Health_assessment_reviewer

Health Assessment Reviewer

Nursing Process

• The Nursing Process is a systematic, rational method for planning and providing individualized nursing care.

• This process is cyclical; its components follow a logical sequence, although multiple components may be involved simultaneously.

• The term "Nursing Process" originated from the work of several theorists, including Lydia Hall (1955), Dorothy Johnson (1959), Ida Jean Orlando (1961), and Ernestine Wiedenbach (1963).

• These theorists were pioneers in formalizing the phases that describe nursing practice.

Phases/Steps of the Nursing Process

• Scope and Standards of Nursing Practice outlines six phases of nursing practice according to the American Nurses Association (ANA, 2010):

  • Assessment: Collection and analysis of data about the client's health status.

  • Diagnosis: Identification of client health problems based on the assessment data.

  • Outcome Identification: Defining expected outcomes for the client based on the diagnosis.

  • Planning: Developing a care plan with nursing interventions to meet the identified outcomes.

  • Implementation: Executing the nursing interventions outlined in the care plan.

  • Evaluation: Assessing the effectiveness of the care plan and modifying it as necessary.

• The national licensure examination for registered nurses (NCLEX) utilizes the five core phases:

  • Assessment

  • Diagnosis

  • Planning

  • Implementation

  • Evaluation

• Most nurses commonly use these five phases; however, terminology may vary among practitioners.

Assessment/Assessing

• The assessment phase involves a systematic and continuous process of collecting, organizing, validating, and documenting relevant data and information.

  • Steps involved include:

    • Collect Data: Gathering information pertinent to the client's health status.

    • Organize Data: Structuring collected data in a coherent manner.

    • Validate Data: Ensuring the accuracy of the information obtained.

    • Document Data: Recording data in a factual manner for future use.

Data Collection/Collect Data

• Data collection is crucial for evaluating the client’s health status, focusing on being systematic and continuous to ensure no significant information is overlooked, which reflects changes in the client's health.

Data Base

• This component contains all pertinent information regarding the client's health, including medical history, current medications, allergies, and past treatments.

Data Collection/Sources of Data

• Primary Sources: The client is the main source of data, providing direct information about their condition.

• Secondary Sources: These include family members, healthcare professionals, medical records, laboratory and diagnostic reports, and relevant literature, which serve as indirect sources of information.

Types of Data

• Subjective Data: Often referred to as symptoms, these are statements made by the client indicating their experiences, feelings, and perceptions.

• Objective Data: Known as signs, these are measurable or observable data collected during the physical examination or diagnostic tests.

Collection Methods

• The main methods to collect data include:

  • Observing/Observation: Noticing non-verbal cues and behaviors that contribute to understanding the client’s condition.

  • Interviewing/Interview: Engaging with the client to gather history and current information through structured or unstructured questions.

  • Examining/Examination: A physical assessment to gather objective data through inspection, palpation, percussion, and auscultation.

Validating Data

• This involves double-checking or verifying collected data to confirm its accuracy.

  • Cues: These are subjective or objective data directly observed by the nurse, which can lead to further questions or investigations.

  • Inferences: Conclusions drawn by the nurse based on observed cues, requiring clinical judgment.

Documentation

• Documentation aims to accurately describe collected data for accessible reference. Essential aspects include:

  • Ensuring all client health status data is recorded factually and comprehensively to provide a clear account of care and progress.

Diagnosis/DIAgnosing

• This phase is pivotal, utilizing critical thinking skills to interpret assessment data and determine the client's strengths and issues.

Taxonomy

• Taxonomy refers to the classification system used to categorize nursing diagnoses based on defined principles and relationships.

Definitions of Nursing Diagnosis

• Diagnosing: Represents the reasoning process that nursing professionals use to evaluate information.

• Diagnosis: A formal statement regarding the nature of a phenomenon based on collected data.

• Diagnostic Labels: Standardized names from NANDA International, used to classify nursing diagnoses.

• Nursing Diagnosis: The client’s problem statement, consisting of the diagnostic label and the etiology (the causal relationship between the problem and its associated factors).

Components of NANDA Nursing Diagnosis

• The nursing diagnosis has three major components:

  1. The Problem and Its Definition (Diagnostic Label): Identifies the client's health issue.

  2. The Etiology: The underlying cause or factors that contribute to the problem.

  3. The Defining Characteristics: Observable signs and symptoms validating the problem.

Differentiate Nursing Diagnosis from Medical Diagnosis

• Nursing Diagnosis: Represents nursing judgments about client needs and issues within the realm of nursing practice, addressing conditions that nurses are licensed to treat.

• Medical Diagnosis: A diagnosis made exclusively by a physician, relating to diseases or medical conditions that require a doctor's treatment.

Planning

• This is a deliberate and systematic part of the nursing process, with a focus on decision-making and problem-solving. Key concepts include:

  • Nursing Interventions: Evidence-based treatments guided by clinical judgment and knowledge aimed at achieving the best patient outcomes.

Types of Planning

• Initial Planning: The initial plan created after assessment to set short- and long-term goals.

• Ongoing Planning: Adjusting and modifying plans based on client progress and feedback.

• Discharge Planning: Preparing the client for post-discharge care, ensuring continuity and safety in care transitions.

Implementing

• This is the action phase where nursing interventions are performed, consisting of the following steps:

  1. Reassessing the Client: Continuously evaluating the client's status and needs.

  2. Determining the Nurse’s Need for Assistance: Recognizing when to seek help from other healthcare professionals.

  3. Implementing Nursing Interventions: Carrying out the planned interventions and treatments effectively.

  4. Supervising Delegated Care: Ensuring that care provided by other team members meets established standards.

  5. Documenting Nursing Activities: Accurately recording nursing actions taken during implementation.

Evaluation

• This phase is an ongoing activity designed to determine the client’s progress towards set goals and the overall effectiveness of the nursing care plan. This includes:

  • Reassessing outcomes and modifying plans and interventions as necessary based on client feedback and clinical observations.

Vital Signs

• Vital signs are fundamental reflections of the body’s physiological status, which include:

  • Body Temperature: Monitoring ensures the body maintains a normal range of temperature to indicate health status.

  • Pulse: Measures heart rate, influenced by factors such as age, gender, activity level, and medications.

  • Respiration: Assesses the act of breathing, including rate, depth, rhythm, and quality of breaths.

  • Blood Pressure: Measures pressure exerted by blood on artery walls, which can be affected by various factors including psychological state and physical condition.

  • O2/Oxygen Saturation: Indicates how well oxygen is being transported to the body's tissues.

Assessing Body Temperature

• Methods for measuring temperature include:

  • Mercury-in-glass thermometers

  • Electronic thermometers

  • Disposable thermometers

• Normal temperature range is established as 36º C (96.8 º F) to 37 º C (98.6 º F).

Assessing Pulse Rate

• The pulse rate is an important measurement of heart rhythm and beat, which can vary based on physical activity, emotional status, and health conditions accounting for relevant individual differences in readings.

Assessing Respiration

• Assessing respiration includes scrutinizing various aspects such as depth, rhythm, and the quality of breaths to provide an overview of respiratory health.

Blood Pressure

• Blood pressure is crucial for assessing cardiovascular health, with factors like age and emotional state affecting readings. Key conditions associated with blood pressure issues include:

  • Hypertension: Characterized by elevated pressure in the arteries, posing risks for heart disease and stroke.

  • Hypotension: Refers to reduced pressure, which may lead to fainting and can indicate health problems regarding circulation or blood volume fluctuations.