Health Assessment: An Introduction

Maria Carmela L. Domocmat, RN, MSN

Instructor, Nursing Health Assessment School of Nursing Northern Luzon Ad entist College

Assessment: An Introduction
Purpose Types Sources

Maria Carmela L. Domocmat, RN, MSN

!ho among "ou loo#ed at "ourself in the mirror $efore going to class toda"%

WE ALWAYS PRACTICE ASSESSMENT IN OUR DAILY LIVING

WHAT CAN YOU SAY ABOUT THESE PICTURES? WHAT INFERENCE CAN YOU MA E?

Assess!e"#
& the collection of data a$out an indi idual's health state & first and most critical (hase of the nursing (rocess

Maria Carmela L. Domocmat, RN, MSN

Assess!e"#
& ongoing and continuous throughout all the (hases of the nursing (rocess & is s"stematic and continuous collection, alidation and communication of client data as com(ared to )hat is standard*norm

Maria Carmela L. Domocmat, RN, MSN

+ur(ose:
,o esta$lish a data $ase -all the information a$out the client. to determine the client's o erall le el of functioning in order to ma#e a (rofessional clinical /udgment ,o su((lement, confirm, or 0uestion data o$tained in the nursing histor" ,o o$tain data that )ill hel( the nurse esta$lish nursing diagnoses and (lan (atient care

Maria Carmela L. Domocmat, RN, MSN

,o e aluate the a((ro(riateness of the nursing inter entions in resol ing the (atient1s identified (atho(h"siolog" (ro$lems collect data of (atient's health status, to identif" de iations from normal, to disco er the (atient's strengths and co(ing resources, to (oint actual (ro$lems, and factors that (lace the (atient at ris# for health (ro$lems

Maria Carmela L. Domocmat, RN, MSN

& !holistic data collection. & Nurse collects (h"siologic, (s"chological, sociocultural, de elo(mental, and s(iritual data about the client

Maria Carmela L. Domocmat, RN, MSN

nurse focuses on ho) client's health status affects his acti ities of dail" li ing -ADL. and ho) the client's ADL affect is health
23: client )ith asthma

Maria Carmela L. Domocmat, RN, MSN

assess ho) client interact )ithin their famil", cultures, and communit" and ho) the client's health status affects the famil" and communit"
23: client )ith DM )ho has am(utation4 single (arent mother of a 5 "ear6old child

Maria Carmela L. Domocmat, RN, MSN

& Data from "urs$"% &ssess!e"# can $e classified as su$/ecti e and o$/ecti e.

Maria Carmela L. Domocmat, RN, MSN

Data include:
nursing health histor" (h"sical assessment the (h"sician's histor" 7 (h"sical e3amination results of la$orator" 7 diagnostic tests material from other health (ersonnel

Maria Carmela L. Domocmat, RN, MSN

Performing assessment is like collecting the pieces of a puzzle

Assess!e"#
8 ,he first ste( in determining the health status of the client 8 9ecause the entire (lan of care is $ased on the data collected during this (hase, "ou need to ma#e e er" effort to ensure that "our information is correct, com(lete, and organized in a )a" that hel(s "ou $egin to get a sense of (atterns of health or illness.

Maria Carmela L. Domocmat, RN, MSN

Types o' Assess!e"#

Maria Carmela L. Domocmat, RN, MSN

Types o' Assess!e"#

& & & & & Initial com(rehensi e assessment :ngoing or (artial assessment ;ocused or (ro$lem6oriented assessment 2mergenc" assessment ,ime6la(sed assessment

Maria Carmela L. Domocmat, RN, MSN

Initial com(rehensi e assessment

& assessment (erformed )ithin a s(ecified time on admission

Maria Carmela L. Domocmat, RN, MSN

Initial com(rehensi e assessment

& In ol es collection of su$/ecti e data a$out the
8 client's (erce(tion of his*her health of all $od" (arts or s"stems, 8 (ast health histor", 8 famil" histor", and 8 lifest"le and health (ractices -)hich includes information related to the client's o erall function. as )ell as o$/ecti e data gathered during a ste(6$"6ste( (h"sical e3amination

Maria Carmela L. Domocmat, RN, MSN

Initial com(rehensi e assessment

!hen (erformed% & :n the initial contact )ith the client & )here: hos(ital, communit", clinic or home setting & (ur(ose: to ha e a $aseline com(rehensi e data a$out the client & 23: nursing admission assessment
Maria Carmela L. Domocmat, RN, MSN

Ongoing or partial assessment

Maria Carmela L. Domocmat, RN, MSN

Ongoing or partial assessment

& consists of data collection that occurs after the com(rehensi e data$ase is esta$lished & consists of mini6o er ie) of the client's $od" s"stems and holistic health (atterns as a follo)6 u( on his health status

Maria Carmela L. Domocmat, RN, MSN

Ongoing or partial assessment

& !hen (erformed% & usuall" (erformed )hene er the nurse or another health care (rofessional has an encounter )ith the client

Maria Carmela L. Domocmat, RN, MSN

Ongoing or partial assessment

& (ur(oses: & An" (ro$lems that )ere initiall" detected in the client's $od" s"stem or holistic health (atterns are reassessed in less de(th to determine an" ma/or changes -deterioration or im(ro ement. from the $aseline data. & 9rief reassessment of the client's normal $od" s"stem or )holistic health (atterns is (erformed to detect ne) (ro$lems
Maria Carmela L. Domocmat, RN, MSN

Focused or problem-oriented assessment

& consists of a thorough assessment of a (articular health (ro$lem and does not co er areas not related to the (ro$lem & (ur(ose: to ha e a thorough assessment on the s(ecial health concern of the client identified in an earlier assessment

Maria Carmela L. Domocmat, RN, MSN

Focused or problem-oriented assessment

& !hen (erformed% & (erformed )hen a com(rehensi e data$ase e3ists for a client and he*she comes to the health care agenc" )ith a s(ecial health concern

Maria Carmela L. Domocmat, RN, MSN

Emergency assessment
& a er" ra(id assessment (erformed in a life6 threatening situations & ra(id assessment done during an" (h"siologic*(h"siologic crisis of the client to identif" life threatening (ro$lems

Maria Carmela L. Domocmat, RN, MSN

Emergency assessment
& (ur(ose: to determine the status of the client's life6sustaining (h"sical functions

Maria Carmela L. Domocmat, RN, MSN

Time-lapsed assessment
& reassessment of client's functional health (attern done se eral months after initial assessment to com(are the client's current status to $aseline data (re iousl" o$tained.

Maria Carmela L. Domocmat, RN, MSN

Sources o' D&#&

Maria Carmela L. Domocmat, RN, MSN

Sources o' D&#&

& +rimar" source: & Secondar" source:

Maria Carmela L. Domocmat, RN, MSN

Sources o' D&#&

& +rimar" source:
8 data directl" gathered from the client using inter ie) and (h"sical e3amination.

Maria Carmela L. Domocmat, RN, MSN

Sources o' D&#&

& Secondar" source:
8 data gathered from client's famil" mem$ers, significant others, client's medical records*chart, other mem$ers of health team, and related care literature*/ournals.

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN