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Nursing health assessment: It's Purpose, Types, and Sources
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Health Assessment:
An IntroductionAn Introduction
Maria Carmela L. Domocmat, RN, MSNInstructor, Nursing Health Assessment
School of NursingNorthern Luzon Adventist College
Assessment: An Introduction
• Purpose
• Types
• Sources
Maria Carmela L. Domocmat, RN, MSN
WE ALWAYS PRACTICE
ASSESSMENT IN OUR DAILY
LIVING
Who among you looked at yourself in the mirror before going to class today?
WHAT CAN YOU SAY ABOUT
THESE PICTURES? WHAT
INFERENCE CAN YOU MAKE?
Assessment
• the collection of data about an individual’s health state
• first and most critical phase of the nursing • first and most critical phase of the nursing process
Maria Carmela L. Domocmat, RN, MSN
Assessment
• ongoing and continuous throughout all the phases of the nursing process
• is systematic and continuous collection, • is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm
Maria Carmela L. Domocmat, RN, MSN
Purpose:
�To establish a data base (all the information about
the client) to determine the client’s overall level of
functioning in order to make a professional clinical
judgment
�To supplement, confirm, or question data obtained
in the nursing history
�To obtain data that will help the nurse establish
nursing diagnoses and plan patient care
Maria Carmela L. Domocmat, RN, MSN
�To evaluate the appropriateness of the nursing
interventions in resolving the patient's identified
pathophysiology problems
�collect data of patient’s health status, to identify collect data of patient’s health status, to identify
deviations from normal, to discover the patient’s
strengths and coping resources, to point actual
problems, and factors that place the patient at risk
for health problems
Maria Carmela L. Domocmat, RN, MSN
• Wholistic data collection.
• Nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the clientabout the client
Maria Carmela L. Domocmat, RN, MSN
�nurse focuses on how client’s health status affects his activities of daily living (ADL) and how the client’s ADL affect is health
�Ex: client with asthma�Ex: client with asthma
Maria Carmela L. Domocmat, RN, MSN
�assess how client interact within their family, cultures, and community and how the client’s health status affects the family and community
�Ex: client with DM who has amputation; single �Ex: client with DM who has amputation; single
parent mother of a 6 year-old child
Maria Carmela L. Domocmat, RN, MSN
• Data from nursing assessment can be classified as subjective and objective.
Maria Carmela L. Domocmat, RN, MSN
Data include:
�nursing health history
�physical assessment
�the physician’s history & physical examinationexamination
�results of laboratory & diagnostic tests
�material from other health personnel
Maria Carmela L. Domocmat, RN, MSN
Performing assessment is like
collecting the pieces of a puzzle
Assessment
– The first step in determining the health status of the
client
– Because the entire plan of care is based on the data
collected during this phase, you need to make every collected during this phase, you need to make every
effort to ensure that your information is correct,
complete, and organized in a way that helps you
begin to get a sense of patterns of health or illness.
Maria Carmela L. Domocmat, RN, MSN
Types of Assessment
Maria Carmela L. Domocmat, RN, MSN
Types of Assessment
• Initial comprehensive assessment
• Ongoing or partial assessment
• Focused or problem-oriented assessment
• Emergency assessment• Emergency assessment
• Time-lapsed assessment
Maria Carmela L. Domocmat, RN, MSN
Initial comprehensive assessment
• assessment performed within a specified time on admission
Maria Carmela L. Domocmat, RN, MSN
Initial comprehensive assessment
• Involves collection of subjective data about the
– client’s perception of his/her health of all body parts or
systems,
– past health history,
– family history, and – family history, and
– lifestyle and health practices (which includes information
related to the client’s overall function) as well as objective
data gathered during a step-by-step physical examination
Maria Carmela L. Domocmat, RN, MSN
Initial comprehensive assessment
When performed?
• On the initial contact with the client
• where: hospital, community, clinic or home settingsetting
• purpose: to have a baseline comprehensive data about the client
• Ex: nursing admission assessment
Maria Carmela L. Domocmat, RN, MSN
Ongoing or partial assessment
Maria Carmela L. Domocmat, RN, MSN
Ongoing or partial assessment
• consists of data collection that occurs after the comprehensive database is established
• consists of mini-overview of the client’s body systems and holistic health patterns as a follow-systems and holistic health patterns as a follow-up on his health status
Maria Carmela L. Domocmat, RN, MSN
Ongoing or partial assessment
• When performed?
• usually performed whenever the nurse or another health care professional has an encounter with the clientencounter with the client
Maria Carmela L. Domocmat, RN, MSN
Ongoing or partial assessment
• purposes:
• Any problems that were initially detected in the
client’s body system or holistic health patterns
are reassessed in less depth to determine any are reassessed in less depth to determine any
major changes (deterioration or improvement)
from the baseline data.
• Brief reassessment of the client’s normal body
system or wholistic health patterns is performed
to detect new problems
Maria Carmela L. Domocmat, RN, MSN
Focused or problem-oriented assessment
• consists of a thorough assessment of a particular health problem and does not cover areas not related to the problem
• purpose: to have a thorough assessment on the • purpose: to have a thorough assessment on the special health concern of the client identified in an earlier assessment
Maria Carmela L. Domocmat, RN, MSN
Focused or problem-oriented assessment
• When performed?
• performed when a comprehensive database exists for a client and he/she comes to the health care agency with a special health concernhealth care agency with a special health concern
Maria Carmela L. Domocmat, RN, MSN
Emergency assessment
• a very rapid assessment performed in a life-threatening situations
• rapid assessment done during any physiologic/physiologic crisis of the client to physiologic/physiologic crisis of the client to identify life threatening problems
Maria Carmela L. Domocmat, RN, MSN
Emergency assessment
• purpose: to determine the status of the client’s life-sustaining physical functions
Maria Carmela L. Domocmat, RN, MSN
Time-lapsed assessment
• reassessment of client’s functional health pattern done several months after initial assessment to compare the client’s current status to baseline data previously obtained.data previously obtained.
Maria Carmela L. Domocmat, RN, MSN
Sources of Data
Maria Carmela L. Domocmat, RN, MSN
Sources of Data
• Primary source:
• Secondary source:
Maria Carmela L. Domocmat, RN, MSN
Sources of Data
• Primary source:– data directly gathered from the client using
interview and physical examination.
Maria Carmela L. Domocmat, RN, MSN
Sources of Data
• Secondary source:– data gathered from client’s family members,
significant others, client’s medical
records/chart, other members of health team, records/chart, other members of health team,
and related care literature/journals.
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN