NCMHAS1 – Health Assessment _ The Nursing Process

ROLE OF THE PROFESSIONAL NURSE -identify expected outcomes for a plan individualized
to the patient or the situation
Patient
–center of practice Planning
- includes: individuals, families, communities, -develop a plan that strategies and alternatives to
population group attain expected outcomes
Nursing
–not simply a collection of specific skills, not simply Implementation
a person trained to perform tasks -implementation of the identified/formulated plan
–is a profession - coordination of care coordinates care delivery
- health teaching and health promotion
- Consultation –a lower level consults a higher
Science and Art of Nursing Practice: level ( from novice to expert)
- multidimensional and constantly changing. - Prescriptive authority and treatment

5 Levels of Proficiency (Benner, 1984) Evaluation

Novice –evaluate progress toward attainment of outcomes
Advanced beginner
Competent
Proficient Standards of Practice
Expert - describe a competent level of nursing care
- application of the nursing process:
Expert Clinical nursing practice assessment, diagnosis, outcomes
Knowledge identification and planning,
Ethics implementation, and evaluation
Aesthetics
Clinical experience Standards of Professional Performance
- describe a competent level of behavior in the
Critical thinking and decision making professional role
Knowledge - assures patients that they are receiving high-
Experience quality care
Critical thinking - measures are in place to determine whether
Standard of care nursing care meets the standards.

