Introduction to Health Assessment – Nursing is a profession within the healthcare sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses may be differentiated from other healthcare providers by their approach to patient care, training, and scope of practice. Nurses practice in many specialisms with differing levels of prescriber authority.
Many nurses provide care within the ordering scope of physicians, and this traditional role has shaped the public image of nurses as care providers. However, nurses are permitted by most jurisdictions to practice independently in a variety of settings depending on training level. In the postwar period, nurse education has undergone a process of diversification towards advanced and specialized credentials, and many of the traditional regulations and provider roles are changing.
Nurses develop a plan of care, working collaboratively with physicians, therapists, the patient, the patient’s family, and other team members, that focus on treating illness to improve quality of life. Nurses may help coordinate the patient care performed by other members of an interdisciplinary healthcare team such as therapists, medical practitioners, and dietitians. Nurses provide care both interdependently, for example, with physicians, and independently as nursing professionals.
Introduction to Health Assessment
Concept of Health Assessment
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
Or,
Health assessment is a plan of care that identifies the specific needs of the client and how those needs will be addressed by the healthcare system.
Or,
Health assessment is an examination performed by a primary health care provider in order to. determine appropriate health plan for Medicaid eligible individuals.
Types of Health Assessment:
In general, there are four fundamental types of assessments that nurses perform:
A. Initial Assessment
- The initial assessment, also known as triage, helps to determine the nature of the problem and prepares the way for the ensuing assessment stages.
- The initial assessment is going to be much more thorough than the other assessments used by nurses
B. Focused Assessment
- The focused assessment is the stage in which the problem is exposed and treated.
C. Time-Lapsed Assessment
- Once treatment has been implemented, a time- lapsed assessment must be conducted to ensure that the patient is recovering from his malady and his condition has stabilized,
D. Emergency Assessments
- During emergency procedures, a nurse is focused on rapidly identifying the root causes of concern for the patient and assessing the airway, breathing and circulation (ABCs) of the patient.
General Principles of Health Assessment
1. The first step in caring for a patient and setting active cooperation is to gather a careful and complete history
- In all patient concerns and problems and accurate history is the foundation on which data collection and the process of assessment are based.
- The comprehensiveness of the history elicited will depend on the information available in the patient’s record and the reliability of the patient.
2. Time span early in the nurse patient relationship gathering detailed information about what the patients knows thinks and feels about the problems will prevent errors and misunderstanding later.
3. Skill in interviewing will affect both the accuracy of information elicited and the quality of relationship establish with the patient.
Purposes/Significance/Benefits/Importance of Health Assessment:
1. To gather data/information that
- Surveying the client’s health status and risk factors for particular health problem.
- Identifying latent or occult (undetected) disease.
- Screening for a specific disease such as diabetes or hypertension (ie, case finding).
- Identifying risks for particular health problems.
- Determining functional impact of disease (ie, human response to actual or potential health problems.
- Evaluating the effectiveness of the health care plan.
2. To perform physical examination.
3. Early detection of the disease.
4. Identification of the patients’ individual actual problem.
5. To review the records.
6. To establish a nursing diagnosis.
7. To identify the nursing needs of the patient.201
8. To prepare a nursing care plan.
9. To provide complete nursing care.
Components/Elements Assessment Process:
1. Good communication.
2. A systematic approach to data collection.
3. Interpretation based on nursing knowledge.bl
4. Empirics’ measurement of knowledge with scientific fact.
5. Aesthetics gained through empathy and is how a nurse becomes sensitive to a patient’s pain, worry or joy.
6. Ethics concerned with motivation, morality, human rights and law. 7. Personal knowledge awareness that the nurse has an impact on patient care.
Assessment Strategies:
1. Observation/Inspection.
2. Asking question to the clients.
3. Physical examination by-
- Inspection.
- Palpation.
- Auscultation.
- Percussion.
Technique of Health Assessment:
The nurse mainly uses four technique during performing physical assessment. The following techniques are given below-
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
A. Inspection-critical observation *always first
- Take time to “observe” with eyes, ears, nose (all senses)
- Use good lighting
- Observe for odors from skin, breath, wound
- Develop and use nursing instincts
- Inspection is done alone and in combination with other assessment techniques
B. Palpationlight and deep touch
- Back of hand (dorsal aspect) to assess skin temperature
- Fingers to assess texture, moisture, areas of A tenderness
- Assess size, shape, and consistency of lesions and organs
- Deep = 5-8 cm (2-3″) deep; Light = 1 cm deep
C. Percussion-sounds produced by striking body surface
- Produces different notes depending on underlying mass (dull, resonant, flat, tympanic)
- Used to determine size and shape of underlying structures by establishing their borders and indicates if tissue is air-filled, fluid-filled, or solid
- Action is performed in the wrist,
D. Auscultation- listening to sounds produced by the body
- Direct auscultation – sounds are audible without stethoscope
- Indirect auscultation – uses stethoscope
- Know how to use stethoscope properly [practice skill]
- Fine-tune your ears to pick up subtle changes [practice skill]
- Describe sound characteristics (frequency, pitch intensity, duration, quality) [practice skill
- Flat diaphragm picks up high-pitched respiratory res sounds best.
- Bell picks up low pitched sounds such as heart murmurs.
- Practice using BOTH diaphragms
Phases/Steps of Assessment in the nursing process
1. Subjective data collection.
2. Objective data collection.
3. Validation of data,
4. Documentation of data
A. Subjective data collection:
a) Subjective data are sensation or symptoms (e.g. pain, hunger), feelings (e.g. Happiness, sadness), perceptions desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.
b) To elicit accurate subjective data, the nurse must learn to see effective interviewing skills with a variety of clients in different settings.
c) The major areas of subjective data include.-
- Biographical information, (e.g. name, age, religion, occupation).
- Physical symptoms related to each body part or system (e.g. eyes and ears, abdomen)
- Past and family history
- Holistic information regarding the client’s health (eg. Health practices that put the client at risk, nutrition, activity, relationships).
B. Objective data collection
a) Objective data are directly observed or indirectly observed through measurements. This data can be
- Physical characteristic (skin color, posture).
- Body functions (heart rate, respiratory rate).
- Measurement (Blood pressure, temperature, height, weight).
- The results of laboratory testing (platelet count, X-ray findings).
b) This type of data is obtained by general observation and by using the four physical examination techniques:
- Inspection.
- Palpation.
- Percussion.
- Auscultation.
c) Objective data may also be observations noted by the family or significant others about the client
C. Validation of data:
a) Validation of assessment data is a crucial part of assessment that often occurs along with collection of subjective and objective data
b) It serves to ensure that the assessment process is not ended before all relevant data have been collected.
c) It helps prevent documentation of inaccurate data.
D. Documentation of data;
a) Documentation of assessment data is an important steps of assessment because it forms the database for the entire nursing process and provides data for all other members of the heath care team.
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