HEALTH ASSESSEMENT

THE NURSING HEALTH HISTORY

FELIPE A. MERANO, RN, MSN Associate Professor

INTRODUCTION
OVERVIEW: HEALTH ASSESSMENT REQUIREMENTS
Lecture : 60 % SKL: 40% 1 Notebook: Lesson Plan Good Background of ANATOMY & PHYSIOLOGY Reference: Jenet Weber

NURSING HEALTH HISTORY

The systematic collection of subjective data (stated by the client) and objective data (observed by the nurse) used to determine a clients functional health pattern status.

The Nurse Collects Data:

Physiologic Psychological Socio-cultural Developmental, and Spiritual client data.

The Nurse Collects Data:

Needed in identifying Nursing

Diagnoses and/or Collaborative Problems

Three Categories of Nursing Diagnoses: WAR Wellness Actual Risk

 Wellness Diagnoses human responses about an individual, family, or community that have a readiness for enhancement, may be described as opportunities for enhancement of healthy state

 Actual Nursing Diagnosis is a human response to health conditions/ life processes that currently exist in an individual, family, or community that can be validated by the defining characteristics of that diagnostic category.

 Risk Diagnosis human responses of an individual , family or community and is supported by risk factors that contribute to increase vulnerability

COLLABORATIVE PROBLEMS
Certain physiological complications that nurses monitor to detect their onset or changes in status. Manage by nurses using physician prescribed and nursing prescribed interventions to minimized complications.

 The Definitive Treatment for Nursing Diagnosis is developed by the nurse; The Definitive Treatment for Collaborative Problem is developed by both the nurse and the physician

SUBJECTIVE DATA
DESCRIPTION

OBJECTIVE DATA

SOURCES

Data elicited and verified by the client Client, Family and significant others, Client record, Other health care professionals

Data directly or indirectly observed through measurement Observations and physical assessment findings of the nurse or other health care professionals, Documentation of assessments made in client record. Observation made by the clients family or significant others.

SUBJECTIVE DATA
METHODS USED TO OBTAIN DATA SKILLS NEEDED TO OBTAIN THE DATA

OBJECTIVE DATA

CLIENT INTERVIEW

Observation and Physical Examination

EXAMPLES

INTERVIEW, NSPECTION THERAPEUTIC COMMUNICATION PALPATION SKILLS, PERCUSSION CARING ABILITY AND EMPATHY, AUSCULTATION LISTENING SKILLS I have a headache Respiration 16 per minute It frightens me BP 180/100, apical pulse 80 I am not hungry

and irregular X-ray firm reveals fractured pelvis.

COMPARISSON OF WELLNESS, RISK AND ACTUAL NURSING DIAGNOSES

WELLNESS
CLIENT STATUS

ACTUAL Human responses to health conditions/life processes that exist

RISK Human responses that may develop in a vulnerable individual, family or community

Human responses to levels of wellness that have a readiness for enhancement

FORMAT

Readiness for Enhanced ..

Nursing Diagnoses Risk for and related to clause

COMPARISSON OF WELLNESS, RISK AND ACTUAL NURSING DIAGNOSES

WELLNESS
EG

ACTUAL
Disturbed body image related to wound on hand that is not healing Dysfunctional Family Processes: Alcoholism Ineffective Breast Feeding related to poor mother-infant attachment Impaired Skin integrity related to immobility.

RISK
Risk for Disturbed Body Image Risk for Interrupted Family Processes Risk for Ineffective Breast Feeding Risk for Impaired Skin Integrity

Readiness for enhanced body image. Readiness for enhanced Family Process Readiness for Enhanced Effective Breast Feeding Readiness for Enhanced Skin Integrity

Examples of Medical Diagnoses, Nursing Diagnoses and Collaborative Problems MEDICAL COLLABORATIVE NURSING FRACTURED JAW Potential complication for aspiration Altered Oral mucous membrane related to difficulty with hygiene secondary to fixation devices

DIABETES MILLITUS
PNEUMONIA

Potential Complication: Hyperglycemia

Potential Complication: Hypoglycemia, Hypoxymia

Impaired skin integrity related to poor circulation to lower extremities

Ineffective Airway Clearance related to presence of excessive mucus production

GUIDELINES FOR OBTAINING A NURSING HEALTH HISTORY

Phases of the Nursing Interview
Communication process that focuses on the clients developmental, psychological, physiologic, socio-cultural, and spiritual response that can be treated with nursing and collaborative interventions.

INTRODUCTORY PHASE

Phases of the Nursing Interview

INTRODUCTORY PHASE
Introduce yourself Describe your role Explain the purpose of interview
To collect data, to identify needs, to plan nursing care

Explain the purpose of note taking, confidentiality and the type of questions to be asked. Provide comfort, privacy and confidentiality.

Phases of the Nursing Interview

WORKING PHASE
Facilitate the clients comments about major biographical data Reasons for seeking health care, and Functional health pattern responses. Use: Critical Thinking Skills: observe cues, interpret and validate information. Collaborate with the client to identify problems and goals.

Phases of the Nursing Interview

SUMMARY AND CLOSURE PHASE
Summarize information obtained during the working phase and validate problems and goals with the client.

ASSESSMENT: STEP ONE IN NURSING PROCESS

Phases Title 1 2 ASSESSMENT DIAGNOSIS Description Collecting subjective and objective Data Analyzing subjective and objective data to make professional nursing judgment (nursing diagnosis, collaborative problems, referral) Determining outcome criteria and developing a plan Carrying out the plan

PLANNING

IMPLEMENTATION

EVALUATION

Assessing whether outcome criteria have been met and revisiting the plan as necessary.

TYPE OF ASSESSMENT
Initial comprehensive assessment Ongoing or partial assessment Focused or problem oriented assessment Emergency Assessment