Scope and Standards of Practice

- knowledge from social and behavioral ANA Standards of Professional Performance
sciences - Ethics
- biological and physiological sciences - Education
- nursing theories - Evidenced-Based Practice and Research
- ethical and social values - Quality of Practice
- professional autonomy - Communication
- a sense of commitment and community - Leadership
- Collaboration
Nursing is - Professional Practice Evaluation
- protection, promotion, and optimization of - Environmental Health
health and abilities
- prevention of illness and injury Professional Responsibilities and Roles.
- alleviation of suffering through the diagnosis
and treatment of human response Autonomy and Accountability
- advocacy in the care of individuals, families, Autonomy
communities, and populations -initiation of independent nursing interventions
without medical orders.
Accountability
ANA Standard of Nursing Practice (ADPIE) -regulated through nursing audits and standards of
Assessment practice.
–collect comprehensive data pertinent to the
patient’s health and/or the situation Caregiver – helps patient; maintenance
Advocate – protect
Diagnosis Educator – explain and demonstrate
-analyze the assessment data to determine the Communicator – coordinate
diagnoses or issues Manager – collaborate
Outcome identification Administrator – manages, strategize
Researcher – conducts evidence-based practice
NCMHAS1 – Health Assessment _ The Nursing Process
Career Development ▪ Sterile
- growth of nursing as a profession, and a ▪ Clean
- greater concern for job enrichment, o Gown
- different career opportunities, opportunities o Wear a gown that is appropriate to the
include: task, to protect skin and prevent soiling
o advanced practice registered nurses or contamination of clothing during
(APRNs) procedures and patient care activities
o nurse researchers when contact with blood, body fluids,
o nurse risk managers secretions, or excretions is anticipated.
o quality improvement nurses ▪ Surgical gown
o consultants ▪ Emergency Dept Gown
o business owners ▪ Neonatal Intensive Care Unit
Gown
Roles o Mask, Eye, Nose Protection
Provider of Care o Use PPE to protect the mucous
-direct patient care in an acute care setting (hospital, membranes of the eyes, nose, and
home, community) mouth during procedures and patient
care activities that are likely to
Advanced Practice Registered Nurses generate splashes or sprays of blood,
-independently functioning nurse and has advanced body fluids, secretions, and excretions.
education and expertise in a specialized area ▪ Goggles
▪ Face shield
- Clinical Nurse Specialist ▪ Mask
o Geriatrics - REMEMBER:
o Critical Care o Use aseptic technique to avoid
o Rehabilitation contamination of sterile injection
o Disease specialty equipment.
- Certified Nurse Practitioner o Do not administer medications from
o Provides care to a group of patients a syringe to multiple patients, even if
- Certified Nurse Midwife the needle or cannula on the syringe is
o Nurse-midwifery changed.
- Certified RN Anesthetist o Use single-dose vials for parenteral
o Advanced nurse anesthesia-accredited medications whenever possible.
program o Use fluid infusion and
administration sets for one patient
only, and dispose of them
appropriately after use.
o If multidose vials must be used, both
the needle or cannula and syringe
used to access the multidose vial must
be sterile.
o Do not keep multidose vials in the
immediate patient treatment area
SAFETY PRECAUTION AND PREVENTION and store in accordance with the
OF INFECTION manufacturer’s recommendations;
discard if sterility is compromised or
STANDARD PRECAUTIONS - Assume that questionable.
every person is potentially infected (CDC) o Do not use bags or bottles of
UNIVERSAL PRECAUTIONS – Handwashing intravenous solution as a common
and Hand hygiene (WHO) source of supply for multiple
PREVENTION patients.
PPE
- Wear PPE when the nature of the anticipated
patient interaction indicates that contact with
blood or body fluids may occur.
- Prevent contamination
o Gloves
o Wear gloves when it can be
reasonably anticipated that contact
with blood or other potentially
infectious materials, mucous
membranes, nonintact skin, or
potentially contaminated intact skin
NCMHAS1 – Health Assessment _ The Nursing Process
NURSING ASSESSMENT - systematic collection Types of Questions
of information about a patient - Open-ended
- Leading
• Subjective Data – Interview - Back-channeling
• Objective Data – Assessment and - Probing
observations - Direct
Types of Assessment
- Health history taking NURSING DIAGNOSIS
o Present Medical Illness - clinical judgment made on the basis of
o Past Medical Illness information
o Heredofamilial history / Familial - diagnostic conclusions
o Lifestyle
- Physical assessment North American Nursing Diagnosis Association
o Inspection International (NANDA-I)
o Palpation
o Percussion TYPES OF NURSING DIAGNOSES:
o Auscultation NANDA-I nursing diagnoses include three types:
o Olfaction - problem-focused,
- Periodic assessment - risk, and
Cue – information obtained through senses - health promotion
Inference – judgement or interpretation of cues
Data Clustering
Comprehensive Patient History - organizing all of a patient's data into
- Detailed assessment of patient meaningful and usable data clusters
- Two approaches
o Watson and Foster’s Model of “The Data Interpretation
Attending Caring Nurse” - analyzing clusters of defining characteristics
o Gordon’s Model of 11 Functional or risk factors
Health Patterns
- The 13 Areas of Assessment Formulating a Diagnostic Statement
Types of Data - select the correct nursing diagnostic
- Subjective Data statement
o Verbal description - Diagnostic Label - describes the essence of a
o Patient’s feelings, perceptions, and patient's response to health conditions
self-report of symptoms - Related Factor - appropriate for problem-
- Objective Data based and some health promotion diagnoses
o Observations and measurements of
patient status
Sources of Diagnostic Errors
o Vital signs, IPPAO
Sources of Data - Error in Data Collection
- Patient - Error in Interpretation
- Family and Significant others - Error in Data Clustering
- Health care team - Error in Diagnostic Statement
o Hand-off (endorsement)
- Medical Records
- Other records and Scientific Literature
- Nurse’s Experience
Patient-centered Interview
- Organized conversation
- Motivational interviewing
o Counseling and health teaching
- Communication Calls
o Courtesy
o Comfort
o Connection
o Confirmation
Phases of Interview
- Orientation
- Working
- Termination
NCMHAS1 – Health Assessment _ The Nursing Process
NURSING PLANNING SYSTEMS FOR PLANNING NURSING CARE
- after making a medical diagnosis - Traditional Charting
- health care provider will choose - EHR or Electronic Health Record
interventions
- communicate the plan to the health care The Nursing Care Plan (NCP)
team - nursing diagnoses, goals and/or expected
outcomes, specific nursing interventions,
Establishing Priorities and a section for evaluation findings
- ordering of nursing diagnoses or patient - a guideline for coordinating nursing care,
problems using notions of urgency and promoting continuity of care, and listing
importance outcome criteria to be used later in
- ABC evaluation
- Maslow’s Hierarchy of needs
- Classification of Importance
o High
o Intermediate
o Low
- Priorities in Practice
o Successful priority setting also
involves working well with the
health care team
o helping a patient achieve or maintain
a desired level of health.
- Roles of Patient
o Compliance Hand-off Reporting
- Selecting Goals and Expected Outcomes - transferring essential information (along
o patient-centered goal reflects a with responsibility and authority) from one
patient's highest possible level of nurse to the next during transitions in care
wellness and independence - provide accurate, up-to-date, and pertinent
o nursing-sensitive patient outcome information to the next nurse assuming
is a measurable patient, family, or patient care
community state, behavior, or
perception largely influenced by and Student Care Plan
sensitive to nursing interventions - problem-solving techniques, the nursing
o Goals should be “SMART” process, skills of written communication,
▪ Specific – precise and organizational skills for nursing care
▪ Measurable - observe if
change takes place in a Care Plans for Community-based settings
patient's status - Planning care for patients in community-
▪ Attainable - mutually set with based settings applies the same principles of
the patient nursing practice.
▪ Realistic - realistically reach - Same with NCP but Health Promotion is
and patient willingness included
▪ Time-bound - common time
frame for problem resolution

Types of Intervention
- Nurse-initiated
- Healthcare provider initiated
- Collaborative intervention

Six important factors in choosing interventions

- desired patient outcomes,
- characteristics of the nursing diagnosis,
- research base knowledge for the
intervention,
- feasibility for doing the intervention,
- acceptability to the patient, and
- your own competency
NCMHAS1/NCLHAS1 – Health Assessment
NURSING INTERVENTION Standard of Care
- Actions taken by the nurse to achieve - minimum level of care
patientgoals and get desired outcomes - pain-control measures, mouth
careguidelines, and diet therapy
Actions
- Dx – Diagnostic Approach Standard of Evaluation
- Tx – Therapeutic Approach - resolve actual health problems,
- Ex – Educative Approach - prevent the occurrence of
potentialproblems, and
Implementations - maintain a healthy state
- Independent intervention
- Physician intervention Collaborate and Evaluate Effectiveness
- Collaborative intervention ofIntervention

Outcomes Document Results

- Goal Met
- Goal Partially Met
- Goal Not Met

NURSING EVALUATION
- final step of the nursing process
- evaluative measures to determine if
yourpatients met expected outcomes,
not if nursing interventions were
completed

Evaluative Measures
- remained the same
- improved
- worsened
- changed

Critical Thinking in Evaluation

- Examine Results
o Reflection in action -
continuouslyexamine results
- Compare Achieved Effect with Goals
andOutcomes
o evaluate whether the results of
carematch the expected outcomes
and goals set for a patient
- Interpreting and Summarizing Findings
o interpret or learn to recognize
relevant evidence about a
patient'scondition
- Recognize Errors or Unmet Outcomes
o engage in self-reflection, you
cannotassume that your treatment
approaches will be successful
▪ Self-reflection and
Correctionof Errors
▪ Care plan revision
▪ Discontinuing a Care Plan
▪ Modifying a Care Plan
▪ Reassessment
▪ Redefining Diagnosis
▪ Goals and
Expected
Outcomes
▪ Interventions
NCMHAS1/NCLHAS1 – Health Assessment
TECHNIQUE IN PHYSICAL ASSESSMENT • Consistency of structure (solid, fluid-
Indications for Physical Assessment filled)
- Routine screening • Slow and systematic
- Eligibility prerequisite for health insurance, • Light to deep
military service, job, sports, school • Light palpation (tenderness)
- Admission to a hospital or long term care • Deep palpation (abdominal
facility organs/masses)
- For Accurate Palpation
Steps in Assessment • Examiner finger nails should be
- Think short.
- Organize • Use sensitive part of the hand.
- Environment
• Light Palpation precedes deep
- Accommodate special needs (cultural
palpation - start with light then deep
sensitivity)
palpation
- Equipment - clean surface & clean
• Tender area are palpated last
equipment
- Room - quiet, warm & well lit • Tell client to take slow deep breath
- Maintain privacy to enhance muscle relaxation.
- Observe & Listen • Examine condition of the abdominal
- REVIEW GENERAL INFORMATION organs
- INTRODUCE SELF TO CLIENT • Depressed areas must be
- OBTAIN HEALTH HISTORY approximately “2cm”
- CONDUCT PAIN ASSESSMENT • Assess turgor of skin measured by
lightly grasping the body part with
Physical Assessment finger tips.
Inspection - Light palpation – 1-2cm
- “the use of the senses of vision, smell and - Deep palpation – 3-4cm
hearing to observe the normal condition or
any deviations from normal of various body Percussion
parts.” - Tap a portion of the body to elicit
• Use vision, hearing & smell tenderness that varies with the density of
• Always first underlying structures.
• Look for symmetry - Direct method
• Use good lighting • Involving striking the body surface
directly with one or two fingers.
• Use good exposure
- Indirect method
- For accurate inspection
• Use a quick & sharp stroke
• good lighting either day light or
artificial light is suitable. • Plexor (dominant)
• expose body part/s being observed • Pleximeter (non dominant)
only. - Fist percussion
- Tympany – Large pneumoThorax
• look before touching.
- Resonance – NoRmal lung
• warm room for examination of the
- Hyper-resonance – EmpHysematous lung
client “not cold not hot".
- Dullness – “De Liver”
• Observe for color, size, location, - Flatness - Muscle
texture, symmetry, odors, and
sounds. TTRRHHDeliverFM
• Compare each area inspected with
the opposite side of body if Auscultation
possible. - “To listen for various breath, heart, and
• Use pen light to inspect body bowel sounds”
cavities. - Direct or immediate
