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

2.  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

3.  Three primary components:  History (subjective data)  Physical examination (objective data)  Documentation of data Copyright © 2013 by Mosby, an imprint of Elsevier Inc.3

4.  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 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.4

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6.  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 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.6

7.  Amount of information gained during a health assessment depends on several factors, including:  Context of care  Patient need  Expertise of the nurse Copyright © 2013 by Mosby, an imprint of Elsevier Inc.7

8.  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. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.8

9. Types of assessment:  Comprehensive health assessment  Problem-based or focused health assessment  Episodic assessment  Screening assessment Copyright © 2013 by Mosby, an imprint of Elsevier Inc.9

10.  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. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.10

11.  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. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.11

12.  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. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.12

13. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.13

14.  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 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.14

15.  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. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.15

16.  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. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.16

17.  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. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.17

18.  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. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.18

19.  Framework for health promotion efforts found in Healthy People 2020 :  http://www.healthypeople.gov/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. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.19

20.  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. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.20

21. 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. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.21

22. 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 action B. Reflection in action C. Tertiary prevention of health care-associated infections D. Reasoning patterns Copyright © 2013 by Mosby, an imprint of Elsevier Inc.22

23. 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 education B. Primary prevention C. Secondary prevention D. Tertiary prevention Copyright © 2013 by Mosby, an imprint of Elsevier Inc.23