Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Importance of Health Assessment DSN Kevin...

CHAPTER 1

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Importance of Health Assessment

DSN Kevin Dobi, MS, APRN

Why Learn Health Assessment?

Health assessment is a systematic method of collecting and analyzing data.

Utilize the American Nurses Association’s (ANA) Standards of Practice, which incorporates the nursing process.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 2

Components of Health Assessment

Three primary components: History (subjective data) Physical examination (objective data) Documentation of data


Components of Health Assessment (contd.)

Data collection Symptom: What the patient

feels/communicates (subjective) Sign: Clinical findings (objective) collected

during physical examination Clinical manifestations = signs and/or

symptoms collected utilizing inspection, palpation, percussion, and auscultation


Documentation of Data

Improves plan of care Legal document of patient’s health status Baseline for

Evaluation Changes and decisions related to care

Must be accurate, concise, and without bias or opinion


Types of Health Assessment

Amount of information gained during a health assessment depends on several factors, including: Context of care Patient need Expertise of the nurse


Context of Care

Context of care refers to circumstance or situation related to health care delivery. May be related to the setting or environment. May be related to the physical, psychological,

or socioeconomic circumstances involving the patient.


Examples: Types of Assessments

• Types of assessment: Comprehensive health assessment Problem-based or focused health

assessment Episodic assessment Screening assessment


Patient Needs

Patient needs vary widely: Type of health assessment performed by the

nurse is driven by the patient’s need. Nurse must be prepared to conduct

appropriate level of assessment. Patient’s age, general level of health,

presenting problems, knowledge level, and support systems are among the variables that impact patient need.


Experience of the Nurse

Expertise of the nurse is gained with specialization within a given area of practice: A nurse in an adult intensive care unit has

expertise assessing a patient with hemodynamic instability.

A family nurse practitioner working in a women’s clinic has expertise in performing routine pelvic examinations.


Clinical Reasoning and Judgment

The nurse must analyze and interpret data before initiating a plan of care.

The outcome of a health assessment is a portrait of the patient’s physical status, strengths, weaknesses, abilities, support system, health beliefs, and activities to maintain health, as well as the patient’s health problems and available resources to maintain health.


Data Organization

Organization and clustering of data allows problems to be more clearly apparent

Can be based on body system format: Cardiovascular, musculoskeletal, etc.

Can be based on conceptual format: Oxygenation, perfusion, mobility


Analysis, Interpretation, and Clinical Judgment

Data analysis, interpretation, and clinical judgment include: Identifying abnormal findings. Correctly interpreting findings to select

appropriate plan of care. Applying clinical judgment to interpret or

make conclusions regarding patient needs, concerns, or health problems.

After understanding the situation, the nurse responds by determining appropriate interventions.


Health Promotion andHealth Protection

Central component of nursing. Begins with health assessment—data to identify

patient’s health status, practices, and risk factors.

Interpretation of data allows the nurse to target health promotion needs.


Definitions of Health Promotion and Health

Protection Health promotion:

Behavior motivated by desire to increase well-being and actualize health potential.

Health protection: Behavior motivated by desire to avoid illness,

detect illnesses early, and maintain functioning when ill.


Three Levels of Health Promotion

Three levels of health promotion: Primary = Preventing disease from developing

through promoting healthy lifestyle. Secondary = Screening efforts to promote

early detection of disease. Tertiary = Minimizing disability from acute or

chronic illness or injury and allowing for most productive life within limitations.

Nurses provide education and care to help meet health promotion needs.


Health Promotion andHealth Protection (contd.) Framework for health promotion efforts found in

Healthy People 2020: http://www.healthypeople.gov/2020/

Managed by U.S. Department of Health and Human Services.

Objectives address most significant preventable threats to health with goals to reduce threats.


http://www.healthypeople.gov/2020/

Goals of Healthy People 2020

Objectives address most significant preventable threats to health, with goals to reduce threats

Four overarching goals: Attain high quality, longer lives, free from

preventable diseases. Achieve health equity, eliminate disparities,

and improve the health of all groups. Create social and physical environments that

promote health for all. Promote quality of life, healthy development,

and healthy behaviors across all life stages.


Question 1

A mother of three is being seen for a screening assessment. While planning the initial part of the visit with this patient, the nurse needs to ensure that:

A. The patient receives a refill for her thyroid medication.

B. The patient is instructed on preventive measures for hypertension.

C. Other family members are present during the interview.

D. Information about the patient’s lifestyle habits is gathered.


Question 2

The medical-surgical nurse is reviewing the practice related to a patient who acquired pneumonia while recovering from a hip replacement. The unit documents this event as failure to rescue and would like the nurse to develop a personal professional action plan. This plan will most likely include:

A. Reflection on actionB. Reflection in actionC. Tertiary prevention of health care-associated

infectionsD. Reasoning patterns


Question 3

A nurse is assessing a female teenager. The nurse asks the young woman to bend over and touch her toes. The nurse assesses the curvature of the spine as a means of detecting scoliosis. Assessing the curvature of the spine is an example of:

A. Health educationB. Primary preventionC. Secondary preventionD. Tertiary prevention


Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Importance of Health Assessment DSN Kevin...

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