Overview: Nurse’s Role in Health Assessment Flashcards
The promotion, & optimization of health and
abilities
Promotion of Health
Prevention of illness and injury
Alleviation of suffering
Health restoration
Nursing is (ANA)
Diagnosis and treatment of human
responses
“EMPHASIS:
Accurate client assessments
Effectiveness of nursing interventions
BASIS:
Continuously collects data systematically
Patients, their relatives, the healthcare
team is involved in providing the data.
Prioritizes data collection activities,
immediate needs comes first
The Nurse:
Makes use of instruments and assessment tools
Documents information gathered
Data gathered becomes basis for
identifying a problem or a need
Nursing interventions appropriated
according to the need of the patient
Makes use of instruments and assessment tools
Documents information gathered
Data gathered becomes basis for
identifying a problem or a need
Nursing interventions appropriated
according to the need of the patient
The Nurse
Makes use of instruments and assessment tools
Documents information gathered
Data gathered becomes basis for
identifying a problem or a need
Nursing interventions appropriated
according to the need of the patient
The Nurse
Period: Nurses relied on their senses to detect
the clients conditions like changes in
the body temperature, and other signs
visible to the eyes and felt by the
hands.
Palpation is limited to locating the
fundus of the pregnant mother or
taking the pulse rate
Late 1800”s to early 1900”s:
Eyes: discoloration of the skin, mucous
membrane of the eyes, signs of cuts and bruises,
redness and swelling , urine output amount and
character etc.
Hands: body temperature
Nose: body odor, urine odor
Ears: hear the beat of the heart , air in the
lungs
USING THE FIVE SENSES
Period: Nursing practice was significant for
case finding and prevention of
communicable diseases
1930’s to 1949:
Period: nurses were hired and work in offices
and do pre-employment health
assessment and physical examinations
1950’s to 1969:
Period: Nurses have been actively involved in PHC
services and actively do health assessment &
physical exams plus psychosocial examinations
1970- 1989:
Period: Nurses role evolved from being on the side of
the doctors to apparently at the same levels as
doctors.
Nurse practitioners became common
Advance nurse practitioners were on the rise
1990’s to the Present:
Birth of Forensic Nursing, Nurse
Anesthetist, Nurse therapist, Nurse
Informatics . Rescue Nurses, Ambulance
Nurses , Nurse in the Academe..etc..
Nurses have to do intensive assessments,
do diagnosing and referrals.
Nurses documents all assessment results
and interventions provided as they
portray more independent roles.
Roles became more advanced and crucial
Advance nurse practitioners
It is a systemic approach used by
the nurse to allow her to
provide the best nursing care
she could.
ADEQUATELY
EFFECTIVELY
HOLISTICALLY
Nursing Process
Coined by LYDIA HALL
It is an ORGANIZED ,
SYSTEMATIC manner of
providing goal –oriented &
humanistic care that is both
EFFICIENT &
EFFECTIVE
Nursing Process
Series of actions
directed
toward a common goal-
OPTIMUM LEVEL OF
WELLNESS
a. identifying a need
b. determining a problem
c. identify goals and plan of
actions
d. implement the plan of care
e. evaluate effectiveness of
care rendered
WHY USE THE NURSING
PROCESS?
Cost
Efficient
Promotes
professionalism
Provides
Framework
and
collaboration
Improves
efficiency &
timeliness of care
Steps of Nursing Process
ADPIE
ASSESSSMENT
DIAGNOSIS
PLANNING
IMPLEMENTATION
EVALUATION
- Collection of Subjective data
- Collection of Objective data
- Validation of data
- Documentation of data
The assessment phase of the Nursing process has
four major steps
= OBSERVATION + INTERVIEW +
PHYSICAL EXAM
ASSESSMENT
Sensations or symptoms
Perceptions and feelings
Desires and preferences
Beliefs, ideas, and values
Personal information
- All that can be validated by the patient
himself
SUBJECTIVE DATA
Obtained by general observation
Makes use of the four physical examination techniques
(IPPA)
Medical records can also be a source of objective data
(Documentation)
Observations made by family and significant others.
Physical characteristics
- Body functions
- Appearance
- Behaviors
- Measurements
- Laboratory results
OBJECTIVE DATA
planned,
purposeful
conversation
Interview-
Use of the five senses
Physical
Examinations
Interpretation of
laboratory results
Observation
PRIMARY SOURCE:
PATIENT
SECONDARY SOURCE:
FAMLY MEMBERS
PATIENTS CHART/
RECORDS
HEALTHCARE TEAM
RELATED
LITERATURES
ensuring that the
information collected are relevant and
validated
This will also ensure that the information are
accurate for documentation
VALIDATING
is vital in assessment
It is an important step because it forms the
database of all that are involved in the
patient care.
