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Chapter 1—The Nurse’s Role in Health Assessment

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1 Chapter 1—The Nurse’s Role in Health Assessment

2 Role of the Professional Nurse
American Nurses Association (ANA)- according to the ANA nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy Four broad goals To promote health To prevent illness To treat human responses to health or illness To advocate for individuals, families, communities, and populations

3 Role of the Professional Nurse—(cont.)
Nursing: Scope and Standards of Practice (ANA, 2010b) and Code of Ethics for Nurses with Interpretive Statements (ANA, 2010a) Nursing activities to promote health and prevent illness Appropriate nursing interventions Implementing educational programs Coordinating community resources Patient/family teaching

4 Role of the Professional Nurse—(cont.)
Care responsibilities Independent interventions Patient teaching Therapeutic communication; physical procedures Member of a profession Scholarship and research-to provide care based on current evidence Advocacy- nurses take responsibility to protect the legal and ethical rights of patients. Nursing values-beliefs or ideals to which a person is committed ie. Respect, Unity, Diversity Integrity, Excellence

5 Role of the Professional Nurse—(cont.)
Registered nurse and advanced practice nurse roles APRN education MSN; doctorate (2015) APRN roles Nurse Practitioner (NP) Certified Nurse Midwife (CNM) Certified Registered Nurse Anesthetist (CRNA) Clinical Nurse Specialist (CNS)

6 Purpose of Health Assessment
Health assessment: “Gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings and evaluating patient care outcomes” (AACN, 2011) A health assessment includes Health history; physical assessment Additional necessary factors assessed Psychological; sociocultural; spiritual; economic; lifestyle Nursing process begins with a complete, accurate health assessment.

7 Wellness and Health Promotion
Wellness: “An integrated method of functioning, which is oriented toward maximizing the potential of which the individual is capable” (Dunn, as cited in Zimmer, 2010) Nurses collaborate to promote higher levels of wellness. Facilitate wellness via health promotion, teaching National model for health promotion, risk reduction Healthy People Ten foci: goals; evaluation and revision Risk assessment, health-related patient teaching

8 Wellness and Health Promotion—(cont.)
Interventions promoting healthy change Primary prevention: strategies aimed at preventing problems Secondary prevention: early diagnoses, prompt treatment Tertiary prevention: preventing complications of existing disease, promoting highest health level possible

9 Primary, secondary or tertiary prevention
Immunizations Pap smears Diet teaching for pt. with DM BP screening Inhaler teaching for pt with lung disease Health teaching Safety precautions Vision screening Exercise programs for pt w/ MI TB skin test Nutrition counseling

10 Wellness and Health Promotion—(cont.)
The three levels of prevention

11 Assessment in the Nursing Process
Systematic problem-solving approach, identifying and treating human responses to actual or potential health difficulties (ANA, 2013) Nursing process components (nonlinear, interactive) Assessing Diagnosing Planning Implementing Evaluating

12 Assessment in the Nursing Process—(cont.)
Assess: complete, accurate health data compilation Diagnose: data clustering to determine patient’s condition North American Nursing Diagnosis Association (NANDA-I) Plan goals, outcomes: formulation of measurable, realistic, patient-centered goals Patient outcomes are more specific than goals. Plan care: determining resources; targeting nursing interventions; writing plan of care

13 Assessment in the Nursing Process—(cont.)
Implement: any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient outcomes (Bulechek, et al., 2007) Monitoring health status; prevent, resolve, control a problem Assist with ADLs; promote optimal health and independence Evaluate: judgment of nursing care efficacy in meeting patient goals and outcomes based on patient responses to nursing interventions Requires knowledge of care standards, expected patient responses, conceptual models and theories

14 Critical Thinking Purposeful, outcome-directed (result-oriented) thinking Driven by patient, family, community needs Based on nursing process, evidence-based thinking, scientific method Requires specific knowledge, skills, experience Guided by professional standards and codes of ethics Continually reevaluating, self-correcting, striving for improvement

15 Question Is the following statement true or false?
A health assessment includes both a health history and a physical assessment.

16 Answer True Rationale: A health assessment is made up of the following two parts: a health history and a physical assessment.

17 Diagnostic Reasoning Gathering and clustering data to draw inference and propose diagnoses Based on nurse’s critical thinking Seven-step process used within context of health assessment Identify abnormal data, strengths Cluster data Draw inferences Propose nursing diagnoses

18 Diagnostic Reasoning—(cont.)
Seven-step process used within context of health assessment—(cont.) Check for presence of defining characteristics Confirm or rule out nursing diagnosis Document conclusions Collaborative problems

19 Types of Assessments Three common types of nursing assessments
Emergency: life-threatening or unstable situation Comprehensive: complete health history and physical assessment performed: Annually for outpatients Upon hospital/long-term care admission Every 8 hours in critical care Focused: occurs in all settings, smaller in scope but increased depth for specific issue(s)

20 Priority Setting Prioritize assessments and care upon the patient’s health care situation In determining priorities, use Clinical experience Knowledge; expertise; judgment Life-threatening situation is top priority. Patient issue of top import should be considered high priority.

21 Frequency of Assessment
Varies due to Patient needs; data collection purpose Nurse’s role; health care setting Health care setting Long-term care Intensive care Focused assessments posttreatment Outpatient setting

22 Frequency of Assessment—(cont.)
Well visit assessments Most common screening, prevention services Birth to 10 years Monitor growth, development 11 to 24 years 25 to 64 years 65 years and older Treatment of acute, chronic illness

23 Lifespan Issues Comprehensive assessment Cognitive development
Emotional development Physical growth Identify Expected growth, development patterns Expected variations, aberrations, deviations

24 Question When are focused assessments conducted?
A. At different ages across the lifespan B. After specific treatments are given C. When a patient is in the acute care setting D. Only in the outpatient setting

25 Answer B. After specific treatments are given
Rationale: Patients also have focused assessments following treatments to monitor their effectiveness.

26 Cultural Considerations
Cultural competence: complex combination of knowledge, attitudes, and skills health care providers use to deliver care that considers the total context of the patient’s situation across cultural boundaries (Purcell, 2009) Knowledge of cultural diversity is essential for competent nursing practice Subcultures Assess import of spirituality and religion on patient’s health

27 Components of the Health Assessment
Observe patient’s verbal and nonverbal communication. Maintain patient confidentiality. Purpose: Collect family and personal histories of risk factors and past issues. Subjective data: Patient is primary source. Therapeutic dialogue Objective data: measurable information Vital signs; auscultation; visual appearance

28 Documentation and Communication
Documentation is essential. Legal Communication with other providers Collaborative care Shift or departmental transfer report Various forms, formats SOAP Confidentiality is essential.

29 Frameworks for Health Assessment
Three major health assessment frameworks Functional assessment Focuses on functional patterns all humans share Head-to-toe assessment Most organized Body systems approach Organizational for documentation, communication Promotes critical thinking

30 Evidence-Based Practice
Relies on research findings, high-grade scientific support Minimizes intuition, personal experience Solve common problems using four steps Clearly identify issue or difficulties based upon accurate analysis of current nursing knowledge and practice. Search literature for relevant research. Evaluate research evidence using established criteria regarding scientific merit. Choose interventions, justifying selection with most valid evidence.

31 Question Which physical assessment framework promotes critical thinking? A. Functional B. Head-to-toe C. Comprehensive D. Body systems

32 Answer D. Body systems Rationale: A body systems approach is a logical tool for organizing data when documenting and communicating findings. This method promotes critical thinking and allows nurses to analyze findings as they cluster similar data.

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