NURSES’ ROLE IN

H E A LT H A S S E S S M E N T
“Nursing is the protection, promotion and optimization of health and
abilities, prevention of illness and injury, alleviation of suffering through
the diagnosis and treatment of human responses and advocacy in the
care of individuals, families, communities and populations.”

- American Nurses Association, 2010

NURSING SCOPE AND
STANDARDS OF PRACTICE
STANDARD 1

“The registered nurse collects comprehensive data pertinent to the

patient’s health or situation.”

- American Nurses Association, 2010

 THE NURSE:
• Collects in a systematic and ongoing process

• Involves the patient, family, other health care providers and environment,
as appropriate, in a holistic data collection

• Prioritizes data collection activities based on the patient’s immediate

condition, or anticipated needs of the patient or situation
 THE NURSE:
• Use appropriate evidence-based assessment techniques
and instruments in collecting pertinent data

• Uses analytical models and problem- solving tools

• Synthesizes available data, information, and knowledge

relevant to the situation to identify patterns and
variances
THE NURSE:
• Document relevant data in a retrievable format
STANDARD 2

“The registered nurse analyzes the assessment data to determine the

diagnoses or issues”.

- American Nurses Association, 2010

THE REGISTERED NURSE:

• Derives the diagnosis or issues based on assessment data

• Validates the diagnoses or issues with the client, family and other
healthcare providers when possible and appropriate.
THE REGISTERED NURSE:

• Documents diagnoses or issues in a manner that facilitates the

determination of the expected outcomes and plan.
THE NURSE’S ROLE IN HEALTH
ASSESSMENT
• The nurses’ role in health assessment has changed significantly over
the years.
ü Acute Care Nurses
ü Critical Care Outreach Nurses
ü Ambulatory Care Nurses
ü Home Health Nurses
ü Public Health Nurses
ü School Nurses
ü Hospice Nurses
EVOLUTION OF THE NURSE’S
ROLE IN HEALTH ASSESSMENT
• Late 1800’s – Early 1900’s

– Nurses relied on their natural senses: the client’s face

and the body would be observed for “changes in color,
temperature, muscle strength, use of limbs, body
output, and degrees of nutrition, and hydration”
(Nightingale, 1992).
• Late 1800’s – Early 1900’s

– Palpation was used to measure pulse rate and quality and to locate the
fundus of the puerperal woman
• Late 1800’s – Early 1900’s

– Examples of independent nursing practice using inspection, palpations

and auscultations have been recorded in Nursing journal. It includes
gastrointestinal palpation, testing eight cranial nerve function, and
examination of children in school systems.
• 1930- 1949

– Routine client and home inspection by public health nurses in the 1930s
(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 the Red Cross
• 1950- 1969

– Nurses were hired to conduct pre-employment health stories and

physical examinations for major companies, such as New York Telephone
• 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 heath histories and physical and psychological
assessments
• 1990- present

– Over the last 20 years, the movement of health care from the acute care
setting to the community and the proliferation of the baccalaureate and
graduate education solidified the nurse’s role in holistic assessment
• 1990- present

– Documentation was a major demand

– Critical pathways or care maps were develop to guide client’s
progression
– Advance practice nurses have been increasingly used in the hospital
• There is a tremendous growth of the nursing role in the managed
care environments.
 FACTORS THAT WILL PROMOTE
OPPORTUNITY FOR NURSES WITH
ADVANCE ASSESSMENT SKILLS:
• Rising educational costs and focus on primary care that affect the numbers
and availability of medical students

• Increasing complexity of acute care

 FACTORS THAT WILL PROMOTE
OPPORTUNITY FOR NURSES WITH
ADVANCE ASSESSMENT SKILLS:
• Growing aging population with complex comorbidities

• Expanding health care needs of single parents

 FACTORS THAT WILL PROMOTE
OPPORTUNITY FOR NURSES WITH
ADVANCE ASSESSMENT SKILLS:
• Increasing impact of children and the homeless on communities

• Intensifying mental health illness

 FACTORS THAT WILL PROMOTE
OPPORTUNITY FOR NURSES WITH
ADVANCE ASSESSMENT SKILLS:

• Expanding health service networks

• Increasing reimbursement for health promotion and preventive care

services
 PHASES OF NURSING
PROCESS
PHASE TITLE DESCRIPTION

I Assessment Collecting subjective and objective data

II Diagnosis Analyzing subjective and objective data to
make a professional nursing judgment
III Planning Determining outcome criteria and
developing a plan
IV Implemen- Carrying out plan
tation
V Evaluation Assessing whether outcome criteria have
been meet and revising the plan as
necessary
• Assessment is the most critical phase of the process. If the data
collection is inadequate or inaccurate, incorrect nursing judgment may
be made that adversely affect the remaining phases of the process.
HEALTH ASSESSMENT IS

• more than just gathering information about the health status of the
client. It is analyzing and synthesizing the data, making judgment about
the effectiveness of nursing interventions and evaluating client care
outcomes. The nursing process should be thought of as circular, not
linear.
THE NURSING PROCESS