Palpation • w/o amplifying device
- Touch & feel with hands - Mediate auscultation
• Texture – use fingertips (roughness, • Use of steth
smoothness). - Purpose:
• Temperature – use back of hand • Listening to body sounds
(warm, hot, cold). • Movement of air (lungs)
• Moisture (dry, wet, or moist).
• Blood flow (heart)
• Organ location and size • Fluid & gas movement (bowels)
NCMHAS1/NCLHAS1 – Health Assessment
• Remember the sound changes in the VITAL SIGNS
abdomen Temperature
- How to begin: - Heat produced by body processes
• Positions for physical exam - Types of Body Temperature
• Using a stethoscope: • Surface Temperature – skin
• Longer the tube – more sound has to temperature
travel • Core temperature –temperature of
• Hold diaphragm firmly against the deep tissues
client’s skin (NOT THROUGH - Factors that affect heat production
CLOTHING) • Basal metabolic rate
• If using bell – less pressure • Muscle activity
• Warm in your hands first! • Thyroxine output
• Listen / Concentrate on the sounds • Epinephrine, norepinephrine and
sympathetic stimulation
Olfaction • Fever
- certain alteration is body function create - Processes Involved in Heat Loss:
characteristic body odors, smelling can • Radiation (electromagnetic)
detect abnormalities that unrecognized by • Conduction (direct)
other means. • Convection (air)
• Alcohol odor from oral cavity • Evaporation (water vapor)
means ingestion of alcohol. - Alterations
• Ammonia from urine means • Pyrexia / Hyperthermia / Fever
urinary tract infection.  Intermittent Fever - where
• Body odor from skin, particularly in the temperature elevation is
areas where body parts rub together present only for a certain
means poor hygiene, excess period, later cycling back to
perspiration (bromidrosis). normal
• Foul odor from wound site means  Malaria
wound abscess,  Leishmaniasis
• Foul odor from vomitus this means  Pyemia
bowel obstruction,  Sepsis
• Foul odor from rectal area this  Remittent Fever - where the
means fecal incontinence. temperature remains above
• Foul–smelling stools in infant from normal throughout the day
stool means mal absorption and fluctuates more
syndrome. than 1 °C in 24 hours
• Halitosis from oral cavity means  Ineffective
poor dental and oral hygiene, gum endocarditis
disease.  Brucellosis
• Sweet, fruity ketones from oral  Relapsing Fever - recurring
cavity may be from diabetic bouts of fever
acidosis.  Constant Fever -continuous
• Musty odor from casted body part  Stages of Fever
means infection inside cast.  Onset (chill phase)
• Fetid odor from tracheostomy or  Course (plateau
mucous secretions means infection phase)
of bronchial tree (pseudomonas  Deferverescence
bacteria). (flush)
Summary  Diagnosis
- Obtain a nursing history and survey  Risk for imbalanced
- Maintain privacy. body temperature
- Explain the procedure  Ineffective
- Always inspect, palpate, percuss, and then thermoregulation
auscultate  Hyperthermia
*except abdominal start with  Hypothermia
auscultate
- Compare symmetrical sides
- If abnormality (Symptom analysis)
- Client teaching
- Allow time for client’s questions.
NCMHAS1/NCLHAS1 – Health Assessment
• HEAT STROKE - Assessment:
S – Stomach – irrigate! • Rate
T – towel and hypothermia blankets • Rhythm
R – remove – excess clothing • Volume
O – oscillating fan • Arterial wall elasticity
K – keep in a cold environment • Presence or absence of bilateral
E – emergency treatment and IVF equality.
• HEAT EXHAUSTION – occurs when - Clinical signs of cardiovascular alterations
profuse diaphoresis • Dyspnea
• HYPOTHERMIA • Fatigue
 Signs • Pallor
C – cyanosis • Cyanosis
O – opinion/judgment - POOR • Palpitations
L – loss of memory
• Syncope
D – depression
• Impaired peripheral tissue perfusion
D – drop – VITAL SIGNS
- Nurse – be aware of:
U – unresponsive to pain
S – shivering • Medications
 Implementation • Physically active – wait 10-15
W – Wrap with blanket minutes
R – remove – wet and • Baseline data
replace – with dry • Position
A – allow – hot drinks - Pulse Sites
P – place – warm are • Temporal artery
place – heating pads • Facial artery
- Formula for Conversion of Temperature: • Carotid artery
C = (Fahrenheit temperature – 32) x 5/9 • Brachial artery
F = (Celsius temperature x 9/5) + 32 • Radial artery
• Femoral artery
Pulse • Popliteal artery
- is a wave of blood created by contraction • Posterior tibial artery
of the left ventricle of the heart. • Dorsalis pedis artery
- Compliance – the ability of the arteries to - Implementation
