Chapter 1: Health Assessment in Nursing Practice

Chapter 1: Health Assessment in Nursing Practice Professional Nursing Practice · Nursing process (ADPIE): assessment, analysis, planning, implementation, evaluation · Nurses are also planners, coordinators, and managers of care on the interprofessional team · Nurses focus on how diseases affect patient's abilities to perform activities of daily living and what their coping mechanisms are for dealing with health issues and losses of function ↳ take in to account how a condition influences the patient's functional ability, relationships, and quality of life · Independent nursing includes therapeutic communication, health teaching, taking comprehensive health histories, performing urgent, focused, or comprehensive physical examinations, and carrying out physical procedures - - - Advocacy · Nurses advocate for patients in many ways: Keeping them safe, communicating their needs, identifying side effects of treatment and finding better options, and helping them understand their diseases and treatments so that they can optimize self-care · Nurses take responsibility to protect the legal and ethical rights of patients and speak out against inequality and inequity. They may also look at the bigger picture of system redesign · The seven primary nursing values in the CNA Code of Ethics: 1) providing safe, compassionate, competent, and ethical care 2) promoting health and well-being 3) promoting and respecting informed decision-making 4) honouring dignity 5) maintaining privacy and confidentiality 6) promoting justice 7) being accountable · Nurses provide accurate, nonbiased, and comprehensive information to patients and their family to promote patient autonomy and always respect patient privacy and confidentiality - Scholarship and Research · Nurses demonstrate and perform research to provide evidence-informed care · Nurses use systems to influence health care policy, finance, and regulatory agencies Registered Nurse and Advanced Practice Nurse Roles · Advanced practice nurses include: nurse practitioners (NPs), midwives, and clinical nurse specialists · RN's are regulated and licensed by Canadian provinces or territories and practice independently within the scope of nursing practice and diagnosis · Advanced practice nurses meet additional educational and clinical practice requirements, preferably a master's level beyond the basic nursing education and licensing required of all RN's ↳ they perform more direct care and advanced assessments Purposes of Health Assessment · Health assessment: the collection of subjective and objective data to develop a database about a patient's health status (past and present), health concerns, and usual coping mechanisms so that a care plan can be created ↳ health history, physical examination, documentation of findings, and analysis of the data · health history includes: skillful interviewing to collect the patient's current symptoms, history of the present concern(s), past medical, surgical, gynecological/obstetric, and psychiatric histories, and personal, social, and relevant family history ↳ comprehensive health history includes: nutritional, developmental, mental, social, cultural, and spiritual dimensions. It also includes safety issues, risk factors, topics for health promotion, and functional abilities · Other purposes of health assessment are to gain further insight into the current condition, and to establish or update a database. Nurses identify patterns and trends in findings to determine if a patient's condition is improving or worsening through analyzing data and using critical thinking · A complete and accurate health assessment assists nurses to promote health at the highest level. It is extremely important that health assessment data be complete, accurate, and current. Health Promotion and Health Assessment · Nurses start by using screening questions in the health history and asking follow-up questions in higher risk areas and address those that the patient is willing to make changes to · The social determinants of health are taken into consideration in health assessment and promotion ↳ income, age, culture, gender, education, social support environments, work conditions · The SDOH created the Canadian Population Health Model to understand the SDOH and how they can improve or worsen health · The CDC developed a Behavioural Risk Factor Surveillance System to assess public health issues such as risk, chronic health conditions, and use of preventive services Risk Assessment and Health Prevention ① Primary prevention: involves strategies aimed at preventing health concerns eg. immunizations, health teaching, safety precautions, nutrition counselling ② Secondary prevention: the early diagnosis and treatment of health issues to prevent complications eg. Vision screening, pap smears, BP screening, hearing testing, tuberculin skin testing ③ Tertiary prevention: preventing complications of an existing disease/condition and promoting health to the highest possible level eg. diet teaching patients w/diabetes, inhaler teaching for patients w/lung disease The Nursing Process · the nursing process is a systematic problem-solving approach to identifying and treating human responses to actual or potential health conditions ↳ it is patient-centered, and provides individualized care to individuals, families, groups, communities, and populations · The 5 phases are: assessing the patient, analyzing the