Nurses Role in Health Assessment

lOMoAR cPSD| 16912828
Chapter 1 Nurse’s Role in Health Assessment Collecting and

Analyzing Data
Chapter 1 Nurse’s Role in Health Assessment:

Collecting and Analyzing Data
Learning Objectives
1. Discuss how nursing assessment skills are needed for every situation the nurse
encounters.
a. As a nurse you will observe situations and collect info to make nursing
judgments no matter whatthe setting. Professional nursing assessments you
make on a client family or community determinenursing interventions that
directly or indirectly influence their health status
2. Differentiate between a holistic nursing assessment and a physical medical
assessment.
a. HOLISTIC- collects holistic subjective & objective data to determine
overall level of functioning to make a nursing diagnosis
i. The nurse assesses the physiologic, psychologic,
sociocultural, developmental, & spiritual data about a client.
ii. The mind, body, & spirit are interdependent factors.
iii. The nurse focuses on how the client's health status affects
ADLs, on how clients interact w/ their family/community, &
how it affects them.
b. Physical medical assessment
i. focuses of physiological status
ii. Less focus may be placed on psychological, sociocultural, or
spiritual well-being.
3. Describe which phases of the nursing process involve assessment by the nurse.
a. Assessment is ongoing and continuous throughout all phases of the nursing
process; therefore all phases of the nursing process involve assessment.
4. List and describe the steps of the nursing process, explaining how some steps
overlap and may have to be repeated many times when caring for a client.
I Assessment Collecting subjective and objective data
• Analyzing & synthesizing (combining) data
• Making judgements about effectiveness of
nursing interventions
• Evaluating client care outcomes
• Steps of HA: collect subj. data, collect obj.
data, validate, & documentation.
First & most critical phase
If data is inaccurate, it may cause the nurse to make
incorrect judgements, which can affect the remaining
phases of the process.
Assessment phase is ongoing & continuous throughout
all the phases.
Health assessment consists of health history & physical
examination
II Diagnosis Analyzing subjective and objective data to
make a professional nursing judgment
(nursing diagnosis, collaborative problem, or

referral)
III Planning Determining outcome criteria and
developing a plan
IV Implementati Carrying out the plan
on
V Evaluation Assessing whether outcome criteria have
been met and revising the plan as necessary
5. Describe the steps of the “analysis phase” of the nursing process.

a. 7 major steps of data analysis
i. Identify abnormal data & strengths
ii. Cluster data
iii. Draw inferences & identify probs.
iv. Propose possible nursing dx
v. Check the defining charac. Of dx
vi. Confirm/rule out nursing dx
vii. Document conclusions
b. Purpose: arrive to a conclusion about client’s health at the ned of the
assessment.
c. Analyzing & stynthesizing data reveals if it’s a:
i. Nursing concern: nursing diagnosis: a clinical judgement
concerninga human response to health conditions
ii. Collaborative problem: nurse implements physician & nurse
prescribed interventions
iii. Refferal: a Concern that needs to be reffered
1. Nurse uses a holistic assessment & identifies problems that
require assistance from other HCM.
6. Compare and contrast the four basic types of nursing assessment:
a. Initial comprehensive: collection of subj. & obj. data
i. Ex: physical examination on a new pt
b. Ongoing or partial: data collection after the comprehensive database is
established.
i. brief assessment used to detect new probs./ see if any problems got
better/ worse
ii. Ex: a pt who came to the clinic last week for the first time comes again
to get checked a month later
1. partial assessment of a client admitted to the hospital w/ lung
cancer requires frequent assessment of resp. rate, oxygen
saturation & capillary refill.
c. Focused/problem oriented: thorough assessement of a particular client prob.
& does NOT address areas NOT r/t the prob.
i. Ex: a pt tells you that they have ear pain, use COLDSPA to get more
info about the are & you wouldn’t ask him questions that are not r/t the
issue.
d. Emergency: rapid assessment performed in life-threatning situations
i. Ex: evaluating a pt’s ABCs when cardiac arrest is suspected.
7. Explain how the nurse’s role in assessment has changed over the past century.
a. Today, nurse's not only use their physical senses to makes assessment, like it
was used in the past century. The advancement of technology has allowed
the expansion of the nurse's assessment. Furthermore, the increased

necessity of assessment skills
b. Technology has changed/ health care system change over years
c. Nurse’s make independent interventions that they are responsible for.
8. Describe what the nurse’s role in assessment may be 25 years from now.
a. There will be an increase in specialization & diversity of assessment skills for
nurses. As technology advances & patient acuity, & health challenges, will
involve the need for nurse's to use assessment skills.
9. 4 major steps of the assesemnt phase
a. Collection of subjective data- subjective data are sensations/symptoms(ex:
pain/hunger) feelings (ex: happiness/sadness) perceptions, desires, personal
info, etc. that can verified by the patient
i. Major areas of S.D-
1. Biographical info (name, age, occupation, religion)
2. History of present health concern
3. Personal health history
4. Fam. History
5. Health & lifestyle
6. Review of systems
b. Collection of objective data- examiner directly observes objective data
i. Inc.:
1. Physical characteristics (skin color/posture)
2. Body func. (heart/respiratory rate)
3. Appearance (dress/hygiene)
4. Behavior (mood/affect)
5. Measurements (BP/temp/weight/height)
6. Lab results
ii. This type of data is obtained by general observation & the 4
physical examination techniques:
1. inspection, palpitation, percussion, & auscultation.
2. Also, by medical/health records & observations noted by fam.
Of the client
c. Validation of data - CRUCIAL PART OF ASSESSMENT
i. Often happens w/ collection of subjective & objective date
ii. Serves to ensure that assessment process isn't completed before ALL
RELEVANT data is collected. This helps prevent inaccurate data
d. Documentation of data- forms the database for the entire nursing process &
provides data for all other membs. Of the health care team.
i. Accurate documentation is VITAL bc it ensures that valid conclusions
are made.

Nurses Role in Health Assessment

Uploaded by

Copyright:

Available Formats

Nurses Role in Health Assessment

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nurses Role in Health Assessment

Uploaded by

Copyright:

Available Formats

lOMoAR cPSD| 16912828

Chapter 1 Nurse’s Role in Health Assessment Collecting and

Chapter 1 Nurse’s Role in Health Assessment:

(nursing diagnosis, collaborative problem, or

5. Describe the steps of the “analysis phase” of the nursing process.

the expansion of the nurse's assessment. Furthermore, the increased

You might also like