Health Assessment

Week - 1

y
Melinda L. Gonzales MAN RN
 Overview of Nursing Process (ADPIE),
Health Assessment in Nursing Practice, &
Nurses Role in Health Assessment
DEFINITION OF
NURSING
Nursing is both A SCIENCE
and an ART that is concerned
Nursing is the
diagnosis and with the individual’s:
treatment of human 1.Physical
responses to health 2.Psychological
and illness – ANA 1995 3.Sociological
4.Cultural
5.Spiritual
4 ESSENTIALS FEATURES OF THE
NURSING PRACTICE - ANA 1995
1. Full range of human experiences and
responses to health and illness w/o
restriction to a problem focused
orientation (attention)
2. Caring relationship that facilitates
health and healing
3. Understanding and integration of
objective data based on the client’s
subjective experience
4. Knowledge (scientific) for diagnosis and
treatment
 Health Assessment is:
• The first step of the Nursing Process.
• The most important because it directs the rest of
the process
• A thinking, doing, and feeling process – think as
you act and interact with patients
• think critically as you go with the process
• A skill
• learning the normal
• identify the normal and differentiate it from the
abnormal
The Nursing Process
cont.

- Is a systematic, organized method of planning,

and providing quality and individualized nursing
care.

- It is synonymous with the Problem Solving

Approach that directs the nurse and the client to
determine the need for nursing care, to plan and
implement the care and evaluate the result

5
The Nursing Process
cont.
- The Nursing Process is a systematic
Problem Solving Approach where diagnosis
and treatment are achieved
- It is a G O S H approach for efficient and
effective provision of nursing care.
- G - goal
oriented
- O - organized
- S - systematic
- H – humanistic 6
5 steps of the Nursing Process
assessment diagnosis

evaluation
planning
intervention
7
 1. Assessment
Identifies
your
patient’s
strengths
Sets the
and
tone for the
Systematic The most limitations
rest of the
and is
collection important process, and
performed
of data step the rest of
not just
the process
once, but
flows from it
continuously
throughout
the nursing
process 8
2. Diagnosis
A. Clinical judgment
concerning a human
response to health
conditions / life
processes, or
B. Analysis of data to
vulnerability for that
identify the problem
response by an
individual, family or
community that the
nurse is licensed and
competent to treat
C. Formulating a nursing diagnosis involves
identifying and prioritizing actual or
potential health problems or responses.
a.An actual nursing diagnosis identifies an
occurring health problem for your patient.
b.A potential nursing diagnosis identifies a
high-risk health problem that most likely will
occur unless preventive measures are taken.
c.A possible nursing diagnosis is one that
needs further data to support it
D. Types of Nursing Diagnosis
1. Problem – focused Nursing Diagnosis

a. Problem + Etiology + Signs and Symptoms

b. Example:
“Acute pain related to trauma of surgical incision
as evidenced by facial grimace and guarding
behavior”

“Ineffective Airway clearance related to seizure

activity as manifested by increase oral secretion.”
2. Risk Nursing Diagnosis
a. Problem + Etiology
b. Example
“Risk for infection related to surgical incision”

“Risk for Bleeding related to trauma from abortion”

3. Health Promotion Nursing Diagnosis
a. Problem: Grieving, Hopelessness
b. Example:
“Readiness for enhanced Knowledge: expresses an
interest in learning”
“Readiness for enhanced decision-making as
evidenced by participation in healthcare decisions”
4. Syndrome Nursing Diagnosis
• Specific cluster of nursing diagnosis that
occur together and have similar nursing
interventions to resolve the situation
• Chronic pain syndrome as manifested by
anxiety and disturbed sleep pattern.
• Defining Characteristics (Signs and
Symptoms)
Observable assessment cues such as patient
behavior, physical signs
• Related Factor (Etiology)
• Etiological cause or causative factor for
3. Planning
- Desired outcomes

- Appropriate interventions

- Involves setting goals and outcomes

- Individualized plan of care for your

patient is ready once diagnosis have
been prioritized
Planning con

- Priority Setting
- Ordering of nursing diagnoses or patient
problems using notions of urgency and
importance to establish a preferential order for
nursing interventions

