Collaboration:

    • Work with healthcare team members to provide comprehensive care.

  3. Supervision:

    • Monitor the implementation of care, ensuring appropriate delegation of responsibilities.

  4. Patient Involvement:

    • Encourage patient participation in their care.

  5. Referral for Continuing Care:

    • Recommend specialists or additional services as needed.

NURSING PROCESS OVERVIEW

  • Steps in Nursing Process:

    1. Assessment

    2. Diagnosis

    3. Planning

    4. Implementation

    5. Evaluation

NURSING PROCESS: ASSESSMENT

  • Data Collection:

    • Review clinical records

    • Conduct patient interviews

    • Health history details

    • Physical examination findings

    • Functional assessments including Activities of Daily Living (ADLs)

    • Consultation for expert opinions

    • Literature review for supplementary data.

NURSING PROCESS: DIAGNOSIS

  • Data Interpretation:

    • Identify clusters of cues from the collected data.

    • Make inferences and document findings.

    • State the problem clearly, identifying related factors and evidence.

NURSING PROCESS: PLANNING

  1. Setting Priorities:

    • Determine which issues or problems take precedence.

  2. Developing Goals/Outcomes:

    • Outcomes must be specific to the individual and measurable.

    • Create timelines for achieving said outcomes.

NURSING PROCESS: IMPLEMENTATION

  • Review planned interventions and coordinate total care.

  • Collaborate with healthcare team members and supervise the care plan's implementation.

  • Encourage clear communication with patients and their significant others.

  • Document care provided and any changes made.

NURSING PROCESS: EVALUATION

  • Assess progress toward established outcomes based on the evaluated condition and compare actual outcomes to anticipated ones.

  • Document reasons for failure to meet expected outcomes and recommended changes to the care plan.

CARE PLAN FORMAT

Structure of Nursing Care Plans

  1. Client Initials:

    • Identification of the patient (maintaining confidentiality).

  2. Nursing Diagnosis/Clinical Problem:

    • Define the nursing diagnosis/problem and causative factors if known; supported by assessment data.

  3. Assessment Data:

    • Include relevant subjective and objective data justifying the nursing diagnosis.

  4. Client Goals/Desired Outcomes/Objectives:

    • Establish realistic, measurable, time-bound goals focused on what the client should achieve.

  5. Nursing Interventions/Actions:

    • Specific interventions detailing how the objectives will be met, documented with appropriate rationales for each action taken.

  6. Evaluation:

    • Assessment of client progress and any revision needed for goals or interventions.

TYPES OF DATABASES IN ASSESSMENT

  1. Complete Database:

    • Comprehensive health history and physical assessment.

  2. Focused/Problem-Centered Database:

    • Targeted data for specific, short-term problems.

  3. Follow-Up Database:

    • Useful for ongoing assessment and management of conditions.

  4. Emergency Database:

    • Rapid assessment for acute emergencies.

DEVELOPMENTAL TASKS AND HEALTH PROMOTION ACROSS THE LIFE CYCLE

Areas to Assess Through Different Life Stages:

  1. Physical Development: Growth measurements and developmental milestones.

  2. Psychosocial Development: Evaluation of social influences and individual thought processes.

  3. Cognitive Development: Assessment of intellect and problem-solving abilities.

  4. Behavioral Development: Monitoring behavioral changes throughout life stages.

DEVELOPMENTAL MILESTONES BY STAGE:

Infancy (First Year):

  • Physical: Triple birth weight and increase length by 50%; significant brain growth; loss of some reflexes.

  • Psychosocial: Developing trust versus mistrust.

  • Cognitive: Sensorimotor period actively engaged.

  • Behavioral: Milestones include sitting, standing, walking, and babbling.

Toddlerhood:

  • Physical: Average growth of 2.5 kg and 12 cm length; characterized by toddler lordosis.

  • Psychosocial: Navigating autonomy versus shame and doubt.

  • Cognitive: Continuation of sensorimotor developments.

  • Behavioral: Improvements in locomotion and fine motor skills; exhibit negativism and ritualistic behavior.

Preschool Age:

  • Physical: Slower growth; near adult proportions in stature.

  • Psychosocial: Developing a superego and understanding gender roles; initiative versus guilt.

  • Cognitive: Entering the preoperational stage.

  • Behavioral: Advancing fine motor skills; refining language capabilities; shifting towards cooperative play.

School-Age:

  • Physical: Steady growth; transitional facial features; primary teeth replaced by permanent teeth.

  • Psychosocial: Industry versus inferiority, with growing significance of peer approval.

  • Cognitive: Transitioning to concrete operational stage.

Preadolescence:

  • Physical: Statistically, girls experience growth spurts around 10 years, while boys follow at 12.

  • Psychosocial: Increasing emphasis on peer groups and best friendships.

Adolescence:

  • Physical: Puberty onset; health risks include poor decision-making, particularly concerning driving and sexual activity.

  • Psychosocial: Ego identity versus identity confusion; development of peer and romantic relationships.

  • Cognitive: Advancement to the formal operational stage.

Early Adulthood:

  • Physical: Completion of growth, peak physical health.

  • Psychosocial: Focus on intimacy versus isolation.

  • Cognitive: Career and job development become focal points.

Middle Adulthood:

  • Physical: Signs of aging; beginning declines in bodily functions.

  • Psychosocial: Generativity versus stagnation.

  • Cognitive: Experience contributes to IQ.

Late Adulthood:

  • Physical: Various declines including mobility and strength.

  • Psychosocial: Ego integrity versus despair; considerations regarding mortality.

  • Cognitive: Normal decline in reaction times and complex decision-making capabilities.

CULTURAL COMPETENCE AND CULTURAL CARE

Definitions

  • Culture: Refers to the thoughts, communications, actions, beliefs, values, and institutions of specific racial, ethnic, religious, or social groups.

  • Cultural Competence: The ability to understand, appreciate, and interact with individuals from different cultures.

    • Culturally Sensitive: Basic understanding and positive attitudes toward diverse cultural groups.

    • Culturally Appropriate: Application of cultural knowledge to deliver optimal health care.

    • Culturally Competent: Full understanding of the context involving the patient, including factors like immigration status, socio-economic concerns, and cultural variances.

Developmental Care:

  • Culture influences health care decisions, initial treatments, and parents' perceptions of an illness in children.

  • Older patients’ family roles and understanding of medical systems can be markedly affected by cultural beliefs.

THE INTERVIEW PROCESS

Overview of The Interview

  • Subjective Data: The interview's essence is the collection of subjective data through effective communication.

The Contract

  • Establishes expectations between interviewer and patient:

    • Time and place of interview

    • Purpose and length of the meeting

    • Confidentiality agreements

    • Consideration of the presence of others.

Communication Process

  1. Sending Information:

    • The interviewer's delivery of questions and information.

  2. Receiving Information:

    • Patient’s interpretation of the communicated data.

  3. Internal and External Factors:

    • Factors impacting the exchange of information during the interview.

Internal Factors:

  • Liking others

  • Empathy and active listening

  • Self-awareness of biases and attitudes.

External Factors:

  • Ensuring privacy and silence

  • Physical environment conditions (lighting, seating)

  • Limitations of note-taking and potential distractions.

Therapeutic Communication Techniques

  1. Facilitation: Encouraging patients to elaborate on their narratives.

  2. Silence: Allowing moments of quiet reflection, especially after open-ended inquiries.

  3. Reflection: Summarizing patient's sentiments to show understanding.

  4. Empathy: Acknowledging emotions and fostering deeper discussion.

  5. Clarification: Confirming understanding of the patient’s statements.

  6. Confrontation: Addressing contradictions observed.

  7. Interpretation: Suggesting connections or implications.

  8. Explanation: Providing pertinent information.

  9. Summary: Review and reaffirm patient statements.

NONTHERAPEUTIC COMMUNICATION TRAPS

  • Providing false reassurances.

  • Giving unsolicited advice.

  • Relying on authority.

  • Employing avoidance language.

  • Engaging in distancing language.

  • Using medical jargon excessively.

  • Leading or biased questioning.

  • Speaking too much or interrupting the patient.

  • Using “why” questions, which may provoke defensiveness.

SCREENING FOR VIOLENCE

Intimate Partner Violence (IPV)

  • Defined as any threat or evidence of physical or sexual violence, psychological abuse, or coercive tactics.

  • Nurses are mandatory reporters of suspected abuse or neglect to appropriate authorities.

Types of Elder Abuse

  • Physical Abuse: Physical violence perpetrated against the elderly.

  • Neglect: Failing to meet basic needs of an elder.

  • Emotional Abuse: Verbal/physical behavior causing distress.

  • Financial Exploitation: Unauthorized use of an elderly person's resources.

Health Effects of Violence

  • Physical: Injuries and chronic health issues such as neurological, gastrointestinal, or chronic pain conditions.

  • Mental Health: Potential development of depression, PTSD, and substance use disorders.

SCREENING AND DOCUMENTATION PROTOCOLS

  • Screening Frequency: Recommendations specify that all women over 14 receive IPV screenings at every healthcare encounter.

  • Documentation: Maintaining detailed, objective notes is critical in injury assessments, alongside photographic evidence where appropriate.

ASSESSMENT TECHNIQUES IN The Clinical Setting

Physical Assessment Techniques

  1. Inspection: Careful observation and comparison of both sides of the patient’s body under optimal lighting.

  2. Palpation: Involves using touch to evaluate characteristics like texture, size, and tenderness.

    • Two types: Light and deep palpation.

  3. Percussion: Tapping body areas to discern underlying structures based on sound characteristics.

  4. Auscultation: Listening to internal sounds with a stethoscope to identify abnormalities.

PREPARATION FOR EXAMINATION

General Guidelines

  • Ensure proper infection control techniques are in place, including hand hygiene and the use of clean equipment.

  • Facilitate an environment that ensures patient comfort, privacy, and adequate lighting.

Patient Interaction

  • Assist the patient in preparing for the examination, addressing their emotional state and comfort needs, and clearly explaining procedures and expected outcomes.

ASSESSMENT ACROSS AGE GROUPS

Special Considerations:

  • Children: Gather health history from adults; allow for play; use appropriate communication techniques.

  • Adolescents: Maintain confidentiality while engaging them respectfully as individuals.

  • Elderly: Avoid stereotypes; accommodate sensory limitations; provide adequate space; be patient and observant.

CLINICAL SETTING APPROACH

  • Emphasize an organized, step-by-step examination focusing on the patient’s general impressions while ensuring comfort during the assessment.