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Nursing Assessments Focus On The Patient's Responses To Health Problems or Potential Health Problems

Nursing assessments focus on collecting comprehensive patient data through initial assessments, focused assessments, and time-lapsed assessments. The purpose is to establish a baseline database by collecting both subjective and objective data through health histories, interviews, and physical examinations. This data enables nurses to make judgments about patient health status, care needs, and develop individualized care plans.

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29 views20 pages

Nursing Assessments Focus On The Patient's Responses To Health Problems or Potential Health Problems

Nursing assessments focus on collecting comprehensive patient data through initial assessments, focused assessments, and time-lapsed assessments. The purpose is to establish a baseline database by collecting both subjective and objective data through health histories, interviews, and physical examinations. This data enables nurses to make judgments about patient health status, care needs, and develop individualized care plans.

Uploaded by

LisnaWati
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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Nursing assessments focus on

the patient’s responses to health problems or


potential health problems
 the systematic and continuous collection,
validation, analysis, and communication of
patient data, or information.
 These data reflect how health functioning is
enhanced by health promotion or
compromised by illness and injury.
 all the pertinent patient information collected
by the nurse and other healthcare
professionals.
 The database enables a comprehensive and
effective plan of care to be designed and
implemented for the patient.
 Purpose:
◦ Establish a baseline of information on the client and
develop a data base
◦ Determine client’s normal function
◦ Determine client’s risk for dysfunction
◦ Determine presence or absence of dysfunction
◦ Determine client’s strengths
◦ Provide data for diagnostic phase

4
 The purpose is to establish a database by:
◦ Collecting data
 Subjective versus objective
◦ Interviewing and taking a health history
 Subjective and organized
◦ Performing a physical examination
 Vital signs, patient’s behavior, diagnostic and
laboratory data, medical records

5
Baseline data that enable the nurse to:
•Make a judgment about a patient’s health
status, the ability to manage his or her own
healthcare, and the need for nursing
•Refer the patient to a physician or other
healthcare professional, if indicated
•Plan and deliver individualized, holistic
nursing care that draws on the patient’s
strengths
 Subjective Data
◦ Information perceived only the affected person
◦ Cannot be perceived or verified by another person
◦ Examples: feeling nervous, nauseated, chilly

7
 Objective Data
◦ Observable and measurable data
◦ Data that can be see, heard or felt by someone
other than the person experiencing it
◦ Examples: elevated temperature (>101 F), moist
skin, refusal to eat, vital signs

8
 Complete
 Factual and accurate
 Relevant

9
 Interview
◦ Orientation phase
◦ Working phase
◦ Termination

10
 Primary
◦ patient
 Secondary
◦ Family members
◦ Significant other
◦ Other healthcare professionals
◦ Health records

11
 Nursing History
◦ Biographical information
◦ Reasons for seeking healthcare
◦ Present illness or health concern
◦ Health history
◦ Environmental history
◦ Psychosocial and cultural history
◦ Review of systems or functional health patterns

12
 Nursing assessments include:
1. the comprehensive initial assessment,
2. the focused assessment,
3. the emergency assessment, and
4. the time-lapsed assessment.
 The initial assessment is performed shortly
after the patient is admitted to a healthcare
agency or service.
 The purpose of this assessment is to
establish a complete database or problem
identification and care planning.
 The nurse collects data concerning all aspects
of the patient’s health,establishing priorities
for ongoing focused assessments and
creating a reference for future comparison.
 In a focused assessment,the nurse gathers data about a
specific problem that has already been identified.
Helpfulquestions include:
•What are your symptoms?
•When did they start?
•Were you doing anything different than usual when they
started?•
What makes your symptoms better? Worse?
•Are you taking any remedies (medical or natural) for your
symptoms?

 A focused assessment may be done during the initial


assessment if patient health problems surface, but it is
routinely part of ongoing data collection. Another purpose
of the focused assessment is to identify new or overlooked
problems.
 When a physiologic or psychological crisis
presents, the nurse performs an emergency
assessment to identify life-threatening
problems.
 The time-lapsed assessment is scheduled to
compare a patient’s current status to baseline
data obtained earlier.
 Periodic time-lapsed assessments are done to
reassess health status and to make necessary
revisions in the plan of care.
 The purpose is to establish a database by:
◦ Collecting data
 Subjective versus objective
◦ Interviewing and taking a health history
 Subjective and organized
◦ Performing a physical examination
 Vital signs, patient’s behavior, diagnostic and
laboratory data, medical records

18
 Gordon’s 11 Functional Health Patterns
◦ Uses a series of questions which assist in
formulating a nursing diagnosis
 Problem focused assessment
◦ Focuses on the patient’s problem and develop you
plan of care around the problem
 Health perception-  Self-perception-
management self-concept
 Nutritional-  Role-relationship
metabolic  Sexuality-
 Elimination reproductive
 Activity-exercise  Coping-stress-
 Sleep-rest tolerance
 Cognitive -  Value-belief
perceptual

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