1. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Weber Health Assessment in Nursing Chapter 01: Nurse’s Role in Health Assessment: Collecting and Analyzing Data

2. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Nursing assessment Collective subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment Medical assessment Focuses primarily on the client’s physiologic development status

3. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Phases of the Nursing Process

4. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Initial Comprehensive Assessment Collection of subjective data about the client’s perception of health of all body parts or systems Past medical history Family history Lifestyle and health practices

5. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Assessment Ongoing or partial assessment: consists of data collection that occurs after the comprehensive data base is established Focuses on problem-oriented assessment: consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem Emergency assessment: very rapid assessment performed in life-threatening situations

6. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement True or False? A partial assessment is done when the client first enters a health care facility.

7. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. A partial or ongoing assessment of the client consists of data collection that occurs after the comprehensive database is established. This takes place after the client is admitted to the health care facility.

8. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of Health Assessment Preparing for the assessment –Review client’s record –Review client’s status with other health care team members –Educate about client’s diagnosis and tests performed

9. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Collection of Subjective Data Biographical information Physical symptoms related to each body part or system Past health history Family history Health and lifestyle practices

10. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Collection of Objective Data Physical characteristics Body functions Appearance Behavior Measurements Results of laboratory testing

11. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Comparing Subjective and Objective Data

12. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement True or False? Subjective data are sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.

13. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True. Subjective data are sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.

14. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of Health Assessment Validating assessment data Documenting data

15. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Analysis Phase of Nursing Process Identify abnormal data and strengths. Cluster the data. Draw inferences and identify problems. Propose possible nursing diagnoses. Check for defining characteristics of those diagnoses. Confirm or rule out nursing diagnoses. Document conclusions.

16. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement True or False? A nurse is not supposed to draw inferences and identify problems during data analysis.

17. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. A nurse is supposed to draw inferences and identify problems during data analysis after identifying abnormal data and strengths and clustering data.

18. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Physical assessment integral part of nursing Nurses relied on natural senses Palpation Movement of health care from acute care setting to community care and proliferation of baccalaureate and education Advanced practice nurses Evolution of the Nurse’s Role in Health Assessment: Past

19. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Managed care and internal case management has impact on assessment role of the nurse –Acute care nurses –Critical care outreach nurses –Ambulatory care nurses –Home health nurses –Public health nurses –School and hospice nurses Evolution of the Nurse’s Role in Health Assessment: Present

20. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Evolution of the Nurse’s Role in Health Assessment: Future Rising educational cost Increasing complexity of acute care Growing aging population Expanding health care needs Increasing impact of children and homeless Intensifying mental health issues Expanding health services network Increasing reimbursement for health promotion and preventive care services