NRS 119 Health Assessment

Introduction to Health Assessment in Nursing

  • Overview of the course: NRS 119 Health Assessment

  • Topics Covered:

    • Evidence-Based Practice

    • Cultural and Health History Interviews

    • Vital Signs Assessment

    • Safety and Pain Assessment Techniques

    • Documentation Practices

Holistic Nursing Assessment vs. Physician Medical Assessment

  • Purpose of Nursing Health Assessment:

    • To collect both holistic subjective and objective data

    • Aim: To determine a client’s overall level of functioning and make professional clinical judgments

    • Data Types: Physiologic, Psychological, Sociocultural, Developmental, and Spiritual data

  • Physician Medical Assessment:

    • Focus: Primarily on the client’s physiologic status

    • Less emphasis on psychological, sociocultural, or spiritual well-being

The Nurse as a Lifelong Learner

  • Levels of Nursing Competency:

    • Novice

    • Advanced Beginner

    • Competent

    • Proficient

    • Expert

Data Collection in Nursing Assessment

  • Database Formulation:

    • Required Elements: Subjective Data + Objective Data + Patient’s Record + Laboratory Studies

    • Importance of organization in assessment based on complete factual data

Nursing Process Overview

  • Steps of Nursing Process:

    1. Assessment: Collecting subjective and objective data

    2. Diagnosis: Analyzing data to make a nursing judgment (nursing diagnosis, collaborative problem, or referral)

    3. Planning: Determining outcome criteria and developing a plan

    4. Implementation: Carrying out the plan

    5. Evaluation: Assessing achievement of outcome criteria and revising plan as necessary

  • Importance of Critical Thinking in the Diagnostic Process

Case Study: Mrs. Jones

  • Patient Profile:

    • Mrs. Jones, 56 years old, admitted for shortness of breath

    • Vital Signs: BP 140/89, HR 90, RR 24, O2 at 98% on room air

    • Reported pain: 2/10

    • Observations: Lung sounds clear, heartbeat regular, slightly faster breathing

    • Emotional Status: Tearful, stressed about financial troubles

    • Health History: Includes anxiety and depression; labs within normal limits

Hypothetico-Deductive Model Components

  • Initial steps:

    • Attend to cues (deviations from expected findings)

    • Formulate diagnostic hypotheses

  • Data Collection:

    • Continuous evaluation of hypotheses with ongoing data collection

    • Adjustments required as new data is collected

Priority Problem Levels in Nursing

  • First-level Priority:

    • Emergent, life-threatening issues needing immediate attention

  • Second-level Priority:

    • Urgency requiring action to avoid deterioration

  • Third-level Priority:

    • Important for health, but can wait until more urgent problems are addressed

  • Collaborative Problems:

    • Treatment involves multiple disciplines

Types of Patient Data

  • Complete Total Health Database:

    • Comprehensive assessment using complete health history and physical exam

  • Episodic/Problem-Centered Database:

    • Mini database focusing on one body system or cue complex

  • Follow-up Database:

    • Regular evaluation of identified health problems

  • Emergency Database:

    • Rapid collection of data during lifesaving measures

Holistic Model Assessment

  • Emphasizes the impact of

    • External and interpersonal environments on mental and physical health

    • Lifestyle, behavior, culture, values, and stressors

Communication in Assessment

  • Interviewing Process:

    • Phases of the Interview

    • Importance of verbal and non-verbal communication

  • Common Interview Traps:

    • False assurance, unwanted advice, authority language, avoidance language, jargon, leading questions, excessive talking, interruptions, and “why” questions

Complete Health History Sequence

  • Elements of a thorough health history:

    • Reason for seeking health care

    • History of present concern (using COLDSPA: Characteristics, Onset, Location, Duration, Severity, Pattern, Associations)

    • Past health history

    • Medication and allergy history

    • Family health history

    • Review of systems

    • Functional assessment (Activities of Daily Living)

    • Perception of health

Pain Assessment Techniques

  • Types of Pain:

    • Acute: Short term, self-limiting

    • Chronic: Lasting over 6 months

    • Breakthrough: Transient pain spike

  • Assessing Pain:

    • Questions regarding location, duration, quality, intensity, aggravating/relieving factors

    • Effects of pain on quality of life

Pain Rating Scales

  • Purpose:

    • Reflect pain intensity, track changes, evaluate treatment modalities

  • Types of Scales:

    • Numeric scale (0-10)

    • Visual analog scale (marking on a line from no pain to worst pain)

Physical Assessment Techniques

  • General Survey:

    • Study of the whole person: health state, physical characteristics

  • Positioning:

    • Sitting, supine, dorsal recumbent, Sims, standing, prone, knee-chest, lithotomy

  • Assessment Techniques: follow order of IPPA (Inspection, Palpation, Percussion, Auscultation) for most body parts, IAPP for the abdomen

Inspection

  • Use of vision and smell to observe the patient

  • Focus on characteristics: color, patterns, size, location, consistency, symmetry, movement, odor, sounds

Palpation and Percussion

  • Palpation:

    • Sense of touch to confirm findings; light to deep palpation techniques discussed

  • Percussion:

    • Striking an object to produce sounds for assessing pain, location, size, shape, density

Auscultation

  • Listening to body sounds; equipment like stethoscope and Doppler used

  • Techniques to mitigate noise (e.g., eliminating background noise)

Validation of Data

  • Importance of verifying subjective and objective data

  • Steps:

    • Identify discrepancies

    • Methods for validation: repeat assessment, clarify with client, verify with professionals

Documentation in Nursing

  • Importance of patient-specific, accurate charting

  • Formats: SOAP and SBAR for effective summary of patient progress

  • Purposes of Documentation:

    • Comply with legal, accreditation, reimbursement requirements

    • Keep track of care provided, support eligibility for reimbursement

    • Establish basis for validating new diagnoses and educational needs

SBAR Communication

  • Components:

    • Situation: Specific patient issue

    • Background: Context and assessment data

    • Assessment: Nurse’s interpretation of data

    • Recommendation: Suggested physician orders

Electronic Health Records

  • Benefits of digital documentation for meaningfully enhancing patient safety and quality of care

  • Ensures timely updates and efficient communication of patient data

Conclusion

  • Comprehensive overview of conducting a nursing health assessment

  • Emphasis on the importance of critical thinking, thorough data collection, and effective communication in patient care.