data, planning care, implementing/intervening and evaluating A: assessment ↳ collecting subjective and objective data ↳ patient interview, health history, head-to-toe assessment etc. A: analysis ↳ diagnostic phase, formulating a clinical judgement, and validating it with the patient ↳ identify abnormal (unexpected) data and strengths ↳ cluster data, draw inferences, check for defining characteristics ↳ propose possible nursing diagnoses, confirm or rule out nursing diagnoses, document conclusions P: planning goals and outcomes ↳ formation of specific, measurable, attainable, realistic, and time-oriented (SMART) patient-centered goals ↳ eg. assessing the patients pain level and plan to lower it from 7 to 0-2 I: intervention/implementation ↳ actions you perform based on your plan, clinical judgment, and nursing knowledge ↳ eg. therapeutic communication, assessment, education, monitoring, supervision, coordination, referral, support E: evaluation ↳ make judgments about the patient's progress; analyze the effectiveness of nursing care; review potential areas for collaboration/referral to other health care professionals; and monitor the quality of nursing care and its effect ↳ nurses need to have knowledge of the standards of care, expected patient responses, and conceptual models and theories Critical Thinking and Clinical Reasoning · Subjective data: based on patient experiences · 6 dimensions of critical thinking: Knowledge, comprehension, and perceptions application, analysis, synthesis, and evaluation · Objective data: physical examination and · Clinical reasoning is based on critical thinking. It is clinical things that are measurable reasoning that helps formulate a nursing diagnosis · The first step is to gather assessment data (subjective and objective), then you cluster the data and draw inferences/ideas about what the health issue is and review suggested interventions (primary, secondary, or tertiary). Lastly, you document the assessment and diagnosis Types of Health Assessments · Urgent Assessment: performed in life-threatening or unstable situations, such as with a patient in an emergency department (ED) with a traumatic injury A - airway B - breathing C - circulation D - disability E- exposure · Comprehensive Assessment: includes a complete health history and physical examination ↳ your comprehensive history also includes a patient's perception of health, strengths to build on, risk factors for illness, functional abilities, methods of coping, and support systems ↳ a complete physical examination includes all body systems and regions, usually in head-to-toe format · Focused Assessment: based on the patient's issues, is narrower in scope, but more in depth on a specific issue(s) ↳ eg. a patient with a cough → look at general survey, vital signs, ears, nose, throat, thorax, lungs, heart, sputum - - - Priority Setting · Priority setting: being able to distinguish priorities as to what to do first. Nurses use knowledge, clinical experience, expertise, and professional judgment to determine acuities. Expert nurses sometimes prioritize in different ways based on their experiences ↳ CAB always first priority Frequency of Health Assessment · Frequency of health assessment: varies with the patient's needs, the purpose of data collection, and the health care setting. Long term care may need a comprehensive assessment once a month, while patients in hospital may require once per shift. Patients in intensive care have vital signs and focused assessments hourly · In the outpatient setting, the frequency of assessment depends on the course of illness and whether the process is improving or worsening Lifespan Considerations · A comprehensive assessment includes cognitive and emotional development in addition to physical growth · Language, vocabulary, sentences in toddlers · Motor development in infants, babies, toddlers, and young children Documentation and Communication · Documentation of both subjective and objective findings is essential for legal purposes and for communicating findings to others ↳ Freedom of Information and Protection of Privacy Act · communication of assessment data may be shared verbally. Care of the patient is collaborative, and you use an organized method when communicating with other health care professionals (SBAR) · Functional Assessment: focuses on the functional patterns that all humans share: health perception, health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-concept, roles and relationships, coping and stress, sexuality and reproduction, values and beliefs · Head-to-toe Assessment: the most organized system for collecting comprehensive physical data. This method is efficient and respects patient modesty · Body systems: a logical tool for organizing data when documenting and communicating findings. This method promotes critical thinking and allows you to analyze findings as you cluster similar data together to find issues Evidence-Informed Critical Thinking · Evidence-informed practice is an approach to patient care that minimizes intuition and personal experience and instead relies upon research findings and high-grade scientific support · Evidence-informed thinking helps you to solve common health issues using 4 steps: 1) Identify the issue 2) Search the literature for relevant research 3) Evaluate the research evidence using established scientific criteria 4) Choose interventions and justify the selection with the most valid evidence