contract and expand. • Preliminary steps
- Cardiac output – volume of blood pumped  Introduce and explain
into the arteries by the heart and equals the  Hand hygiene
result of the stroke volume (SV) times the  Privacy
heart rate (HR) per minute.  Position
• CO = SV x HR/time • Palpate or Auscultate
- Newborn – 80-180
• Pressure – moderate
- 1yr old – 80-140
• Palms facing down
- 5-8yrs old – 75-120
- Evaluate
- 10yrs old – 50-90
- Teen – 50-90 • Relate to baseline and general health
- Adult – 60-100 status
- Older Adult – 60-100 • Report changes
- Factors Affecting the Pulse: • Appropriate follow-up
• Age
• Gender Respiration
- Act of breathing
• Exercise
• Inhalation/ Inspiration – intake of air
• Fever
into the lungs
• Medications
• Exhalation/ Expiration – breathing
• Hypovolemia
out
• Stress
- Costal Breathing
• Position changes • Thoracic breathing
• Pathology • Involves external intercostal muscles
and other accessory muscles
- Diaphragmatic Breathing
• Abdominal breathing
NCMHAS1/NCLHAS1 – Health Assessment
• Involves contraction and relaxation Blood Pressure
of the diaphragm - Arterial Blood Pressure
- Factors affecting Respiration: • measure of the pressure exerted by
• Exercise the blood as it flows through the
• Stress arteries.
• Increased environmental temperature - Pulse pressure
• Lowered O2 concentration • difference between the diastolic and
• Increased altitudes the systolic - 40 to 100 mmHg
• Medications - Systolic Pressure
- Assessment • the pressure of the blood as a result
• Rate of contraction of the ventricles, that
• Depth is, the pressure height of the blood
wave.
• Rhythm
- Diastolic Pressure
• Quality
• is the pressure when the ventricles
• Effectiveness
are at rest.
- Rate
- Determinants of Blood pressure
• EUPNEA – normal
• Pumping action of the heart
• TACHYPNEA – rapid
• Peripheral vascular resistance
• BRADYPNEA – abnormally slow
• Blood viscosity
breathing
- Factors affecting Blood Pressure:
• APNEA – cessation of breathing
• Stress
- Rhythm
• Exercise
• CHEYNE-STOKESBREATHING
• Race
 rhythmic waxing and waning
of respirations, from very • Gender
deep to very shallow • Medications
breathing and temporary • Obesity
apnea; • Diurnal variations
- Volume • Disease process
• Hyperventilation - Hypertension
• Hypoventilation • A blood pressure that is persistently
- Ease or Effort above normal.
• Dyspnea – difficult and labored • Primary hypertension
breathing  Elevated BP of unknown
• Orthopnea – breath only in upright cause.
sitting • Secondary hypertension
- Diagnosis  Elevated BP of known cause
• Ineffective airway clearance related • Signs and symptoms of hypertension
to inflammatory process and H – headache
dehydration E – ear - ringing
• Impaired gas exchange related to N – nosebleeds
alveolar-capillary membrane F – flushing of face
changes F - fatigue
• Ineffective breathing pattern • Normal = <120/<80
related to upper abdominal • Prehypertension = 120-139/80-89
incisional pain • Hypertension 1 = 140-159/90-99
- Implementation • Hypertension 2 = >160/>100
• Preliminary procedure - Hypotension
• Observe or palpate • A blood pressure that is below
• Observe for the rate, rhythm and normal.
character of respirations • Systolic - <85 and 110 mmHg
• Document • Orthostatic hypotension
- Evaluation  Is a blood pressure that falls
• Relate to baseline and general health when the client sits or stands.
status  Assessment of Orthostatic
• Report changes hypotension
• Appropriate follow-up  Supine – 10 minutes
 Record BP and PR
 Assist to sitting
NCMHAS1/NCLHAS1 – Health Assessment
 Take BP and PR
 Repeat BP – after 3
minutes
 Record
• Signs and symptoms of hypotension
C – cool and clammy skin
D – dizziness
C – cyanosis
M – mental confusion
R – restlessness
T – tachycardia
- Assessing BP on thigh if:
• Cannot be measure on either arms of
the client
• BP on one thigh is compared with
the other.
- BP – not measured on a limb when:
• Shoulder, arm or hand – injured
• Cast or bulky bandage
• Surgical removal of axilla lymph
nodes
• IV infusion
• Arteriovenous fistula
- Assessment
• DIRECT
 Invasive procedure
 Arterial pressure
• INDIRECT
 Palpatory
 Auscultatory
*Ausculatatory gap –
temporary disappearance of sounds.
- Korotkoff Sound
• Phase 1
 First sound – systolic BP
• Phase 2
• Phase 3
• Phase 4
• Phase 5
 Last sound is heard –
followed by a period of
silence
 Diastolic pressure in adults
- Evaluation
• Relate to baseline and general health
status
• Report changes
• Appropriate follow-up