HEALTH-ASSESSMENT-module-1.pptx

•In humans, it is the
ability of individuals
and communities to
adapt and self-
manage when facing
physical, mental or
social changes.
•A state of complete
physical, mental and
social well-being and
not merely the
absence of disease or
infirmity- WHO, 1947

ASSESSMENT:
•A systematic, dynamic process by which the
nurse through interaction with client,
significant others and healthcare providers,
collects and analyze data about the client
- American Nurses
Association

• an organized systematic assessment of human body which
involves the use of one’s senses to determine the general
physical and mental conditions of the body by collecting
both subjective and objective data.
Indications:
On admission
Health camps
On discharge
Before and after diagnostic procedure
On follow ups

• Establish a database for the clients normal abilities,
risk factors, and any current alterations in functions.
• To get a clear picture of a client’s health status and
health related problems.
• To identify cause and extend of disease.
• To identify the problem at early stage.
• To determine the nature of treatment required for the
patient.
• To get a holistic view of the client.

Continuation….
• To contribute in medical research.
• To identify client’s strength, weakness, knowledge,
attitude, motivation, support systems and coping
skills.
• To build rapport with patient and family.
• To identify need for health teaching.
• To compare clients’ health status with an ideal status.

NURSING PROCESS
The cornerstone of the Nursing profession
• Defined as a systematic problem-solving approach
towards giving individualized nursing care. OR
• Is a systematic method that directs the nurse and
patient as together they accomplish the following:
(1) Assess the patient to determine the need for nursing
care; (2) determine nursing diagnosis for actual and
potential health problems; (3) identify expected
outcomes and plan care; (4) implement the care; and (5)
evaluate the results.

NURSING PROCESS - THE ESSENTIAL CORE OF
PRACTICE FOR THE NURSE TO DELIVER HOLISTIC,
PATIENT-FOCUSED CARE.
Assessment (gather subjective and objective data, family history,
surgical history, medical history, medication history, psychosocial history)
Analysis or diagnosis (formulate a nursing diagnosis by using clinical
judgment; what is wrong with the patient)
Planning (develop a care plan which incorporates goals, potential
outcomes, interventions)
Implementation (perform the task or intervention)
Evaluation (was the intervention successful or unsuccessful)

• Systematic: nursing process has an ordered sequence of precise and
accurate activities. Preceding activities influence activities following
them.
• Dynamic: provides active interaction and integration among activities.
Current activity is necessary to influence future activities.
• Interpersonal: ensures that nurses are client-centered rather than
task-oriented. The nursing process encouraged nurses to work and
help clients use their strength to meet their own needs.
• Goal-directed: Np is a means for nurses and clients to work together
in order to identify specific goals related to wellness promotion,
disease and illness prevention, health restoration, and coping with
altered functioning.
• Universally-applicable: allows nurses to practice nursing with well or
sick people, young or old, regardless of race, creed or religion.

NURSING ASSESSMENT-
(what data is collected?)
• Is the collection of data for nursing purposes.
Information is collected using the skills of
observation, interviewing, physical examination, and
intuition and from many sources, including clients,
their family members or significant others, health
records, other health team members.

TYPES OF ASSESSMENT
1. Initial Assessment:
Aim: initial identification of normal function, functional
status, and collection of data concerning actual or
potential dysfunction.
Baseline for reference and future comparison.
Time Frame: within the specified time frame after
admission to a hospital, nursing home, ambulatory
health center.
E.g.: admission assessment
2. Comprehensive Health Assessment: includes

3. Focus Assessment or Ongoing Assessment:
Aim: status determination of a specific problem
identified during previous assessment. To identify new
or overlooked problems.
Time Frame: ongoing process, integrated with nursing
care, a few minutes to a few hours between
assessments.
E.g.: Hourly fluid input and output assessment

4. Time-Lapsed Reassessment:
Aim: comparison of client’s current status to baseline obtained
previously, detection of changes in all functional health patterns after
an extended period of time has passed.
Time Frame: several months (3,6,9 months or more) between
assessment.
E.g.: Reassessment clients’ functional health patterns in home care or
OPD setting
5. Emergency Assessment:
Aim: identification of life-threatening situation
Time Frame: at anytime
E.g.: ABC assessment in Cardiac Arrest
Assessment of suicidal attempt on violence

ASSESSMENT SKILLS
1- OBSERVATION
comprises more than the nurse’s ability to see the
client, nurses also use the senses of smell, hearing,
touch, and rarely, the sense of taste. Observation
includes looking, watching, examining. Observation
begins the moment the nurse meets the client. It is a
conscious, deliberate skill that is developed through
efforts and with an organized approach.
2 Aspects:
a. noticing the data
b.selecting, organizing, and interpreting the

2- INTERVIEW
a planned communication or a
conversation with a purpose, for
example to get or give information,
identify problems of mutual concern,
evaluate change, teach, provide
support.
3- Physical Examination Technique
a systematic data collection
method that uses the senses of sight,
hearing, smell, and touch to detect
health problems.

