Health assessment Flashcards
The very elements of nursing are all but unknown
Florence Nightingale 1859
Nursing is the diagnosis and treatment of human responses to health and illness
ANA 1995
Nursing is both A SCIENCE and AN ART that is concerned with the individual’s
- Physical
- Phychological
- Sociological
- Cultural
- Spiritual
The first step if the nursing process
Health assessment
The most important because it DIRECTS the rest of the process
Health assessment
Identify the normal and DIFFERENTIATE it from the abnormal
Health assessment
The client is a human being who has ? and has ?
worth and has dignity.
The ? is important in the nursing process.
therapeutic nurse-client relationship
“Combines the most desirable elements of the art of nursing with the most relevant elements of systems
theory, using the scientific method” – Shore 1988
THE NURSING PROCESS
“This process incorporates an interactive/interpersonal approach with a problem solving and decisionmaking process” was stated by?
– Peplau 1952
✓ G -
✓ O -
✓ S -
✓ H -
✓ G - oal oriented
✓ O - rganized
✓ S - ystematic
✓ H - umanistic care
THE NURSING PROCESS IS A (?)
SYSTEMATIC PROBLEM-SOLVING APPROACH
5 steps of the Nursing Process (ADPIE)
- ASSESSMENT
- DIAGNOSIS
- PLANNING
- INTERVENTION
- EVALUATION
refers to the body, this marvelous container and complex, finely tuned, machine with
which we interface with our environment and fellow beings. The physical self is the concrete
dimension, the tangible aspect of the person that can be directly observed and examined.
PHYSICAL
pertaining to the mind or to mental phenomena as the subject matter of
psychology. of, pertaining to, dealing with, or affecting the mind, especially as a function of
awareness, feeling, or motivation: psychological play; psychological effect.
PSYCHOLOGICAL
of or relating to sociology or to the methodological approach of sociology. Oriented
or directed toward social needs and problems.
SOCIOLOGICAL
the characteristics and knowledge of a particular group of people, encompassing
language, religion, cuisine, social habits, music and arts
CULTURAL
(?) need enhanced assessment skills to safely assess
critically ill clients who are outside the structured intensive care environment (Coombs &
Moorse, 2002).
Critical care outreach nurses
relating to religion or religious belief. Relating to or affecting the human spirit or soul as
opposed to material or physical things.
SPIRITUAL
The (?) performs a focused assessment, and then incorporates
assessment findings with a multidisciplinary team to develop a comprehensive plan of
care.
acute care nurse
assess and screen clients to determine the need for physician
referrals.
Ambulatory care nurses
make independent nursing diagnoses and referrals for collaborative
problems as needed.
Home health nurses
assess the needs of communities, school nurses monitor the
growth and health of children, and hospice nurses assess the needs of the terminally ill
clients and their families.
Public health nurses
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.
emergency assessment
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 followup 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. In addition, a brief reassessment of the client’s body systems and holistic health
patterns is performed to detect any new problems. This type of assessment is usually performed
whenever the nurse or another health care professional has an encounter with the client. This
type of assessment may be performed in the hospital, community, or home setting. The frequency
of this type of assessment is determined by the acuity of the client.
- Eg.
o A client admitted to the hospital with lung cancer requires frequent assessment of lung
sounds. A total assessment of skin would be performed less frequently, with the nurse
focusing on the color and temperature of the extremities to determine level of oxygenation.