- Goals
- Broad statement that describes a
desired change in a patient’s condition,
perceptions or behavior
-Types of Goals

a. Long Term Goals:

- objective behavior or response that you
expect a patient to achieve over a longer period,
usually over several days, weeks or months

b. Short Term Goals:

- objective behavior or response that you
expect the patient to achieve in short time
usually few hours or less than a week
Planning should be:
specific
SMART
measurable

attainable

realistic

Time-bound
4. Intervention
-Defined as any treatment based on clinical
judgment and knowledge that a nurse performs
to enhance patient outcomes.
-Putting the plan of care into action
-Also called Implementation
-Involves carrying out your plan to achieve goals
and outcomes
-The “doing” phase
-Approach in intervention
a. Direct Care
- Direct intervention
- Interventions are treatment performed
through interaction with patient
- Ex. Giving medication, V/S checking,
insertion of IFC
b. Indirect Care
- Interventions are treatments performed
away from a patient but on behalf of the patient or
group of patient
- Ex. Safety and Infection control
Types of Intervention:
1. Independent
- Action that the nurse initiates without
supervision or direction from others
2. Dependent
- Actions that require an order from a health
care provider or the attending physician.
3. Collaborative
- Interdependent interventions
- Therapies that require the combined
knowledge, skills, and expertise of multiple
health care providers
5. Evaluation
-Final step of the nursing process
-Crucial to determine if the patient’s condition
improved or worsen after application of the
first four steps of nursing process
-Monitoring of clients progress
-Alter the plan as indicated
-Involves determining the effectiveness of
your plan.
-Once again, assess your patient’s response
based on the criteria you set for the outcome.
⊚ The Nurse Must assessment
Take Note:

- The steps of the

nursing process are evaluation diagnosis
interrelated forming
a continuous circle
of thought and
action that is both
dynamic and cyclic.
intervention planning

23
 Characteristics of the
Nursing
Dynamic ProcessPatient
and cyclic
centered
Goal directed Flexible
Problem oriented
Cognitive
Action oriented
Interpersonal
Holistic 24
Purposes Of The Nursing Process

1. To identify a client’s health status; his

Actual/Present and potential/possible health
problems or needs.

2. To establish a plan of care to meet identified

needs.

3. To provide nursing interventions to meet

those needs.
NURSING

ASSESSMEN
T
DEFINITION OF ASSESSMENT

• Assessment is the deliberate

and systematic collection of data to
determine a client’s current and
past health status and functional
status and to determine the client’s
present and coping patterns.
 A. Initial Nursing
4 Different Assessment
B. Ongoing or Partial
Types of Assessment
Nursing C. Focused or Problem
Assessment Oriented Assessment
D. Emergency Assessment
1. INITIAL COMPREHENSIVE ASSESSMENT
Known as “TRIAGE”
The nurse typically collects both subjective data and
objective data
Also involves collection of subjective data about the
client’s perception of his or her health of all body parts or
systems, past health history, family history, and lifestyle
and health practices.
Time Performed:
Performed within a specified time after admission to a
healthcare agency
Purposes:
To establish a complete database for problem
identification, reference, and future comparison
Example:
2. ONGOING OR PARTIAL ASSESSMENT
• Consists of data collection that occurs after the
comprehensive database is established.
• Consists of a mini-overview of the client’s body systems
and holistic health patterns as a follow-up on health
status.
• Any problems that were initially detected in the client’s
body system or holistic health patterns are reassessed
to determine any changes (deterioration or
improvement) from the baseline data.
• This type of assessment is usually performed whenever
the nurse or another health care professional has an
encounter with the client.
• The frequency of this type of assessment is determined
3. FOCUSED OR PROBLEM-ORIENTED ASSESSMENT
• A focused or problem-oriented assessment does not
replace the comprehensive health assessment.
• It is performed when a comprehensive database
exists for a client who comes to the health care
agency with a specific health concern.
• A focused assessment consists of a thorough
assessment of a particular client problem and does
not cover areas not related to the problem.
• Ex: Problem is Pain
- ask questions the character, location of pain, onset,
relieving and aggravating factors, and associated
symptoms.
4. Emergency Assessment
• An emergency assessment is a very rapid
assessment performed in life-threatening situations.
• In such situations (choking, cardiac arrest,
drowning), an immediate assessment is needed to
provide prompt treatment.
• An example of an emergency assessment is the
evaluation of the client’s airway, breathing, and
circulation (known as the ABCs) when cardiac arrest
is suspected.
• The major and only concern during this type of
assessment is to determine the status of the client’s
life sustaining physical functions.
NURSE’S ROLE IN HEALTH
ASSESSMENT
• The acute care
nurse performs a
focused assessment,
and then incorporates
assessment findings
with a
multidisciplinary team
to develop a
comprehensive plan of
care.
• Critical care outreach
nurses need enhanced
assessment skills to safely
assess critically ill clients
who are outside the
structured intensive care
environment (Coombs &
Moorse, 2002).