4- INTUITION
-use of insight, instinct, and clinical experience
to make clinical judgements about the client.
Intuition plays a role in the nurse’s ability to
analyze cues rapidly, make clinical decisions,
and implement nursing actions even though
assessment data may be incomplete or
ambiguous.
It is a process based on knowledge and
care experience and has a place beside
research-based evidence. Nurses integrate both
analysis and synthesis of intuition alongside
objective data when making decisions. Nurses

ASSESSMENT ACTIVITIES
1. Collect Data: process of compiling information about the
client, begins with the first client contact.
2. Validate Data: referred to as double checking the information
at hand, is the process of confirming the accuracy of
assessment data collected. Validation assists in verifying and
clarifying cues and inference.
3. Organize Data: clusters the information together in order to
identify areas of strength and weaknesses.
4. Documenting Data: accurate documentation is essential
which include all data collected about client’s health status.
Record in a FACTUAL manner NOT interpretation.
e.g.- Recording the breakfast intake as- “ate 2 pcs of bread

1. Primary Source---PATIENT-
Alert, oriented patient is most reliable source.
2. Secondary Source—family members, significant
others, other health professionals medical records and
reports, laboratory and diagnostic procedures analyses,
and relevant literatures are secondary source or indirect
sources.

-SUBJECTIVE DATA also known as symptoms or covert cues
include the client’s feeling and statement about his or her
health problems and are best recorded as direct
quotations from the client, such as
“ Every time I move, I feel nauseated.”
Information perceived only by the affected person.
- OBJECTIVE DATA also known as signs or overt cues, are
observable and measurable (quantitative) that are obtained
through observation, standard assessment techniques
performed during the PE, laboratory and diagnostic testing.

Let’s review!
SUBJECTIVE or OBJECTIVE???
1. Headache
2. Temp. 37.9
3. RR: 20 br/min
4. Toothache
5. Client states, “ I haven’t moved my bowel since
Friday (3 days)
6. Cyanosis
7. Urine output: 60 ml
8. Ate only half of the food served

• O = Onset what you were doing when the pain started?
was the onset sudden or gradual?
• P = Provokes what causes pain?
what makes it better? what makes it worse?
• Q = Quality what does it feel like? Is it sharp, dull,
stabbing, burning, crushing? (try to let patient describe the
pain)
• R = Radiates where does the pain radiates? Is it in one
place? Does it goes anywhere else? Did it start elsewhere
and now localized to one spot?

• S = Severity how severe is the pain on a scale of 1-10
• T = Time -time pain started? How long did it last?

• A process which results to a diagnostic statement Nursing
Diagnosis. It is the clinical act of identifying problems.
• to diagnose in nursing, it means to analyze assessment
information and derive meaning from this analysis.
• Statement of patient’s potential or actual alteration of
health status. It uses the critical-thinking skills of analysis
and synthesis.
Format use in diagnosing:
P = problem P = problem
R = related factors E = etiology
S = signs and symptoms S = signs and

HTTPS://NURSESLABS.COM/NURSING-
DIAGNOSIS/

• Example:
1. Anxiety related to insufficient knowledge regarding
surgical experience.
2. Ineffective airway clearance related to
tracheobronchial infection as manifested by weak
cough, adventitious breath sounds, and copious
green sputum production.
Exercises: Correct or incorrect Nursing Diagnosis???
Acute pain related to physical exertion.
Acute pain related to myocardial infarction.
Ineffective breathing pattern related to pneumonia.
Ineffective breathing pattern related to increased airway secretions.

NURSING DIAGNOSIS
• Statement of nursing judgement
that made by nurse base on
education, experience, expertise
and license to treat.
• Describes human response to an
illness or a health problem.
• May change when client’s
responses changes.
• Independent nursing function
(areas of health care that are
unique to nursing, separate and
distinct from medical management.
MEDICAL DIAGNOSIS
• Made by a physician
• Refers to disease processes
• A client’s medical diagnosis
remains the same as long as long
as the disease process is present.
• Dependent nursing function
(physician-prescribed therapies and
treatments)

• Involves decision making and problem solving
• It is the process of formulating client goals and
designing the nursing interventions required to
prevent, reduce, or eliminate the client’s health
problem.
TYPES:
1. Initial planning: done after the initial assessment
2. Ongoing planning: a continuous planning
3. Discharge planning: planning for needs after
discharge

a) Setting priorities
deciding which nursing diagnosis requires
attention first. The nurse usually uses Maslow’s
Hierarchy of Needs when setting priorities.

