TOPIC 1: Conceptual Overview of Nursing Health Assessment

NURSING PROCESS is the cornerstone of the Nursing Profession.Lydia Hall originated the term Nursing Process in 1955.It is a systematic, organized manner of providing goal-oriented and humanistic care that is both efficient and effective.

Nursing Process is organized and systematic because it is composed of six sequential and interrelated steps, namely: ASSESSMENT, DIAGNOSIS, OUTCOME IDENTIFICATION, PLANNING, IMPLEMENTATION AND EVALUATION.

It is goal oriented because of the ff:The plan is implemented in consideration to the unique needs and concerns of the individual patient.It is individualized.It involves aspect of human dignity.

It is efficient because it is relevant to the needs of the patient.It is effective because it utilizes resources wisely in terms of human, time and cost resources.

ASSESSMENTDIAGNOSISOUTCOME IDENTIFICATIONEVALUATIONIMPLEMENTATIONINDIVIDUALFAMILIESCOMMUNITIES

I. ASSESSMENT. Is collecting, validating, organizing and recording data about the patients health status.Purpose- To establish a data base.Activities during assessment: 1. Collecting Data- This involves gathering information about the patient, considering the physical, psychological, emotional, sociocultural

And spiritual factors that may affect his/ or her health status.Types of Data:a. Subjective (Symptoms). Those that can be described only by the person experiencing it.e.g. vertigo (dizziness), tinnitus (ringing in the ears), anorexia (loss of appetite), pain, thirst, nervousness.

b. Objective data (Signs). Those that can be observed and measured.e.g. pallor (paleness), diaphoresis (excessive sweating), jaundice, reddish urine, body temperature of 37 degree centigrade.Methods of Collecting Data:a. Interview. It is planned, purposeful conversation.

e.g. collection of data for health history.admission of pt in the hospital.b. Observation. e.g. use of senses, use of units of measure, physical examination, interpretation of lab results.

Sources of Data:Primary Source- patient.Secondary Source- family members, friends, significant others, patients record or chart, health team members.

2. Verifying/ Validating Data. Making sure your information is accurate.Eg. The patients urine is dark in color. This may indicate dehydration or the patient may had taken certain medication or food. To validate if the patient is dehydrated ask if the pt was vomiting or having inadequate fluid intake.

If no data supports dehydration ask if the pt has been taking medications like rifampicin w/c make cause the urine to orange in color.II. Diagnosing. Is the clinical act of identifying health problems. To diagnose in nursing means to analyze assessment information and derive meaning from this analysis.

Purpose. To identify the patients health care needs and to prepare diagnostic statements.Nursing Diagnosis. Is a statement of patients potential or actual alteration in health status.It uses either the PRS/PES FORMAT:P- roblemR- elated to factorsS- igns and symptoms

P- roblemE- tiologyS- igns and symptomsACTIVITIES during Nsg. Dx1. Organizing Data. Cluster facts into groups of info.e.g. Data about patients nutritional status.

Subjective data: I have no appetite to eatFoods and fluids tastes bitterI feel weak & easily get tiredI feel dizzy most of the timeObjective data:Weight loss of 10 lbs in a weekPallorPoor skin turgorUnable to perfrom ADLDry and sore mucous membrane

2. Compare data gathered during assessment against standards (accepted norms, measures, or patterns for purposes of comparison)e.g. The standard color of skin is pink.The standard rbc level is 5 million.The standard pulse rate of and adult is 60-100 bpm.

3. Analyzing data after comparing with standards.E.g. Passage of frequent watery stools may lead to dehydration and loss of electrolytes like potassium and sodium.Pallor, dyspnea, weakness, fatigue, RBC count of < 5 million cells, and Hgb of less thant 10 g/dl may signify inadequate oxygenation.

4. Identify gaps and inconsistencies in data. E.g. Patient claims she is gaining too much weight but actually, she is underweight.5. Determine the patients health problems, health risks, and strengths.E.g. inadequation nutrition, inadequate oxygenation.

6. Formulate the nursing diagnosis.E.g. Fluid volume deficit related to frequent passage of watery stools.Alteration in nutrition: less than body requirements related to poor appetite.Inadequate oxygenation related to poor oxygen- carrying capacity of the blood.

Comparison of Correct and Incorrect Nsg. Dx1. Correct: Acute pain related to physical exertion.Incorrect: Acute pain related to myocardial infarction.2. Correct: Ineffective breathing pattern related to increased airway secretions.

Incorrect: Ineffective breathing pattern related to pneumonia.III. Outcome Identification. Refers to formulating and documenting measurable, realistic, patient focused goals.Purposes: To provide individualized care.To promote patient and significant others participation.To plan care that is realistic and measurable.

Activities During Outcome Identification:1. Establish priorities.A priority is something that takes precedence in position, deemed to be the most important among several items. Priority setting is a decision- making process that ranks the order of nursing diagnoses in terms of importance to the client.