It is important to arrive as a valid
conclusion or diagnosis.
DOCUMENTATION
a specific result of
analyzing and is the problem statement that
nurses use to communicate to the healthcare
team.
Nursing diagnosis
Establish priorities according to importance and
time.
Highest priority is given
to life threatening
situations or issues.
PLANNING
Determining beforehand the strategies or
course of actions to be taken before
implementing nursing care.
To be effective, involve the patient and his
family.
PLANNING
Instruct client on technique to splint painful site during
activity.
Administer analgesics 30 minutes before exercise as
ordered by the physician
DEVELOP INTERVENTIONS
To identify and communicate actions to be delivered.
CREATE A CAREPLAN
Establish SMART goals
THE CLIENT WILL STATE THAT PAIN IS
RELIEVED TO A LEVEL OF 2/10 WITHIN 30
MINUTES
Is this a good goal?
OBJECTIVE SETTING
CARE PLAN
physical care
Counselling
Observing for adverse reactions among other things
performed with the client.
DIRECT CARE
-Advocacy
- Supervising
Delegating
- Evaluating
INDIRECT CARE
PROCESS:
Evaluate the interventions
Identify if client goals/ outcomes were
achieved
Document findings / judgment
Terminate, continue or revise the care
plan.
EVALUATION
A comprehensive collection of
information from the client necessary to
provide effective nursing care
HEALTH ASSESSMENT
Initial Comprehensive
On-going or Partial
Focused or Problem Oriented
Emergency Assessment
FOUR BASIC TYPES
Assessment that 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 as
well as health practices
Objective data gathered during the
step by step physical assessment
Initial Comprehensive Assessment
The assessment that is done after a
comprehensive assessment is completed.
It will consist of a mini overview of the
health systems. Any abnormal findings
initiated during the comprehensive
assessment will be looked into to detect
new problems
Done frequently in every encounter with
the client or whenever the need arises
Frequency is determined by the acuity
or whenever the patient perceives a
problem
Ongoing or Partial Assessment
An assessment made when a database
exist for a specific client that comes back
to the health facility with a specific
health concern.
A thorough assessment of a particular
client problem , focusing only on the
health concern itself.
Focused or Problem Oriented
Assessment
A rapid assessment performed in life
threatening situations like cardiac
arrest, choking, drowning where
immediate assessment is vital to have a
prompt treatment
The only concern is to determine the
health status of the client’s life
sustaining functions
Emergency Assessment
Provides biographical information of
the client ( age ,sex, religion,
educational level & occupation)
Information of chronic diseases,
medications and allergies
Impact of the illness on the client’s
ADL’s
Review the clients medical records (when
available)
Do not assume that the information
you have collected are valid
Find time to validate with the client
Prepare to collect additional
information
Avoid premature judgments
Review diagnosis and diagnostic / laboratory tests
done to the patient to learn the results and its
implications
Educate yourself
PROCESS OF DATA ANALYSIS
- IDENTIFY ABNORMAL DATA
AND STRENGTHS
-CLUSTER THE DATA
- DRAW INFERENCES AND
IDENTIFY PROBLEMS
-PROPOSE POSSIBLE NURSING
DIGNOSIS
-CHECK FOR DEFINING
CHARACTERISTICS
-CONFIRM NURSING DIAGNOSIS
- DOCUMENT CONCLUSIONS
Be objective as possible
FACTORS AFFECTING
HEALTH ASSESSEMNT
1.CULTURE
- FAMILY
- COMMUNITY
is a Nurse’s ability to
understand, be aware of, be sensitive to
and vicariously experience the feelings,
thoughts, and experiences of the patients
and their families.
Empathy
involves knowing and trusting the
patient, an interest in their growth and
well being, honesty, courage and humility.
Caring
The exchange of thoughts, messages, or
information which is vital to the nursing
process.
COMMUNICATION
The most important role of a nurse is to
assist patients and their families with
receiving information necessary for
maintaining a patient’s optimal health.
TEACHING
Nurses must be able to think critically and
make decisions when problems are not
clear. A nurse must question, wonder, and
be able to explore various perspective and
possibilities in order to give patients the best
care.
CRITICAL THINKING
are best learned through practice after
achieving an understanding of the basic
principles of skills as part of the nursing
education
PSYCHOMOTOR SKILLS
A nurse applies therapeutic modalities like
pharmacologic and nutritional interventions.
APPLIED THERAPEUTICS
The code of ethics for nurses provides the
ideal framework for safe and correct practices
and behaviour.
ETHICAL AND LEGAL
CONSIDERATION
Involves the characteristics of a nurse that
reflects his or her professional status. These
characteristics involves behaviours with
regard to self, patient, others, and the public
as they reflect the values of the nursing
profession
PROFESSIONALISM