b) Establishing client goals/desired outcomes
- the nurse set goals for each nursing diagnosis. Goals maybe short
term or long term. Short-term goal – a statement distinguishing a shift in
behavior that can be completed immediately, usually within a few hours or
days. Long-term goal – indicates an objective to be completed over a longer
period, usually over weeks or months.
c) Selecting nursing interventions and activities.
d) Writing individualized nursing interventions on care plans.
Nursing Intervention is any treatment that a nurse performs to improve
patients’ health.
Types:
Independent: are activities that nurses are licensed to initiate on the
basis of their knowledge and skills.
Dependent: carried out under the orders or supervision of licensed
physician.
Collaborative: actions the nurse carries out in collaboration with

CHARACTERISTICS OF NURSING PROCESS
 Problem-oriented
 Goal-oriented
 Orderly, planned, step by step (systematic)
 Open to accepting new information during its application. It is flexible
to meet the unique needs of client, family, group or community.
 Interpersonal. It requires that the nurse communicates directly and
consistently with the patient.
 Permits creativity among nurses and patients in devising ways to
solve the health problems.
 Cyclical. Steps may overlap because they are interrelated.
 Universal. It is applicable to all individuals, families and communities.

BENEFITS of NURSING PROCESS
PATIENTS:
 Quality patient care. It meets standard of care.
 Continuity of care
 Participation by the patients in their health care. This
reflects respect for human dignity.
NURSES:
 Consistent and systematic nursing education.
 Job satisfaction
 Professional growth
 Avoidance of legal action.

Critical Thinking- in nursing:
 Entails purposeful, outcome-directed (result-oriented) thinking
 Driven by patient, family, and community needs
 Based on the nursing process, evidenced-based thinking, and
the scientific method.
 Requires specific knowledge, skills and experience
 Guided by professional standards and code of ethics.
 Constantly reevaluating, self-correcting, and striving to
improve.

TYPES OF NURSING ASSESSMENT
1. EMERGENCY AND URGENT ASSESSMENT
Involves a life-threatening or unstable situation, such as a
patient who has experienced a critical traumatic injury. Staff
members use triage to determine the level of urgency by
considering assessments based on the mnemonics
o A – Airway
o B – Breathing – rate, depth, use
accessory muscles
o C – Circulation – pulse rate and
rhythm. Skin color
o D – Disability – level of consciousness, pupils, movement
o E – Exposure

2. COMPREHENSIVE ASSESSMENT
 Includes a complete health history and physical
assessment. In the clinic, the history may be obtained by
having the patient initially fill out a written form with family
history of illness, personal illness, and medical treatment or
surgeries.
 A comprehensive history also includes a patient’s perception
health, strengths to build upon, risk factors for illness,
functional abilities, methods of coping, and support system.
 A comprehensive physical examination includes all body
systems and areas usually in a head-to-toe format.

3. FOCUSED ASSESSMENT
Based on the patient’s health issues. This type of
assessment occurs in all setting. It usually involves one or
two body systems and is smaller in scope than the
comprehensive assessment, but more in depth on the
specific issue or issues.
Example:
A patient who presents to the clinic with a cough. The health history
focuses on the duration of the cough, associated symptoms such as
wheezing or shortness of breath, and factors that relieve or worsen the
cough. The physical assessment includes an evaluation of the nose
and throat, auscultation of the lungs, and inspection of sputum.

FRAMEWORKS FOR HEALTH ASSESSMENT
1. Functional Assessment
Focuses on the functional patterns that all humans share: health
perception and health management, activity and exercise, nutrition and
metabolism, elimination, rest and sleep, cognition and perception, self-
perception and self-concept, roles and relationships, coping and stress
tolerance, sexuality and reproduction, and values and beliefs (Gordon,
1993).
2. Head – to – Toe assessment
Most organized system for gathering comprehensive physical data.
3. Body System Approach
A logical tool for organizing data when documenting and
communicating findings. This method promotes critical thinking and allows
you to analyze findings as you cluster similar data.

WATCH THIS VIDEO FOR THE
COMPARISON OF MEDICAL AND
NURSING DIAGNOSIS:
https://www.youtube.com/watch?v=-gYTueSoGgI
l

HEALTH-ASSESSMENT-module-1.pptx

HEALTH-ASSESSMENT-module-1.pptx

More Related Content

What's hot

Similar to HEALTH-ASSESSMENT-module-1.pptx

Recently uploaded

HEALTH-ASSESSMENT-module-1.pptx