Priority setting involves the following:Life threatening conditions should be given highest priority, e.g. difficulty in breathing, chest pain, hemorrhage, suicidal tendencies.Use the principles of ABC (airway, breathing, circulation) Airway is given the highest priority.Use the Maslows Hierarchy of Needs. Physiologic needs are given the highest

Priority. E.g. attend first to patient who is vomiting before a patient who is anxious.d. Consider something that is very important to the patient like pain.e. Patients who are unstable are given priority first against those who are stable. E.g. attend first to a patient who has fever rather than the patient who is scheduled for physical therapy in the afternoon.

f. Consider the amount of time, materials, equipment, required to care for patients. E.g. attend to the patient who requires dressing change for post-op wound before attending to a patient who requires health teachings and is ready to be discharged late in the afternoon. Health teaching requires more time and should not be done in a hurried manner.

g. Actual problems take precedence over potential concerns. E.g. fluid volume deficit (actual problem) should be given priority before high risk for infection (potential problem).h. Attend to the patient before the equipment. E.g. assess the patient first before checking contraptions like IV, urinary catheter, drainage tubes.i. Do assessments before implementation, e.g. when a patient complains of pain,

Check for location, severity, etc. and check vital signs before administering an analgesic.Nursing Diagnoses are classified as high priority, medium priority, and low-priority.- High priority Nsg. Dx. are those w/c are potentially life threatening and require immediate action: Impaired gas exchange, ineffective breathing pattern, self- directed risk for violence.

Medium priority Nsg. Dx.- are those that could result in unhealthy consequences, such as physical or emotional impairment, but are not life threatening. E.g. fatigue, activity intolerance, ineffective coping.Low- priority Nsg. Dx.- involve problems that usually can be resolved easily with minimal interventions and are unlikely to cause significant dysfunction. Eg. Sensation of hunger in a patient who is

NPO, in preparation of a diagnostic procedure, minimal pain on the third postop day related to ambulation.2. Establishing patient goals and outcome criteria.A patient goal is an educated guess, made as a broad statement, about what the patients state will be after the nursing intervention is carried out.Behavioral goals are written to indicate a

desired state. They contain an action verb and a qualifier that indicate the level of performance that needs to be achieved.Examples of Behavioral verbs used in Patient goals are as follows:ExplainDistinguishClassifyListIdentifyDemonstrateVerbalizePerformUseThe qualifier is a description of the parameter for achieving the goal.

Examples: Ambulates safely with one-person assistance.Demonstrates signs of sufficient rest before surgeryStates the importance of adopting appropriate health nursing maintenance behaviors.Goals may be short-term or long-term. Short-term goals (STG) can be met in a relatively short period (within days to

Less than a week). Long-term goals can be requires more time (within weeks to months).Outcome criteria are specific, measurable, realistic statements of goal attainment. Outcome- criteria are written in a manner that they answer the questions: who, what actions, under what circumstances, how well, and when.

Therefore a well stated outcome criteria are as follows:S- martM- easurableA- ttainableR- ealisticT- ime- framed

Example of goals and outcome criteria are as follows:Goal: The patient will report a decreased anxiety level regarding surgery.Outcome Criteria: During health teaching, the patient discusses fears and concerns regarding surgical procedure.After health teaching, the patient verbalizes decreased anxiety.

IV. Planning. Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care. To be effective, involve the patient and his family in planning.Purposes:To identify the patients goals and appropriate nursing interventions.To direct patient care activities.

To promote continuity of care.To focus charting requirements.To allow for delegation of specific activities.Activities During Planning1. Planning nursing interventions-To direct activities to be carried out in the implementation phase.- Nursing interventions are any treatment, based upon clinical judgement and knowledge, that a nurse performs to

enhance patient outcomes. They are used to monitor health status; prevent , resolve, or control a problem; assist with activities of daily living (ADLs); promote optimum health and independence.Nursing interventions are also called nursing orders. Nursing interventions/ collaborative activities that nurses carry out to provide patient care.

2. Writing a nursing care plan of care.The nursing care plan of care is written summary of the care that patient is to receive. It is the blueprint of the nursing process.The plan of care is nursing centered. This is essential to identify the scope and depth of the nursing practice. By focusing on the treatment of human responses to actual or potential health problems, the nurse remains in the nursing practice

domain. The plan of care is a step-by-step process. This is evidenced by the following.Sufficient data are collected to substantiate nursing diagnoses.At least one goal must be stated for each nursing diagnosis.Outcome criteria must be identified for each goal.Nursing interventions must be specifically

designed to meet the indentified goal.Each intervention should be supported by a scientific rationale. The scientific rationale is the justification or reason for carrying out the intervention.Evaluation must address whether each goal was completely, partially met or completely unmet.

