nursing health assessment: purpose, types, sources cld

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


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


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


�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


• Wholistic data collection.

• Nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the clientabout the client


�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


�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


• Data from nursing assessment can be classified as subjective and objective.


Data include:

�nursing health history

�physical assessment

�the physician’s history & physical examinationexamination

�results of laboratory & diagnostic tests

�material from other health personnel


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.


Types of Assessment


Types of Assessment

• Initial comprehensive assessment

• Ongoing or partial assessment

• Focused or problem-oriented assessment

• Emergency assessment• Emergency assessment

• Time-lapsed assessment


Initial comprehensive assessment

• assessment performed within a specified time on admission



• 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



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


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



• When performed?

• usually performed whenever the nurse or another health care professional has an encounter with the clientencounter with the client



• 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


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


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


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


Emergency assessment

• purpose: to determine the status of the client’s life-sustaining physical functions


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.


Sources of Data


Sources of Data

• Primary source:

• Secondary source:


Sources of Data

• Primary source:– data directly gathered from the client using

interview and physical examination.


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.


nursing health assessment: purpose, types, sources cld

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