Ongoing or Partial Assessment
An (?) identifies an occuring health problem for your patient
Actual nursing diagnosis
A (?) identifies a high-risk health problem that most likely will occur unless preventive measures are taken
Potential nursing diagnosis
A (?) is one that needs further data to support it
Possible nursing diagnosis
Full range of human experiences and responses to health and illness w/o restriction to a problem
focused orientation
Attention
Caring relationship that facilitates (?) and (?)
health and healing
Understanding and integration of objective data based on (?)
client’s subjective experience
Knowledge (?) for diagnosis and treatment
scientific
Human experience is (?) and (?) defined.
contextually and culturally
Observable assessment cues such as patient behavior, physical signs
Signs and Symptoms
- Desired outcomes
- Appropriate interventions
- Involves setting goals and outcomes
- Individualized plan of care for your patient is ready once diagnosis have been prioritized
PLANNING
Broad statement that describes a desired change in a patient’s condition, perceptions or
behavior
Goals
objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks or months
Long term goals
objective behavior or response that you expect the patient to achieve in
short time usually few hours or less than a week
Short term goals
Planning should be (SMART)
✓ Specific
✓ Measurable
✓ Attainable
✓ Realistic
✓ Time-bound
- 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
INTERVENTION
▪ Direct intervention
▪ Interventions are treatment performed through interaction with patient
▪ Ex. Medication administration, VS checking, insertion of IFC
Direct Care
▪ Interventions are treatments performed away from a patient but on behalf of the
patient or group of patient
▪ Ex. Safety and Infection control, Delegating nursing care
Indirect care
▪ Action that the nurse initiates without supervision or direction from others
Independent
▪ Actions that require an order from a health care provider
Dependent
▪ Interdependent interventions
▪ Therapies that require the combined knowledge, skills, and expertise of multiple
health care providers
Collaborative
- 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 client’s 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.
Evaluation
PURPOSES OF THE NURSING PROCESS
- To identify a client’s health status; his Actual/Present and potential/possible health problems or
needs. - To establish a plan of care to meet identified needs.
- To provide nursing interventions to meet those needs.
- To provide an individualized, holistic, effective and efficient nursing care.
According to (?) and (?): Assessment is a part of each activity the nurse does for and
with the patient.
Atkinson and Murray (1991)
According to (?)
“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.”
Carpenito
The four basic types of assessment are:
- Initial comprehensive assessment
- Ongoing or partial assessment
- Focused or problem-oriented assessment
- Emergency assessment
- 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 (which
includes information related to the client’s overall function) as well as objective data gathered
during a step-by-step physical examination. - The nurse typically collects subjective data and objective data in many settings (hospital,
community, clinic, or home). Depending on the setting, other members of the health care team
may also participate in various parts of the data collection.
Eg.
o In a hospital setting the physician usually performs a total physical examination when the
client is admitted (if this was not previously done in the physician’s office). In this setting,
the nurse continues to assess the client as needed to monitor progress and client
outcomes. A physical therapist may perform a musculoskeletal examination, as in the case
of a stroke patient, and a dietitian may take anthropometric measurements in addition to
a subjective nutritional assessment.
o In a community clinic, a nurse practitioner may perform the entire physical examination.
o In the home setting, the nurse is usually responsible for performing most of the physical
examination.
Initial Comprehensive Assessment
Another crucial part of the first step in the nursing process
DOCUMENTING DATA
The common term used in the field of nursing when it comes to documentation
CHARTING
- It is a permanent record of patient’s information.
- Tracks the progress of the patient’s condition during the hospitalization as well as the status upon
discharge. It serves as an information sheet of the medications and procedures rendered to the
patient. - Legal evidence for cross-examination whenever complaints or malpractice claims have been
sighted out. - It serves as the evidence of continuity of care.
- It serves as a research material for retrospective study.
Charting
o traditional form of charting
o source-oriented record
o advantage is that it provides organized section for each member of the healthcare team
o disadvantage in using this type of recording is that the information is scattered throughout
the chart
Narrative charting
- give focus on the problems that patients face
- each medical personnel can contribute and collaborate on the plan of care
- advantage seen in this type of charting is collaboration among medical personnel
- the disadvantage here is that it takes complete and on time assessment of problem lists
Problem-oriented charting
- usually used since it gives a quick look at the observation of each nurse as well as the
nursing action on each observation.