NANDA- NORTH AMERICAN NURSING DIAGNOSIS ASSOCIATION has accepted list of nursing diagnoses. List in priority order. Use the diagnostic label and related to, followed by manifested by (supporting defining characteristics).V. Implementation. Is putting the nursing care plan into action.Purpose. To carry out planned nursing interventions to help the patient attain goals and achieve optimal level of health.

Activities:Reassessing. To ensure prompt attention to emerging problems.Set priorities. To determine the order in w/c nursing interventions are carried out.Perform nursing interventions. These may be independent, dependent, or interdependent/ collaborative measures.Record actions. To complete nursing interventions, relevant documentation

must be done. NOTE: Something not written is considered not done.Requirements of implementation.Knowledge. Includes intellectual skills like problem- solving, decision making and teaching.Technical skills. To carry out treatments and procedures.Communication skills. Use verbal and

Non verbal communication to carry out planned nursing interventions.4. Therapeutic Use of Self. It is being willing and being able to care.VI. Evaluation. Is assessing the patients response to nursing interventions and then comparing the response to predetermined standards and outcome criteria.Purpose. To appraise the extent to which

Goals and outcome criteria of nursing care have been achieved.Activities:Collect data about the clients response.Compare the patients response to goals and outcome criteria.The four possible judgments that may be made are as follows:The goal was completely met.

The goal was partially met.The goal was completely unmet.Ne problems or nursing diagnoses have developed.Analyze the reasons for the outcomes.Modify care plan as needed.Characteristics of Nursing ProcessProblem oriented. It is comparable with scientific problem solving approaches.

Goal oriented.Orderly, planned and step by step.Open to accepting new information during its application. It is flexible to meet the unique needs of client, family, group or community (dynamic).Interpersonal. It requires that the nurse communicates directly and consistently with the patient.Permits creativity, cyclical.

Universal. It involves the individual, families and communities.TYPES OF DATA:a. SUBJECTIVE DATA symptoms; covert datab. OBJECTIVE DATA signs; overt data (use your senses) VITAL SIGNS TPRB & PainLAB TEST RESULTS

c. CONSTANT DATA dont change over time (e.g. race or blood type)d. VARIABLE DATA change quickly, frequently, or rarely (e.g. BP, age)

Critical Thinking in Relation to Health AssessmentDefinition: a purposeful, goal-directed thinking process that strives to problem solve patient care issues through the use of clinical reasoning (Estes, 2010)

Purpose:To establish potential strategies to assist patients in reaching their desired health goalsComponents of Critical Thinking (in relation to health assessment)1. Interpretation of situations requires the nurse to decode hidden messages, clarify the meaning of the information, and categorize the information.

Example: A patient may claim to be seeking health care for a bad cough and cold, but actually may be concerned about whether the cough is a sign of lung cancer.2. Analysis the nurse examines the ideas and data that were presented, identifies any discrepancies, and reflects on the reason for the discrepancies.

Example: A patient may complain of insomnia but upon questioning reveals that he or she sleeps 6 hours at night and takes a 2-hour nap each afternoon.3. Inference speculates, derives or reasons a specific premise based on information and assumptions obtained from patient; drawing conclusions based from a level of knowledge and experience

Example: If a patient complains of an exacerbation of asthma every morning, the nurse can inquire about a history of heartburn or GERD. An experienced nurse would make the association between these causative factors.4. Explanation requires that the conclusions drawn from the inferences are correct and can be justified.

Example: GERD as a contributing factor of asthma is well documented in the literature; there is a documented scientific link between GERD and asthma. 5. Evaluation examines the validity of the information and hypothesis that leads to a final conclusion that can be implemented.

Example: The nurse assesses a 5-year-old child with cystic fibrosis who is experiencing labored breathing and wheezing. Based on findings, the nurse implements a nebulizer treatment, postural drainage and chest physiotherapy.6. Self-regulation the nurse reflects on the critical thinking skills w/c were employed and determines w/c techniques were effective and which are

problematic.Example: After interviewing the patient, the nurse reflects on whether leading, biased, or judgmental questions were posed to the patient. The nurse might also reflect on the use of open-ended questions and effectiveness of an interpreter.

The Client in the Context of Culture, Spirituality and FamilyHealth assessment involves assessment of the individual as a whole. When you look at a client, you need to see the client in contexts that affect the client (and that the client affects in return). The client is not an isolated individual.

Culturethe totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristic off a population or people that guide these worldview and decisionmaking (Purnell and Paullanka)

Characteristics of CultureIt is LEARNED. - transmitted from generation to generation through socialization and life-experiences.It is SHARED. shared to others through interaction and socializationIt is associated with ADAPTATION TO THE ENVIRONMENT. The group changes to improve its ability to survive as environmental circumstances change.

