Health Assessment

HEALTH ASSESSMENT It is the orderly collection of objective information about the clients health status (objective data are
re observable, measurable, and verifiable by more than one person) It is the foundation of all nursing care (physical assessment is part of every holistic health evaluation.)
ASSESSMENT First and most critical phase of nursing process A complete yet organized assessment is obtained by using a combination of head to toe and body systems approach. The nurse is responsible for assessing the patient for any problems or needs; determining when those findings require the attention of a nurse, physician, or other professional; notifying the appropriate persons of the assessment findings; and ensuring follow up for the patient. Assessment involves the collection of data about the system (individual, family, or community). Data is collected by way of interview, physical examination, research, and review of records. The complete body of information about the patient is called the patient data base At times, it may be necessary to perform a focus assessment instead of a complete assessment. For example, you may be ambulating a patient and he may complain about being constipated. You won't want to collect a complete history and physical at this time because that has already been done. However, you would want to focus on the problem of constipation and find out how long it has been going on, the last bowel movement, the characteristics of the bowel movement, any pain the patient may be having, what factors contributed to the constipation, the client's diet and fluid intake, and his usual treatment for constipation.
PURPOSES Collect subjective and objective data to determine a clients overall level of functioning in order to make a professional clinical judgment. Collect physiologic, psychological, socio- cultural, developmental and spiritual data of the client. Focuses on how the client health status affects his activities of daily living and vise versa.
What is nursing process? Nursing process >A cyclical process that nurses use to identify; analyze; plan; and evaluate the strengths, weaknesses, and needs of the focus system whether it is an individual, family, group, or community. >The nursing process provides a means of applying the knowledge and skills required of nurses >For students, it provides guidance in learning "how to think" like a nurse and applying the magnitude of knowledge gained through classroom education. > For practicing nurses, it provides for a consistent standard of care and communication between colleagues.
PHASES OF NURSING PROCESS Phase I II Title Assessment Diagnosis Description > Collecting subjective and objective data > Analyzing subjective and objective data to make a Professional nursing judgment-nursingnursing diagnosis, Collaborative problem or referral) > Determining outcome criteria and developing a plan. > Carrying out the plan. > Assessing whether outcome criteria have been met and revising the plan as necessary
III IV V
Planning Implementation Evaluation
The Nursing Process involves five steps that correlate with the problem solving method 1. Assessment - The collection of information or data necessary to determine the patient's health status and understand to understand the patient= strengths and problems more clearly. (Gathering the pieces of the puzzle). 2. Diagnosis After gathering the information it is analyzed to identify strengths and actual and potential problems. 3. Planning - A plan of care is developed in cooperation with the patient and significant others. The plan of care is aimed at reducing or eliminating the problems and promoting health. To plan, priorities must be set, expected outcomes must be established, and you must determine what interventions will help achieve the expected outcomes that you have established. You also determine who needs to be involved and how and when the interventions will be done. 4. Implementation - Your plan of care is put into action. During implementation, you assess the patient's current status to see if his/her plan is still appropriate or whether there are new problems. The interventions and activities are then performed and you continue to assess the patient to see of there is any response or whether the intervention made a difference. Finally, you report any data that requires additional treatment, e.g., physician consultation, and record the nursing actions, patient response, and other significant assessment data.
5. Evaluation - During evaluation you and the patient determine whether the plan has worked and whether changes need to be made. Have any new problems developed? Are there new priorities? Have the expected outcomes been achieved? Should new expected outcomes be set? Have the goals been partially met or not at all? Why? Were the goals realistic? Was the assessment accurate? Did other problems get in the way? What changes are you going to make?
FOUR DIVISION OF HEALTH ASSESSMENT 1. 2. 3. 4. Present health history Past health history Family history Lifestyle and health practiced
PHYSICAL ASSESSMENT INCLUDES: 1. Procedure 2. Normal findings of the body system 3. Abnormal findings of the body system Nursing Health assessment result: 1. 2. 3. 4. Formulation of nursing diagnosis (wellness, risk or actual) that require nursing care. Identification of collaborative problems that require nursing care. Identification of collaborative problems that requires interdisciplinary care. Identification of medical problems that require immediate referral.
Types of Assessment 1. 2. 3. 4. Initial comprehensive assessment Ongoing or partial assessment Focus or problem oriented assessment Emergency assessment
1. Initial comprehensive assessment

Involves collection of subjective data about the clients perception of her health of all body parts or systems, past health history, family history and health practices. Involves objective data gathered during step-by-step physical examination. Regardless of who collects the data, total health assessment (subjective and objective data) is needed when the client enters a health care system to establish Baseline data against to which future health status changes can be measured and compared.

Health Assessment

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HEALTH ASSESSMENT It is the orderly collection of objective information about the clients health status (objective data are

Planning Implementation Evaluation

1. Initial comprehensive assessment

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