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.