It is UNIVERSAL. Cultural and Biological Variations affect physical assessmentWithin a culture, there are VARIATIONS of beliefs and practices, and these variations are considered normal.BIOLOGIC VARIATIONS also exists among cultures, and these are also considered normal.

For example, heights and weights may vary significantly, yet the variations are normal. Only the extremes of height and weight are considered abnormal.Why variations?VARIATIONS DUE TO GENETICS AND ENVIRONMENT (nature vs. nurture)Mutations occur in genes, and interbreeding groups whose members mate mostly within the group develop

distinct biological characteristics. Gene variations cause obvious differences such as eye color, and genetic diseases as trisomy 1. In a particular race, members share some distinct biologic characteristics. However, genetic variations do not necessarily occur together, and when looking worldwide, most characteristics vary from high frequency to low frequency across a continuum.

Example: Blonde hair has a high frequency in northern Europe and hair tends to become increasing darker as you move south and east. SELECTED PHYSICAL VARIATIONS RELATED TO HUMAN VARIATIONThe physical variations (resulting from genetic or cultural behaviors) are included directly in the normal and abnormal findings discovered during the assessment process that includes:

1. SURFACE VARIATION example is SECRETIONS. A variation exists among cultures in terms of the number of apocrine and eccrine sweat secretions and the aprocrine secretions of ear wax. Sebacious gland activity and secretions do not show significant variation.

Examples: Eskimos noted to sweat less on their trunks and extremities but sweat more on faces than Caucasians due to adaptation. This allows thermoregulation without dampening clothes.Asians and Native Americans have fewer functioning apocrine glands than do most Cuasians and blacks.

Asians and Native Americans 85% have dry ear waxCaucasians (97%) and Blacks (99%) - have wet ear waxReasons for this genetic variation are thought to include climate and disease susceptibility. For instance, women with dry ear wax have a lower incidence of breast cancer.

2. ANATOMIC VARIATION Example (variation in lower extremity venous valves):Black Africans noted to have fewer valves in the external iliac veins but many more valves lower in the leg than Causcasians thus there is lower prevalence of varicose veins in blacks.3. DEVELOPMENTAL VARIATION Maturity differences appear to be related to both genetics and environment.

Example:African American infants and children end to be ahead of other American groups in motor development.4. BIOCHEMICAL VARIATION AND DIFFERENTIAL DISEASE SUSCEPTIBILITYExamples of these conditions are drug metabolism differences, lactose intolerance, and malaria-related conditions, such as sickle cell disease.

Example:North and Central European ancestry lactose intolerantMediterranean and Africa malaria-related conditionsCultural competence Definition: a dynamic and reflective process of becoming culturally competent5 CONSTRUCTS:

1. CULTURAL DESIRE. This refers to the motivation to want to engage in intercultural encounters and to acquire cultural competence.2. CULTURAL AWARENESS. This refers to the deliberative, cognitive process in which the healthcare provider becomes appreciative and sensitive to the values, beliefs, life ways, practices and problem-solving strategies of a clients culture. It involves SELF-EXAMINATION and

IN-DEPTH EXPLORATION of ones own cultural backgroundStages of Cultural Awareness are:UNCONSCIOUS INCOMPETENCE not aware that one lacks cultural knowledge; not aware that cultural differences exists.CONSCIOUS INCOMPETENCE aware that one lacks knowledge about another culture; aware that cultural differences exist but not knowing what they are or

how to communicate effectively with clients with different cultures.CONSCIOUS COMPETENCE consciously learning about the clients culture and providing culturally relevant interventions; aware of differences; able to have effective transcultural transactions

UNCONCIOUS COMPETENCE able to automatically provide culturally congruent care to client from a different culture; having much experience with a variety of cultural groups and having an intuitive grasp of how to communicate effectively in transcultural encounters)

3. CULTURAL KNOWLEDGE. This refers to the process of seeking and obtaining a sound educational foundation concerning the various worldviews of different cultures.4. CULTURAL SKILL. This refers to the ability to collect relevant cultural data regarding the clients health history and presenting problem as well as accurately performing a physical assessment.

5. CULTURAL ENCOUNTERS. This refers to the process that allows the healthcare provider to engage directly in face-to-face interactions with clients from culturally diverse backgrounds.SpiritualityRELIGION the doingSPIRITUALITY the search for meaning and purpose, seeking to understand and to relate to the sacred

Role of family in Illness: The culture (belief systems and others) in which the family operates and the specific culture developed within the family unit interact to form a context for the client. The familys beliefs about health, illness and related behaviors and the meaning health and illness have for the family tends to affect each members behaviors.

Example: Mr. Thomas drinks excessively. He also smokes and eats whatever he wants (high-fat, calorie-rich diet). His risks for cardiovascular disease are very high. Why does he not maintain a preventive lifestyle? His family believes that men are strong and that it is assign of weakness to practice preventive care.

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