Chapter
Chapter 1
1
Nurse’s
Nurse’s Role
Role in
in Health
Health
Assessment:
Assessment: Collecting
Collecting and
and
Analyzing
Analyzing Data
Data
Assessment: Important for Every
Situation
• Current focus on managed care and internal case
management has had a dramatic impact on the
assessment role of the nurse.
– Acute care
– Critical care
– Ambulatory care
– Home health
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Assessment
• Holistic nursing assessment
– Collects holistic subjective and objective data to
determine a client’s overall level of functioning
in order to make a professional clinical judgment
• Physical medical assessment
– Focuses primarily on the client’s physiologic
development status
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Question
Is the following statement true or false?
Physical medical assessment collects holistic subjective and
objective data to determine a client’s overall level of
functioning in order to make a professional clinical
judgment.
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Answer
False.
Holistic nursing assessment collects holistic subjective and
objective data to determine a client’s overall level of
functioning in order to make a professional clinical
judgment. Physical medical assessment focuses primarily
on the client’s physiologic development status.
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Phases of Nursing Process
• Assessment: Collecting subjective and objective data
• Diagnosis: Analyzing subjective and objective data to
make a professional nursing judgment (nursing diagnosis,
collaborative problem, or referral)
• Planning: Determining outcome criteria and developing a
plan
• Implementation: Carrying out the plan
• Evaluation: Assessing whether outcome criteria have
been met and revising the plan as necessary
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Question
What occurs during the assessment phase of the nursing
process?
A. Collect subjective and objective data
B. Determine outcome criteria and develop a plan of care
C. Carry out the plan
D. Assess whether outcome criteria have been met and
revise the plan as necessary
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Answer
A. Collect subjective and objective data.
Assessment is collection of subjective and objective data.
Planning is determining outcome criteria and developing
a plan. Implementation is carrying out the plan.
Evaluation is assessing whether outcome criteria have
been met and revising the plan as necessary.
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Steps of Health Assessment
• Preparing for the assessment
– Review client’s record (if the patient has been there
before)
– Review client’s status with other health care team
members
– Educate about client’s diagnosis and tests performed
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Collection of Subjective Data
• Biographical information
• History of present health concern; physical
symptoms related to each body part or system
• Personal health history
• Family history
• Health and lifestyle practices
• Review of systems
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Collection of Objective Data
• Physical characteristics
• Body functions
• Appearance
• Behavior
• Measurements
• Results of laboratory testing
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Steps of Health Assessment
• Validation of assessment data
• Documentation of data
• Analysis of data
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Analysis Phase of Nursing Process
• Identify abnormal data and strengths.
• Cluster the data.
• Draw inferences and identify problems.
• Propose possible nursing diagnoses.
• Check for defining characteristics of those diagnoses.
• Confirm or rule out nursing diagnoses.
• Document conclusions.
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Types of Assessment
• Initial comprehensive assessment: Collection of subjective data
about the client’s perception of health of all body parts or
systems, past medical history, family history, and lifestyle and
health practices.
• Ongoing or partial assessment: Data collection that occurs after
the comprehensive database is established.
• Focused/problem-oriented assessment: Thorough assessment of
a particular client problem, which does not cover areas not
related to the problem.
• Emergency assessment: Very rapid assessment performed in
life-threatening situations.
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Question
Is the following statement true or false?
A partial assessment is done when the client first enters a
health care facility.
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Answer
False.
A partial or ongoing assessment of the client consists of
data collection that occurs after the comprehensive
database is established. This takes place after the client is
admitted to the health care facility.
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Question
Is the following statement true or false?
Subjective data are sensations or symptoms, perceptions,
desires, preferences, beliefs, ideas, values, and personal
information that can be elicited and verified only by the
client.
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Answer
True.
Subjective data are sensations or symptoms, perceptions,
desires, preferences, beliefs, ideas, values, and personal
information that can be elicited and verified only by the
client.
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Evolution of the Nurse’s Role in Health
Assessment: Past
• Physical assessment integral part of nursing
• Nurses relied on natural senses
• Palpation
• Movement of health care from acute care setting to
community care and proliferation of baccalaureate and
graduate education
• Advanced practice nurses
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Evolution of the Nurse’s Role in Health
Assessment: Present
• Managed care and internal case management has impact
on assessment role of the nurse
– Acute care nurses
– Critical care outreach nurses
– Ambulatory care nurses
– Home health nurses
– Public health nurses
– School and hospice nurses
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Evolution of the Nurse’s Role in Health
Assessment: Future
• Rising educational cost
• Increasing complexity of acute care
• Growing aging population with complex comorbidities
• Expanding health care needs of single parents
• Increasing impact of children and homeless
• Intensifying mental health issues
• Expanding health services network
• Increasing reimbursement for health promotion and preventive care
services
• Limited number of medical students pursuing practice in primary care
settings
• Aging of the baby boomer generation
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