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Overview of Nursing Health Assessment

The document discusses the history and development of health assessment in nursing. It introduces Lydia Hall who in the 1950s implemented the 3Cs of nursing - core, care, and cure. In the 1970s, the American Nurse Association created the nursing process and expanded the 3Cs. The nursing process involves assessment, planning, implementation, and evaluation (APIE), which was later changed to assessment, diagnosis, planning, implementation, and evaluation (ADPIE). Assessment is the first step of the nursing process and involves collecting subjective and objective data from patients, organizing the data, analyzing it, and documenting it. There are different types of assessments including initial, ongoing, focused, and emergency assessments. Preparation is important prior to

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137 views4 pages

Overview of Nursing Health Assessment

The document discusses the history and development of health assessment in nursing. It introduces Lydia Hall who in the 1950s implemented the 3Cs of nursing - core, care, and cure. In the 1970s, the American Nurse Association created the nursing process and expanded the 3Cs. The nursing process involves assessment, planning, implementation, and evaluation (APIE), which was later changed to assessment, diagnosis, planning, implementation, and evaluation (ADPIE). Assessment is the first step of the nursing process and involves collecting subjective and objective data from patients, organizing the data, analyzing it, and documenting it. There are different types of assessments including initial, ongoing, focused, and emergency assessments. Preparation is important prior to

Uploaded by

Louie Jaie Tired
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Introduction of Health Assessment

Lydia Hall ( 1950s)

 she implemented the 3Cs

CORE- refers to the patient.

CARE- refers to the nurse.

CURE- this refers to the intervention either medical/physician and the nurses.

The 3Cs are interconnected and interrelated.

1970, American Nurse Association

 American Nurse Association created the nursing process.


 American Nurse Association expanded the 3Cs.
 Nursing Process was initiated in the year 1970.
 Lydia Hall is the first key person who created the nursing process.
 APIE was initiated (ASSESSMENT, PLANNING, IMPLEMENTATION, EVALUATION) in the year of
1970.
 APIE was changed in the year 1978 and became ADPIE (ASSESSMENT, DIAGNOSIS, PLANNING,
IMPLEMENTATION, EVALUATION)
 Nursing process is a systematic or flexible or changing and apply scientific basis.
 Nursing process is the backbone of the health assessment.

ASSESSMENT

 it is a process of obtaining data either subjective data or objective data.


 organizing the data, validating/analyzing the data and documenting the data.
 baseline information or basis of nursing care.
 assessment should be at all times.

SKILLS OF ASSESSMENT

 Critical Thinking- it is considered as a skill of assessment because we are analyzing the condition
of the patient.
 Adaptable/Flexible- it is considered as a skill of assessment and it should be flexible depending
on the situation.
 Communication skills – it is considered as a skill of assessment because the nurses communicate
with their patient.

TYPES OF ASSESSMENT

1. Initial Comprehensive Assessment


 it is the baseline upon the entry.
 at the start of your patient admission.
 chronological order.

 THE PATIENT’S INFORMATION


-Age
-Name
-Date of Birth
-Gender

 it uses anthropometric measurements.


Examples;
-Height
-Weight
-Latest Vital Sign

 CHIEF COMPLAINTS
 HISTORY OF PRESENT ILLNESS

2. On Going Assessment
-continuous until patient’s problem has been resolved.
-check the base line for changes
-during patients stay in the hospital.

3. Focused or Problem-Oriented Assessment


-it is performed when a comprehensive database exists for a client who comes to the health care
agency with a specific health concern.
-we are targeting the patient’s chief complaints.

4. Emergency Assessment

-an emergency assessment is a very rapid assessment performed in life-threatening situations. In


such situations(choking, cardiac arrest, drowning), an immediate diagnosis is needed to provide
prompt treatment.

- assess the environment.

ASSESSMENT PHASE OF NURSING PROCESS

1. Collection of subjective data


- Subjective data refers to what the patient verbalize.
- Elicited by interview.
- Ask for their biographical data.
2. Collection of the objective data
- example is physical examination
- subjective data comes first before objective data.
- observed by the nurse or measured by the nurse.
3. Validation of data
-confirming the data that we have assessed.

4. Documentation of data

- charting is an example for documentation.

PREPERATIONS PRIOR TO ASSESSMENT

-Before actually meeting the client and beginning the nursing health assessment, there are
several things you should do to prepare. It is helpful to review the client’s record, if available.

-If a patient tried to decline the assessment try to explain them what is the purpose of the
assessment.

- Review their past health history.

-After reviewing the record or discussing the client’s status with others, remember to keep an
open mind and to avoid premature judgements that may alter your ability to collect accurate
data.

-You should also use this time to educate yourself about the client’s diagnoses or test performed.
The client may have a medical diagnosis that you have never heard of or that you have not dealt
with in the past.

-It’s important to study the patient’s condition because patient look you as a professional nurse.
If you don’t study their condition, they will not give your trust. Once you have gathered some
basic data about client, take a minute to reflect on your own feelings regarding your initial
encounter with the client. Finally, remember to obtain and organize materials that you will need
for the assessment.

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