SOAP formats
S -
O -
A -
P -
S - Subjective
O - Objective data
A - Assessment
P - Plan
S -
O -
A -
P -
I -
E -
R -
S - Subjective
O - Objective data
A - Assessment
P - Plan
I - Intervention
E - Evaluation
R - Revision
includes the patient’s complaints or perception of the present
problem sited.
Subjective
includes the nurse’s observation using his or her clinical eye
Objective
includes the inference made by the nurse from the two types of
data. This is the part wherein the problem is stated. The nursing problem is stated
in a form of nursing diagnoses using the NANDA.
Assessment
this includes the nursing actions to be made in order to solve the stated
problem. This part can be revised.
Plan
This is the part wherein specific nursing actions are stated
Intervention
This is the part wherein the nurse evaluates the reaction
of the patient or progress of the problem being solved.
Evaluation
This is the section that states the changes made in order to
further resolve the problem.
Revision
Ex: My skin is so itchy, especially on the skinfolds.”
Subjective
Ex: Skin appears to be flushed with bumps. Irritation noted on the
armpit and inner thighs.
Objective
Ex: Altered comfort secondary to food intake
Assessment
Ex:
o Inform the patient not to scratch the skin.
o Apply cold compress on the hot spots
o Cut nails in order to prevent skin scratches
o Refer to the physician
o Assess for progress of skin rash
Planning
Ex:
o Instructed not to scratch the skin.
o Cut the fingernails short
o Applied cold compress
o Referred to the physician
Intervention
Ex:
“I feel more comfortable and I do not have the urge to scratch my
skin.”
Evaluation
Ex:
Give antihistamine (Antamin) 1mg/mL as deep intramuscular
injection to left deltoid muscle.
Revision
o This type of charting involves Data, Action and Response category.
o This is a client-focused charting
o Since it the client being talked about most of the documentation, this is a form of holistic
perspective of client’s needs.
Focus charting (FDAR)
F -
D -
A -
R -
Focus
Data
Action
Response
- Nursing Dx, Client Concern, S&S, Event
Focus
- Facial grimacing, graded the nape pain as 7 in the scale of 1 to 10 with 10
as severe pain
Data
- Given Norgesic Forte per orem as now dose.
Action
- Rated pain as 2 and able to walk on her own.
Response
- a model of communication
- one of the most common handover
mnemonic models used in health care - improve quality and patient safety
outcomes when used by health team
members to communicate or hand-off
client information
The SBAR
The SBAR
Situation, Background, Assessment,
Recommendation
- Focused on one major area of the body for clients who have a particular problem
- Examples
▪ Cardiovascular assessment forms
▪ Neurologic assessment forms
- Focused or Specialty Area Assessment Form
- Flowcharts that help staff record and retrieve data for frequent reassessments
- Examples
▪ Vital signs sheet
▪ Assessment flowchart - Emphasis is placed on quality, not quantity of documentation
Frequent or Ongoing Assessment Form
- Is called a nursing admission or admission database
o 4 types
▪ Open – Ended Forms (Traditional form)
▪ Cued or Checklist Forms
▪ Integrated Cued Checklist
▪ Nursing Minimum Data Set
Initial Assessment Form
- Used to manage the huge volume of information required in contemporary health care
- Can integrate all pertinent client information into one record
- Nurse’s responsibilities include storing client’s database, add new data, create and revise
care plans and document client progress - Makes care planning and documentation relatively easy
- Transmit information from one care setting to another
Electronic health records (EHRs)
- Widely used, concise method of organizing and recording data about a client, making
information accessible to all health professionals - Consists of series of cards kept in a portable index file which is particular for a client
- Can be quickly accessed to reveal specific data
- May or may not become a part of the client’s permanent record
Kardex
- Graphic record
- Intake and Output Record
- Medication Administration Record (MAR)
- Skin Assessment Record
Flow sheets
- Completed when the client is being discharged and transferred to another institution or to a
home setting where a visit by a community health nurse is required
Nursing Discharge / Referral Summaries
Best source of data, subjective data
Client
o Family members, friends and caregivers
o Important source of data if the client is young
o unconscious or confused
Support people
o Information documented by other healthcare professionals
Client records
journals, reference texts, published studies
Literature
-verbal reports
Health care professionals
o To gather data using the senses
o A conscious, deliberate skill
o 2 aspects
▪ Noticing the data
▪ Selecting, organizing and interpreting the data
Observing
o Planned communication or conversation with a purpose
o To get or give information
o Identify problems of mutual concern
o Evaluate change, teach, provide support
o Provide counselling or therapy
Interview
o Nurse reviews the medical record before meeting with the client
o If a medical record is not established, the nurse will need to rely on interview skills to elicit
valid and reliable data from the client and that individual’s family or significant other
- Pre -Introductory Phase
o The nurse explains the purpose of the interview, discusses the types of questions that will
be asked, explains the reason for taking notes, and assures the client that confidential
information will remain confidential
o The nurse makes sure that the client is comfortable (physically and emotionally) and has
privacy
o The nurse should develop trust and rapport at this point in the interview
Introductory phase
o Longest Phase
o Verbal / Nonverbal
o The nurse elicits the client’s comments about major biographic data, reasons for seeking
care, history of present health concern, past health history, family history, review of body
systems for current health problems, lifestyle and health practices, and developmental
level
o The nurse listens, observes cues, and uses critical thinking skills to interpret and validate
information received from the client
o The nurse and client collaborate to identify the client’s problems and goals
Working phase
o Summarize / Restate
o Clarify
o The nurse summarizes information obtained during the working phase and validates
problems and goals with the client
o The nurse identifies and discusses possible plans to resolve the problem (nursing
diagnoses and collaborative problems) with the client
o Finally, the nurse makes sure to ask if anything else concerns the client and if there are
any further questions
Summary and closing phase
o Highly Structured
o Controlled by the Nurse
o Elicits specific information
o Nurse uses directive questions
Directive interview
o Rapport – building interview
o Controlled by the client
Non-Directive interview
o Combination of non – directive and directive interview
Information gathering interview
o Used in directive interview
o Answerable only by Yes or No
o Often begin with where, who, what, do, is
o For patients who are highly stressed and has difficulty communicating
o Ex. “Do you feel pain?”
Closed questions
o Used in non – directive interview
o Invites client to explore, elaborate, clarify thoughts or feelings
o Useful in eliciting attitudes and mental status
o Often begin with what and how
o Ex. “What brought you to the hospital?”
Open ended questions
o A question that the client can answer without direction or pressure from the nurse
Neutral questions
o Closed
o Directive
o Persuasive
Leading questions
Distance:
Maintain a 2 to 3 feet distance during interview
Place
Well – lighted, well – ventilated room, free of noise and distractions
Time
When the client is physically comfortable and free of pain
- Physical Examination
o Carried out systematically
o Cephalocaudal or head to toe approach
Examining
o Also called review of systems
o A brief review of essential functioning of various body parts or systems
Screening Examination
- Lays the groundwork for identifying nursing problems and provides a focus for the physical
examination - The importance lies in its ability to provide information that will assist the examiner in identifying
areas of strength and limitation in the individual’s lifestyle and current health status
Complete health history
- FOR: assessment of posture, gait & balance
- CONTRAINDICATION (CI): Patients who
are weak, disabled, or paralyzed may need
assistance or may not be able to assume this
position
Standing
- Back lying position
with knees flexed
and hips externally
rotated; small
pillow under the
head; soles of the
feet on the surface - FOR: Head and
neck, axillae, anteror thorax, lungs, breasts, heart,
