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HEALTH ASSESSMENT I UNIT I : INTRODUCTION TO HEALTH ASSESSMENT CONCEPTS

MUHAMMAD SULIMANPost RN BSc.N

ROYAL COLLEGE OF NURSING SWAT

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Introduction to Health AssessmentYou are doing blood pressure screening at a health fair. You take the blood pressure of a middle-aged man. Your reading is 170/100.

You are working in the emergency department (ED) when a father comes in with his 9-year-old daughter.

He states that she fell off her bike and hit her head but did not lose consciousness. But she has a terrible headache and feels sick.

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Cont…You are making a postpartum follow-up visit to the

home of a young mother who had her first baby 2 days ago.

You are making an initial hospice visit to a 74-yearold

woman with pancreatic cancer.

What do you do? Where do you begin? You begin with assessment. How well you perform your assessment

will affect everything else that follows. You will ask questions, and you will use four of your senses to collect data.

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The Nursing ProcessNursing is the diagnosis and treatment of human

responses to actual or potential health problems.

Diagnosis and treatment are achieved through a process, called the nursing process, that guides nursing practice.

The nursing process is a systematic problem-solving method that has five steps:

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CONT…■ Assessment

■ Nursing diagnoses

■ Planning

■ Implementation

■ Evaluation

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CONT…The nursing process is used to identify, prevent, and treat

actual or potential health problems and promote wellness. It provides a framework in which to practice nursing. Think of it as a continuous, circular process that revolves around your patient. You begin with assessment, collect data, cluster the data, and then formulate nursing diagnoses. Once you have identified the nursing diagnosis, you will develop a plan of care, determine the goals and expected outcomes, implement your plan, and then evaluate it. Then you will begin the nursing process again.

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Characteristics of the Nursing Process

■ Dynamic and cyclic

■ Patient centered

■ Goal directed

■ Flexible

■ Problem oriented

■ Cognitive

■ Action oriented

■ Interpersonal

■ Holistic

■ Systematic

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Communication To assess, you must be able to communicate and

communicate well. The relationship you establish with your patient directly affects your ability to collect data. Communication is a process of sharing information and meaning, of sending and receiving messages. The messages we communicate are both verbal and nonverbal. You need to consider all the factors affecting communication while communicating with your patient to be sure that the message you want to send is the one your patient actually receives.

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How You CommunicateAlways be aware of the messages you are sending

your patient, both verbally and nonverbally. How you respond is critical in establishing the nurse-patient relationship. Qualities that help establish and maintain this relationship include genuineness, respect, and empathy.

■ Genuineness: Be open, honest, and sincere with your patient. Your patient can detect a less-than-honest response or inconsistencies between your verbal and your nonverbal behavior.

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Cont…■ Respect: Everyone should be respected as a person of

worth and value. You need to be nonjudgmental in your approach. You may not always agree with your patient’s decisions or like or approve of his or her behavior, but everyone needs to feel accepted as a unique individual.

■ Empathy: Empathy is knowing what your patient means and understanding how she or he feels. Showing empathy acknowledges your patient’s feelings; shows acceptance, care, and concern; and fosters open communication. Phrases that recognize your patient’s feelings help build a trusting relationship—for example, “That must have been very difficult for you.”

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The Assessment ProcessThe American Nurses’ Association (ANA) has identified

assessment as the first Standard of Nursing Practice (ANA, 1998). The Standard describes assessment as the systematic, continuous collection of data about the health status of patients. Nurses are responsible not only for data collection but also for making sure that the data are accessible, communicated, and recorded. Assessment is an ongoing process. Every patient encounter provides you with an opportunity for assessment.

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Purpose of AssessmentThe purpose of assessment is to collect data

pertinent to the patient’s health status, to identify deviations from normal, to discover the patient’s strengths and coping resources, to pinpoint actual problems, and to spot factors that place the patient at risk for health problems.

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Skills of AssessmentAssessment requires cognitive, problem-solving,

psychomotor, affective/interpersonal, and ethical skills.

Cognitive Skills

Assessment is a “thinking” process. Cognitive skills are needed for critical thinking, creative thinking, and clinical decision making. Your theoretical knowledge base enables you to assess your patient holistically. The knowledge base includes not only biophysical knowledge but also developmental, cultural, psychosocial, and spiritual knowledge. This knowledge base enables you to differentiate normal from abnormal findings and to identify and prioritize actual and potential problems.

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Critical ThinkingCritical thinking is a complex thinking process that

has been defined in many ways. Critical thinking is reflective, reasonable thinking (Ennis, 1985). It is not just doing, it is asking “why?” Critical thinking involves inquiry, interpretation, analysis, and synthesis. It is the art of thinking about thinking that enables you to think better (Paul, 1990).Paul (1990) has identified attitudes or “traits of the mind” that are needed for critical thinking. Think of them as a mindset that enables you to use your cognitive skills to critically think.

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Clinical Decision Making

Assessment also requires clinical decision making. As you collect data, you will make clinical decisions as to its relevance. You will look for cues and make inferences. With experience, you will be able to identify patterns and recognize what differs from the norm and then use the data to make decisions that will best meet your patient’s need. Use your knowledge, experience, and what the patient says to validate the data.

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Problem-Solving SkillsVarious problem-solving methods can be used as you

assess your patient and work through the nursing process. With experience, you will develop your problem-solving skills. Do not limit yourself to one method; instead, select the method that best suits your patient’s needs.

Reflexive thinking The trial-and-error approach The scientific method Intuition

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Psychomotor SkillsAssessment is “doing.” Psychomotor skills are

needed to perform the four techniques of physical assessment: inspection, palpation, percussion, and auscultation. As a beginning practitioner, you may feel unsure of your technique and your findings, but practice will hone your skills. Input from your colleagues will help you perfect your skills and interpret your findings. Through experience, you will become competent at performing the physical assessment and confident in interpreting your findings.

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Affective/Interpersonal SkillsAssessment is also a “feeling” process. Affective

skills are needed to practice the “art” of nursing. Affective skills are essential in developing caring, therapeutic nurse-patient relationships. Interpersonal skills include both verbal and nonverbal communication skills. The quality of your assessment depends on your communication skills and the relationship that you develop with your patient. Establishing trust and mutual respect is essential before you begin the assessment.

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Cont… Seeing your patient as an individual and being

sensitive to his or her feelings conveys a message of caring and promotes human dignity. Illness often makes a patient very vulnerable, but the power of a caring relationship can have a major impact on the patient’s sense of worth and well-being. Such a relationship can be mutually rewarding, affecting both you and your patient personally and professionally.

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Ethical SkillsPart of assessment is being responsible and accountable.

You are responsible and accountable for your practice. You are also an advocate for your patient. You must respect your patient’s rights and ensure patient confidentiality. The ICN & PNC describes the ethical standards that guide nursing practice in its Code for Nurses. The data collected through assessment are used to plan the patient’s care, but it is important to remember that the data are the patient’s information. The Health Insurance Portability and Accountability Act (HIPAA) has established rules to protect patient privacy.

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Role of the Nurse and AssessmentThe role of the nurse has changed drastically over the years.

So have the nurse’s responsibilities. The importance of assessment can be traced to the beginning of modern nursing. Florence Nightingale (1859) stressed the importance of observation and experience as essential in maintaining or restoring one’s state of health. The scope of assessment has also expanded from simple observation to a holistic view of the patient that includes biophysical, psychosocial, developmental, and cultural assessments. The skills of assessments have also expanded—from simple observations to detailed use of physical assessment skills—as the scope of practice has expanded.

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Nursing Assessment versus Medical Assessment

Assessment is not unique to nursing. It is also an integral part of medical practice. Although the assessment process may be the same for nursing and medical practice, the outcomes differ. The goal of medical practice is to diagnose and treat disease. The goal of nursing practice is to diagnose and treat human responses to actual or potential health problems. Nursing assessment focuses not only on physiological and psychological responses but also on the psychosocial, cultural, developmental, and spiritual dimensions.

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CONT…It identifies patients’ responses to health problems as

well as their strengths. Nursing’s aim is to help the patient reach her or his optimal level of wellness. Medical and nursing assessments should complement, not contradict, each other in promoting the patient’s health and wellness. Often, data obtained through the nursing assessment contribute to the identification of medical problems. By working together in a collaborative relationship, nursing and medicine ensure the best possible care for patients.

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Types of AssessmentAssessments can be comprehensive or focused. A

comprehensive assessment is usually the initial assessment. It is very thorough and includes a detailed health history and physical examination. A comprehensive assessment examines the patient’s overall health status. A focused assessment is problem oriented and may be the initial assessment or an ongoing assessment. If a patient’s condition does not warrant a comprehensive assessment, a focused assessment of the patient’s present health problem is done. Once the patient’s condition improves and stabilizes, the comprehensive assessment can be completed.

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CONT…A focused assessment is frequently performed on

an ongoing basis to monitor and evaluate the patient’s progress, interventions, and response to treatments. Even when a focused assessment is performed, it is important to look at the entire picture. A problem in one system will affect or be affected by every other system. So scan your patient from head to toe and note any changes in other systems. Look for clues or pertinent data that will help you formulate your diagnosis.

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Collecting Data Data can be classified as subjective and objective.

Subjective data are covert and not measurable. They reflect what the patient is experiencing and include thoughts, beliefs, feelings, sensations, and perceptions. Subjective findings are referred to as symptoms. The health history is an example of subjective data. Objective data are overt and measurable. Objective data are referred to as signs.

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CONT…The physical examination and diagnostic

studies are examples of objective data. Data sources are either primary or secondary. The patient is a primary data source. Secondary data sources are anyone or anything aside from the patient, including family members, friends, other healthcare providers, and old medical records. Both primary and secondary data can also be subjective or objective.

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Critical Thinking ActivityIdentify the following data as subjective or objective:

• Headache

• Blood pressure (BP) 170/110

• Nausea

• Diaphoresis

• Equal pupillary reaction

• Tingling sensation

• Dizziness

• Decreased muscle strength

• Slurred speech

• Numbness, left arm

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Documentation MethodsThe approach to documentation is usually source

oriented or problem-oriented. Source-oriented documentation is done by department, so each healthcare group has a section to document findings. This method easily identifies each discipline, but it tends to fragment the data, making it difficult to follow the sequencing of events. With problem oriented medical records (POMR), everyone involved in the care of the patient charts on the same form. This allows for better communication of data to resolve the patient’s problems collaboratively

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Cont…No matter which approach you use, a variety of

methods and forms are available for documentation. Many healthcare facilities use standardized nursing assessment forms in a checklist format, which is efficient and time saving. Computerized documentation is also available in a standardized checklist format. The narrative format may also be used, but this is more time-consuming.

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Cont…Two popular methods of problem-oriented documentation

are SOAPIE and PIE.A third popular method, DAR, is used with FOCUS® charting, which focuses more holistically on the patient, identifying both strengths and problems that can be incorporated into his or her care. Another method—charting by exception (CBE)—is a shorthand documentation method frequently used to save time. It includes only significant data, that is, findings that deviate from well-defined standards. A CBE system usually includes flow sheets and standard of care checklists that are kept at the bedside. Any exception is then documented on the chart on either the nurse’s note or the progress note.

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Documentation MethodsConsider the following assessment of Mary Rutherford: Mary

Rutherford, age 43, is 1 day postoperative after a cholecystectomy. Her assessment data include the following:

■ “It hurts to take a deep breath.”

■ Pain rated 8/10

■ Guarding abdomen

■ Vital signs: BP 144/90; pulse 108; respirations 24 and shallow; temperature 100.8F

■ Pulse oximeter 92 percent on room air

■ Decreased breath sounds at bases owing to poor ventilatory effort, also few crackles noted at bases

■ Receiving patient-controlled analgesia (PCA) morphine

■ Dressings dry and intact

Here is how you would document Mrs. Rutherford’s findings using each method:

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SOAPIE Method■ Subjective data

“It hurts to take a deep breath”:Pain increases with activity and breathing, PCA helps; pain is sharp; pain is located in right upper quadrant (RUQ) and epigastric region; pain is rated 8/10; pain only when moving.

■ Objective data

First-day postop cholecystectomy; vital signs: BP, 144/90; pulse, 108; respirations, 24 and shallow; temperature, 100.8F; pulse oximeter, 92 percent on room air; patient guarding abdomen; decreased breath sounds at bases because of poor ventilatory effort, also few crackles noted at bases; receiving PCA morphine.

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Cont…Assessment/clinical judgment

Ineffective breathing pattern related to incisional pain.

■ Plan

Patient will establish effective breathing pattern; patient will experience no signs of respiratory complications.

■ Interventions

Encourage coughing and deep breathing; teach patient to splint incision; control pain with PCA; encourage ambulation; provide instruction on use of incentive spirometer; maintain adequate hydration.

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Cont…■ Evaluation

Patient coughing and deep breathing, splinting incision; using incentive spirometer; ambulating; pain 5/10, using PCA morphine as needed; lungs clear; vital signs: BP 130/86, temperature 99F, pulse 80, respirations 20, pulse oximeter 96% on room air.

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DAR Method■ Data

“It hurts to take a deep breath”; pain increases with activity and breathing, PCA helps; pain is sharp; pain is located in RUQ and epigastric region; pain is rated 8/10; pain only when moving; first-day postop cholecystectomy; vital signs: BP 144/90; pulse 108; respirations 24 and shallow; temperature 100.8F; pulse oximeter 92 percent on room air; patient guarding abdomen; decreased breath sounds at bases because of poor ventilatory effort, also few crackles noted at bases; receiving PCA morphine.

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Cont…■ Action

Encourage coughing and deep breathing; teach patient to splint incision; control pain with PCA; encourage ambulation; provide instruction on use of incentive spirometer; maintain adequate hydration.

■ Response

Patient coughing and deep breathing, splinting incision; using incentive spirometer; ambulating; pain 5/10, using PCA morphine as needed; lungs clear; vital signs: BP 130/86, temperature 99F, pulse 80, respirations 20, pulse oximeter 96 percent on room air.

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PIE Method■ Problem

Ineffective breathing pattern related to incisional pain.

■ Interventions

Encourage coughing and deep breathing; teach patient to splint incision; control pain with PCA; encourage ambulation; provide instruction on use of incentive spirometer; maintain adequate hydration.

■ Evaluation

Patient coughing and deep breathing, splinting incision; using incentive spirometer; ambulating; pain 5/10, using PCA morphine as needed; lungs clear; vital signs: BP 130/86, temperature 99F, pulse 80, respirations 20, pulse oximeter 96 percent on room air.

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Narrative Method■ 08/04/15 8 A.M. Patient stated, “It hurts to take a deep

breath.” Rates pain 8/10, guarding, vital signs BP 144/90, temperature 100.8, pulse 108, respirations 24 and shallow, pulse oximetry 92 percent on room air. Decreased breath sounds at bases owing to poor inspiratory effort. Dressings dry and intact. Reviewed use of PCA morphine and incentive spirometer with patient. Patient instructed to cough and deep breathe with splinting. Asghar, RN.

■ 9 A.M. Patient coughing and deep breathing, using incentive spirometer. ambulating with assistance, using PCA morphine prn pain, 5/10, lungs clear. Vital signs: BP 130/86, temperature 99°F, pulse 80, respirations 20, pulse oximetry 96 percent on room air. Asghar, RN

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Cont…Whatever format or method is used, you need to

document accurately and concisely. Documentation is a part of your patient’s permanent record, and the information is confidential. Because the data should be available to all healthcare members involved in your patient’s care, they should be readily accessible and easy to read. Other members of the healthcare team should be able to peruse the data quickly and identify pertinent findings. Remember, if your plan of care is to be successful, everyone involved in your patient’s care needs to have access to the data.

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Documentation Tips■ Be brief and to the point.

■ Use acceptable abbreviations.

■ If documentation is handwritten, make sure writing is legible.

■ No need to write in complete sentences.

■ State the facts. Avoid interpretations.

■ Avoid terms such as “normal,” “good,” “usual,” and “average.”

■ Avoid generalizations.

■ Document sequentially, in chronological order.

■ Do not leave blanks or skip lines.

■ Use correct spelling and grammar.

■ No erasures or whiting out.

■ Record date and time and sign your full signature.

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References1. Bicklay, L. S. (1999). Bates’ guide to physical examination

and history taking (7th ed). Philadelphia: J. B. Lippincott.

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4. Thompson, B. (1991). Clinical manual of health assessment. (4th ed).St. Louis: Mosby.

5. Weber, J. R. (2001). Nurses' handbook of health assessment (4thed). Philadelphia: Lippincott.

6. Wilson, S. F; Giddens J. F. (2001). Health assessment for nursing practice (2nd ed).St. Louis: Mosby.