Health Assessment: An IntroductionMaria 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 $efore going to class toda"% WE ALWAYS PRACTICE ASSESSMENT IN OUR DAILY LIVING WHAT CAN YOU SAY ABOUT THESE PICTURES? WHAT INFERENCE CAN YOU MA E? . Domocmat. MSN .Assess!e"# & the collection of data a$out an indi idual's health state & first and most critical (hase of the nursing (rocess Maria Carmela L. RN. MSN . alidation and communication of client data as com(ared to )hat is standard*norm Maria Carmela L. Domocmat.Assess!e"# & ongoing and continuous throughout all the (hases of the nursing (rocess & is s"stematic and continuous collection. RN. to determine the client's o erall le el of functioning in order to ma#e a (rofessional clinical /udgment .o su((lement. MSN .o esta$lish a data $ase -all the information a$out the client.+ur(ose: . or 0uestion data o$tained in the nursing histor" .o o$tain data that )ill hel( the nurse esta$lish nursing diagnoses and (lan (atient care Maria Carmela L. Domocmat. confirm. RN. . MSN . and factors that (lace the (atient at ris# for health (ro$lems Maria Carmela L. RN. to identif" de iations from normal. to disco er the (atient's strengths and co(ing resources. to (oint actual (ro$lems.o e aluate the a((ro(riateness of the nursing inter entions in resol ing the (atient1s identified (atho(h"siolog" (ro$lems collect data of (atient's health status. Domocmat. & !holistic data collection. (s"chological. Domocmat. and s(iritual data about the client Maria Carmela L. MSN . RN. & Nurse collects (h"siologic. sociocultural. de elo(mental. RN. Domocmat.nurse focuses on ho) client's health status affects his acti ities of dail" li ing -ADL. MSN . and ho) the client's ADL affect is health 23: client )ith asthma Maria Carmela L. Domocmat. RN. 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.assess ho) client interact )ithin their famil". cultures. MSN . & Data from "urs$"% &ssess!e"# can $e classified as su$/ecti e and o$/ecti e. RN. MSN . Domocmat. Maria Carmela L. MSN .Data include: nursing health histor" (h"sical assessment the (h"sician's histor" 7 (h"sical e3amination results of la$orator" 7 diagnostic tests material from other health (ersonnel Maria Carmela L. Domocmat. RN. Performing assessment is like collecting the pieces of a puzzle . Domocmat. and organized in a )a" that hel(s "ou $egin to get a sense of (atterns of health or illness. MSN . Maria Carmela L. com(lete. "ou need to ma#e e er" effort to ensure that "our information is correct.Assess!e"# 8 .he first ste( in determining the health status of the client 8 9ecause the entire (lan of care is $ased on the data collected during this (hase. RN. RN.Types o' Assess!e"# Maria Carmela L. MSN . Domocmat. Domocmat.ocused or (ro$lem6oriented assessment 2mergenc" assessment .Types o' Assess!e"# & & & & & Initial com(rehensi e assessment :ngoing or (artial assessment . RN.ime6la(sed assessment Maria Carmela L. MSN . Domocmat. RN.Initial com(rehensi e assessment & assessment (erformed )ithin a s(ecified time on admission Maria Carmela L. MSN . MSN . Domocmat. 8 (ast health histor". 8 famil" histor". RN. 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.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. communit". MSN .Initial com(rehensi e assessment !hen (erformed% & :n the initial contact )ith the client & )here: hos(ital. Domocmat. RN. 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. 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 $od" s"stems and holistic health (atterns as a follo)6 u( on his health status Maria Carmela L. Domocmat. RN. MSN . MSN . RN. Domocmat.Ongoing or partial assessment & !hen (erformed% & usuall" (erformed )hene er the nurse or another health care (rofessional has an encounter )ith the client Maria Carmela L. Ongoing or partial assessment & (ur(oses: & An" (ro$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. RN. MSN . & 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. Domocmat. 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. RN. RN. Domocmat.Focused or problem-oriented assessment & !hen (erformed% & (erformed )hen a com(rehensi e data$ase e3ists for a client and he*she comes to the health care agenc" )ith a s(ecial health concern Maria Carmela L. MSN . RN. MSN .Emergency assessment & a er" ra(id assessment (erformed in a life6 threatening situations & ra(id assessment done during an" (h"siologic*(h"siologic crisis of the client to identif" life threatening (ro$lems Maria Carmela L. Domocmat. RN. Domocmat.Emergency assessment & (ur(ose: to determine the status of the client's life6sustaining (h"sical functions Maria Carmela L. MSN . RN.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. MSN . Domocmat. MSN . RN.Sources o' D&#& Maria Carmela L. Domocmat. RN.Sources o' D&#& & +rimar" source: & Secondar" source: Maria Carmela L. Domocmat. MSN . Domocmat. Maria Carmela L.Sources o' D&#& & +rimar" source: 8 data directl" gathered from the client using inter ie) and (h"sical e3amination. RN. MSN . other mem$ers of health team. MSN . RN. Domocmat.Sources o' D&#& & Secondar" source: 8 data gathered from client's famil" mem$ers. and related care literature*/ournals. client's medical records*chart. Maria Carmela L. significant others. RN. MSN .Maria Carmela L. Domocmat.