extremities, peripheral pulses, vital signs and vagina - CI: clients with cardio pulmonary problems. Not used for
abdominal testing because of the increased tension in
abdominal muscles. If patient has abdominal pain, flexing
knees is usually more comfortable
Dorsal Recumbent
- seated position, back unsupported
and legs hanging freely - FOR: Head neck posterior and
anterior thorax breast Breasts
axillae - heart vital signs, upper extremities
lower extremities and reflexes - CI: Elderly and weak clients may
require support
Sitting
- The client is lying on the back. The head and shoulders are
usually elevated with a small pillow. The arms and legs are
extended and the legs are slightly abducted - FOR: head neck axillae, anterior thorax, lungs, abdomen,
extremities, peripheral pulses - CI: Tolerated poorly by clients with cardiovascular and
respiratory problems
Supine
- The client is lying on the side with the body turned at 45
degrees. The lower leg is extended, with the upper leg
flexed at the hip and knee to a 45-to-90-degree angle. - FOR: assessment of rectum and vagina
- CI: Difficult for elderly and people with limited joint
movement
SIM’S
- The client is lying on the abdomen with head turned to the
side. - FOR:
Posterior
thorax, hip joint movement - CI: Often not tolerated by the elderly and people with
cardiovascular and respiratory problem
Prone
- The client is lying on the back with the hips and knees flexed
at right angles and feet in stirrups. - FOR: assessment of female rectum and vagina. (for a brief
period only) - CI: May be uncomfortable and tiring for elderly people. Often
embarrassing
Lithotomy
- assessment of rectal area
- assessment of rectal area (for brief period only)
- Jack Knife
Knee chest
➢ sense of touch
➢ The use of hand to touch and feel the patient’s skin,
organs, mass, and other delineated structures in the
body
➢ The pads of the fingers are used
➢ Assess temperature; turgor; texture; moisture;
vibrations; position, size, shape, consistency and
mobility of organ or masses; distention; pulsation;
and the presence pain upon pressure
Palpation
➢ Striking of the body surface with short, sharp strokes
➢ Palpable vibrations and characteristic sound
➢ location, size, shape
➢ density of underlying structures
➢ to detect the presence of air or fluid in a body space
➢ elicit tenderness
Percussion
▪ using sharp rapid movements from
the wrist, strike the body surface to be
percussed with the pads of two,
three, or four fingers or middle finger
alone
▪ Primarily used to assess sinuses in
the adult
▪ Using one hand to strike the surface
of the body
Direct percussion
▪ percussion in which two hands are
used and the plexor strikes the finger
of the examiner’s other hand, which
is in contact with the body surface
being percussed (pleximeter- the
middle finger of the nondominant
hand)
▪ Using the finger of the one hand to
tap the finger of the other hand
Indirect percussion
✓ Commonly called laboratory tests
✓ Used for basic screening as part of wellness check
✓ Used to help confirm diagnosis, monitor an illness, and provide valuable
information about the client’s response to treatment
Diagnostic tests
✓ Commonly called laboratory tests
✓ Used for basic screening as part of wellness check
✓ Used to help confirm diagnosis, monitor an illness, and provide valuable
information about the client’s response to treatment
Pretest
o specimen collection and performing or assisting with certain
diagnostic testing.
o The nurse uses standard precaution, sterile technique, provides
emotional and physical support while monitoring the client. Also the
nurse ensures correct labelling, storage, and transportation of
specimen to avoid invalid test result.
Intratest
Post-test
o on nursing care of the client and follow-up activities and
observation.
o The nurse compares the previous and current test result and report
this to appropriate health team members.
o commonly used diagnostic tests that can provide valuable
information about the hematologic system
o venipuncture (puncture of a vein for collection of a blood specimen)
is peformed
Blood test
o includes hemoglobin and hematocrit measurements, erythrocyte
(red blood cells) count, red blood cell indices, leukocyte (white
blood cell) count, and a differential white cell count
o CBC is a basic screening test and one of the most frequently
ordered blood tests
Complete blood count (CBC)
