[NCM 100] Nurse’s Role in Health Assessment:
Collecting and Analyzing Data (Pg. 1)
- To establish a baseline data which future health status
changes can be measured and compared
SUB: Health Assessment | PRELIM
Nursing
- the protection, promotion, and optimization of health and
abilities, prevention of illness and injury, alleviation of
suffering through the diagnosis and treatment of human
responses and advocacy in the care of individuals, families,
community and populations.
- “That the registered nurse collects comprehensive data
pertinent to the patient's health or situation.”
To accomplish this pertinent and comprehensive data
collection, the nurse:
1. Collects data in a systemic and ongoing process
2. Involves the patient, family, other health care providers and
environment, as appropriate, in holistic data collection.
3. Prioritizes data collection activities based on the patient’s
immediate condition, or anticipated needs of the patient or
situation.
4. Uses appropriate evidence-based assessment techniques
and instruments in collecting pertinent data
5. Uses analytical models and problem-solving tools
6. Synthesizes available data, information, and knowledge
relevant to the situation to identify patterns and variances.
7. Documents relevant data in a retrievable format.
- “The registered nurse analyzes the assessment data to
determine the → diagnoses or issues.”
PHASES OF THE NURSING PROCESS OVERVIEW
▪ 4 sections asked in each physical systems:
• Collection of subjective data about the client’s
perception of health of all body parts or systems
• History of present health concern
• Past medical history - a narrative or record of past
events and circumstances that are or may be
relevant to a patient's current state of health.
Informally, an account of past diseases, injuries,
treatments, and other strictly medical facts
2. Ongoing or Partial Assessment
- consists of data collection that occurs after the
comprehensive data base is established
3. Focused or Problem-oriented Assessment
- consists of a thorough assessment of a particular client
problem and does not cover areas not related to the
problem
4. Emergency Assessment
- very rapid assessment performed in life-threatening
situations
STEPS OF HEALTH ASSESSMENT
• The assessment phase of the nursing process has four major
steps:
a. Collection of subjective data
b. Collection of objective data
c. Validation of data
d. Documentation of data
• Preparing for the assessment:
a. Review client’s record
b. Review client’s status with other health care team
members
c. Educate about client’s diagnosis and tests performed
A. Assessment (Step 1 of the Nursing Process)
- First and most critical phase of the nursing process.
- It precedes the other phases in the formal nursing
process
- Assessment is ongoing and continuous throughout all
phases of the nursing process.
• Nursing Assessment
- Collective subjective and objective data to determine a
client’s overall level of functioning in order to make a
professional clinical judgment
• Medical Assessment
- Focuses primarily on the client’s physiologic
development status
4 BASIC TYPES OF HEALTH ASSESSMENT
1. Initial Comprehensive Assessment
- Family history - is a record of health information about
a person and his or her close relatives. A complete
record includes information from three generations of
relatives, including children, brothers and sisters,
parents, aunts and uncles, nieces and nephews,
grandparents, and cousins.
- Lifestyle and health practices
• Validating assessment data
- Validation of assessment data is a crucial part of
assessment that often occurs along with collection of
subjective and objective data.
- It serves to ensure that the assessment process is not
ended before all relevant data have been collected,
and helps to prevent documentation of inaccurate data
• Documenting data
- Thorough and accurate documentation is vital to
ensure that valid conclusions are made
COLLECTION OF SUBJECTIVE DATA
• Biographical information
• Physical symptoms related to each body part or system
• Past health history
• Family history
• Health and lifestyle practices
• Physical characteristics
• Body functions
• Appearance
• Behavior
• Measurements
• Results of laboratory testing
CHAPTER 1 Page 1
[NCM 100] Nurse’s Role in Health Assessment:
Collecting and Analyzing Data (Pg. 2)
SUB: Health Assessment | PRELIM
SUBJECTIVE DATA VS OBJECTIVE DATA
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.
• Physical assessment integral part of nursing
• Nurses relied on natural senses
• Palpation
EVOLUTION OF THE NURSE'S ROLE IN HEALTH ASSESSMENT: PAST
• Movement of health care from acute care setting to community care and proliferation of baccalaureate and education
• Advanced practice nurses
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
EVOLUTION OF THE NURSE'S ROLE IN HEALTH ASSESSMENT: FUTURE
• Rising educational cost
• Increasing complexity of acute care
• Growing aging population
• Expanding health care needs
• Increasing impact of children and homeless
• Intensifying mental health issues
• Expanding health services network
• Increasing reimbursement for health promotion and preventive care services
CHAPTER 1 Page 2