• Ambulatory care nurses

assess and screen clients
to determine the need for
• Home health nurses
make independent nursing
diagnoses and referrals for
collaborative problems as
needed.

• Public health nurses

assess the needs of
communities, school
nurses monitor the growth
and health of children, and
hospice nurses assess the
EVOLUTION OF THE NURSE’S ROLE
IN HEALTH ASSESSMENT
LATE 1800s–EARLY 1900s
• Nurses relied on their natural
senses; the client’s face and
body would be observed for
“changes in color,
temperature, muscle strength,
use of limbs, body output, and
degrees of nutrition, and
hydration”was
• Palpation (Nightingale,
used to measure pulse rate and quality
1992).
and to locate the fundus of the puerperal woman
(Fitzsimmons & Gallagher, 1978).
1930–1949
• The American Journal of Public
Health documents routine
client and home inspection by
public health nurses in the
1930s.
• This role of case finding,
prevention of communicable
diseases, and routine use of
assessment skills in poor
inner-city areas was
performed through the
Frontier Nursing Service and
1950–1969
• Nurses were hired to
conduct pre-
employment health
stories and physical
examinations for major
companies, such as New
York Telephone, from
1953 through 1960
(Bews & Baillie, 1969;
Cipolla & Collings,
1971).
1970–1989
• The early 1970s prompted
nurses to develop an active
role in the provision of
primary health services and
expanded the professional
nurse role in conducting
health histories and physical
and psychological
assessments (Holzemer,
Barkauskas, & Ohlson, 1980;
Lysaught, 1970).
• Acute care nurses in the
1980s employed the “primary
1990–PRESENT
• In the 1990s, critical
pathways or care maps
guided the client’s
progression, with each stage
based on specific protocols
that the nurse was
responsible for assessing and
validating.

• Advanced practice nurses

have been increasingly used
in the hospital as clinical
nurse specialists and in the
References:
Weber, J.R., and Kelley, J. H., (2021) Health Assessment in Nursing 7th Edition,
Philadelphia: Wolters Kluwer
D’Amico, D., and Barbarito, C., (2019) Health & Physical Assessment in
Nursing 3rd Edition, Singapore: Pearson Education, Inc.
https://www.registerednursern.com/head-toe-assessment-nursing/
https://www.ahrq.gov/sites/default/files/publications/files/health-assessments_
0.pdf
Week – 1: Assessment Task (20 pts)
PROBLEMS:
a. Diarrhea d. Insomnia
b. Allergy e. Abdominal pain
c. Overweight

1. Choose 1 from above .

• Formulate a Nursing care Plan
• Generate Nursing Diagnosis using:
a. Problem- Focused Nursing Diagnosis

2. Submission will be on Feb. 06, 2025.

Name: Block:
Assessment Nursing Diagnosis Planning Implementation Evaluation
Subjective: Problem- Focused Short Term Goals: Independent:
Nursing Diagnosis

Objective: Long Term Goals: Dependent:

Collaborative:
Thank You