PLANNING

DIAGNOSIS INTERVENTION/
IMPLEMENTATION

ASSESSMENT EVALUATION
 FOCUS OF HEALTH
ASSESSMENT
The purpose of health assessment is to collect subjective and
objective data to determine a client’s overall level of functioning in
order to make a professional clinical judgment.
THE NURSE COLLECTS:

• Physiologic
• Psychologic
HOLISTIC DATA
• Sociocultural
COLLECTION
• Spiritual
• Developmental
FRAMEWORKS FOR HEALTH
ASSESSMENT
• Questions are broken down into four sections:
– History of Present Health Concern
– Personal Health History
– Family History
– Lifestyle and Health Practices
TYPES OF HEALTH ASSESSMENT

• Initial Comprehensive Assessment

• Ongoing or Partial Assessment
• Focused or Problem- Oriented Assessment
• Emergency Assessment
PREPARING FOR HEALTH
ASSESSMENT
1. Review client’s medical record
• Knowing the client’s biographical data
– Age
– Gender
– Religion
– Educational level
– Occupation
– Previous and Current Health Status
– Behaviors and ADLs

• Medical record, other members of the healthcare and significant others can
be the sources of these data
2. Keep an open mind and avoid premature judgment

3. Use this time to educate yourself about the client’s diagnoses or test
performed
4. Once you have gathered the basic information, take a minute to
reflect on your own feeling regarding your initial encounter with the
client
5. Obtain and organize materials/ equipments that you will need for
assessment
INITIAL COMPREHENSIVE
ASSESSMENT
• Collection of Subjective Data
– Client’s perception oh his or her health, past health history, family
history, and lifestyle and health practices
INITIAL COMPREHENSIVE
ASSESSMENT
• Objective data
– Using Diagnostic procedures
– Physical examination
ONGOING OR PARTIAL
ASSESSMENT
• An ongoing or partial assessment of the client consists of data
collection that occurs after the comprehensive database is established.
This consists of a mini- overview of the client’s body systems and
holistic health patterns as a follow-up on health status.
• A client admitted with lung cancer requires frequent assessment of
the lung sounds, A total assessment of the skin would be performed
less frequently, with the nurse focusing on the skin color and
temperature of the extremities to determine the level of oxygenation
FOCUSED OR PROBLEM
ORIENTED ASSESSMENT
• A focused assessment consist of a thorough assessment of a
particular client problem and does not cover areas not related to the
problem.
EMERGENCY ASSESSMENT

• Performed in life-threatening situation

• Choking
• Cardiac Arrest
• Drowning
• An immediate assessment is needed to provide prompt intervention
• The major and only concern during this type of assessment is to
determine the status of the client’s life-sustaining physical functions.
STEPS OF HEALTH ASSESSMENT

1. Collecting Subjective Data

2. Collecting Objective Data
3. Validation of Data
4. Documentation of Data
COLLECTING SUBJECTIVE
DATA
• Subjective data are sensations and
symptoms (pain, hunger), feelings
(happiness, disappointments),
perceptions, desires, preferences,
beliefs, ideas, values and personal
information.
• Can be verified only by the CLIENT
THE MAJOR AREAS OF
SUBJECTIVE DATA INCLUDE:
• Biographical information
• Hx of present concern
• Personal health hx
• Family hx
• Health and lifestyle practices
COLLECTING OBJECTIVE
DATA
• The examiner directly observes objective data
– Physical characteristics
– Body functions
– Appearance
– Behavior
– Measurements
– Results of laboratory testing
• This type of data is generally obtained by general observation and by
the use of IPPA. Another source could be medical/ health record and
observations noted by the SO and other members of the HCT.
VALIDATING ASSESSMENT
DATA
• This is a crucial part of assessment that often occurs during the
assessment of subjective and objective data
COMPARING SUBJECTIVE
AND OBJECTIVE DATA
• Description
• Sources
• Methods used to obtain data
• Skills needed to obtain data
1. 2-3 pus cells 5. 300 Hematocrit level
2. I am upset 6. 120/ 80 mmHg
3. 120 bpm 7. I am in pain
4. 23 cpm 8. The patient is disoriented
[Link] colored urine
10. My wife did not sleep well last night
DOCUMENTING DATA

• This is an important step because it provides a database/ baseline for

the entire nursing process and provides data for all other members of
the HCT.
ANALYSIS OF ASSESSMENT
DATA/ NURSING DIAGNOSIS
• During this phase, you analyze and synthesize data to determine
whether the data reveal a nursing concern, collaborative concern or a
concern that need to be refereed to other health care institutions
• A nursing diagnosis is defined by NANDA as a “clinical judgments
about individuals, family or community responses to actual and
potential health problems and life processes…”
• “….A nursing diagnosis provides the basis for selecting nursing
intervention to achieve outcomes for which the nurse is accountable”
PROCESS OF DATA ANALYSIS

1. Identify abnormal data or strengths

2. Cluster the data
3. Draw inferences and identify problems
4. Propose possible nursing diagnoses
5. Check for defining characteristics of those diagnoses
6. Confirm or rule out nursing diagnosis
7. Document conclusions
THANK YOU J