Nurse’s Role in Health Assessment: Collecting and Analyzing 2.

Satisfaction of making a difference in lives of patients

Data
3. Opportunity to grow professionally

Four Blended Skills

CONCEPT OF NURSING PROCESS
1. Cognitive skills - make sense of the situation and grasp
ASSESSMENT
what is necessary to achieve goals
 Nursing assessment
2. Technical skills - manipulate equipment skillfully to produce
Collective subjective and objective data to determine a
client’s overall level of functioning in order to make a desired outcome

professional clinical judgment 3. Interpersonal skills -establish and maintain caring

 Medical assessment relationships that facilitate achievement of goals

Focuses primarily on the client’s physiologic development 4. Ethical/legal skills - personal moral code and professional
status

 Holistic nursing assessment role responsibilities

Collects holistic subjective and objective data to determine a
client’s overall level of functioning in order to make a
professional clinical judgment Nursing

 Physical medical assessment The protection, promotion and optimization of health and
abilities, prevention of illness and
Focuses primarily on the client’s physiologic development
status injury, alleviation of suffering through the diagnosis and
treatment of human responses and

advocacy in the care of individuals, families, communities and

Nursing Process populations.
 An organized sequence of problem-solving steps used to (ANA, 2010)
identify and to manage the health problems of clients.
Purpose of Nursing Health Assessment
Phases of Nursing Process
1. To collect holistic subjective and objective data to
1. Assessment: Collecting subjective and objective data determine a client’s overall level of
2. Diagnosis: Analyzing subjective and objective data to make functioning in order to make a professional clinical judgment.
a professional nursing judgment (nursing
2. The nurse collects physiologic, psychological, sociocultural,
diagnosis, collaborative problem, or referral) developmental and spiritual
3. Planning: Determining outcome criteria and developing a data about the client.
plan

4. Implementation: Carrying out the plan

NURSE & HEALTH ASSESSMENT
5. Evaluation: Assessing whether outcome criteria have been
met and revising the plan as necessary “An accurate and thorough health assessment reflects the
KNOWLEDGE and SKILLS of a
Characteristics of the Nursing Process
PROFESSIONAL NURSE”
1. Systematic - part of an ordered sequence of activities
ASSESSMENT
2. Dynamic - great interaction and overlapping among the five
steps  The first and most critical phase of the nursing process.

3. Interpersonal - human being is always at the heart of  Defined as a systematic, dynamic process by which the
nursing nurse through interaction with

4. Outcome oriented - nurses and patients work together to client, significant others and health care providers, collects
identify outcomes and analyze data about the

5. Universally applicable - a framework for all nursing client (ANA)

activities
 Ongoing and continuous throughout all phases of the
nursing process.

Benefits of the Nursing Process Four Types of Assessment

Patient 1. Initial Comprehensive Assessment

1. Scientifically based, holistic individualized patient care 2. Ongoing or Partial Assessment

2. Continuity of care 3. Focused or Problem Oriented Assessment

3. Clear, efficient, cost-effective plan of action 4. Emergency Assessment

Nurse Steps of Health Assessment

1. Opportunity to work collaboratively with other healthcare 1. Collection of subjective data

workers
2. Collection of objective data
3. Validation of data 3. Emotional variations

4. Documentation of data

EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT Complete assessment of the sign, symptom, or health
concern
PAST
COLDSPA: Pneumonic device
 Physical assessment has been an integral part of nursing,
since the days of Florence Character

Nightingale. Onset

 Nurses relied on their natural senses. Location

 Palpation was used to measure pulse rate and to locate the Duration
fundus
Severity
PRESENT
Pattern
 Nurses are expanding their assessment and nursing
diagnosis skills Associated symptoms

 The acute care nurse performs a focused assessment and

incorporates findings with PSYCHOSOCIAL, COGNITIVE AND MORAL
multidisciplinary team. DEVELOPMENT
 Critical care need enhanced assessment skills to safely Growth – addition of new skills or components
assessed critically ill clients.
Development – refinement, expansion or improvement of
 Ambulatory care nurse assess and screen clients to existing skills or components.
determine the need for physician
Freud Theory of Psychosexual Development
referrals.

FUTURE
• Sigmund Freud, a Viennese physician, developed the first
 Increased specialization and diversity of assessment skills formal theory of personality.
for nurses.

 Bedside nurses are challenged to make in-depth physiologic

and psychosocial  He originated the concept of psychoanalysis and

assessment while correlating clinical data from multiple believed that personality development was based on
technical monitoring devices Interviewing understanding the individual life history of a person

Phases of the Interview

1. Introductory  Freud postulated that the psychological nature of

2. Working human beings is determined by the result of

3. Summary and Closing conflict between biological drives (instincts) and

Communication during the interview social expectations.

Nonverbal

 Appearance Three Levels of Awareness

 Demeanor Consciousness – whatever a person is sensing, thinking

 Facial expression about or experiencing at any given moment.

 Silence Pre- consciousness – involves all of a person’s memories

Verbal and stored knowledge that can be recalled and brought to the
conscious level.
 Open-ended questions
Unconsciousness – largest and most influential;
 Closed-ended questions
corresponds to socially unacceptable sexual desires,
 Laundry list
shameful impulses and irrational wishes, as well as anxieties
 Rephrasing and fears.
 Well-placed phrases

 Inferring

 Providing information

Special considerations during the interview regarding

communication

1. Gerontological variations

2. Cultural variations
Three Basic Structures of Personality

 Id – containing the basic motivational drives for such

entities as air, water,

warmth and sex; it seeks instant gratification and supplied the

psychic energy for the ego and superego. Knows no
perception of reality and morality.

Ego – intermediary between the id and the external world or

reality.

Includes many processes such as learning perceptions,

memory and problem-solving and decision making.

- realistic part that mediate between the desires of the id and

the super ego

 Superego – Moral component of personality, provides

feedback to the

person regarding how closely his behavior conforms to the

external value system.

- operates as a moral conscience

ID is entirely unconscious, while the parts of EGO and SUPER

EGO is conscious

The ID consist of our primary drives and primitive desires

The EGO acts as reminder not to act on these desires in

socially unacceptable or inappropriate manners

The SUPER EGO consist of our sense of morality

Piaget Theory of Cognitive Development

• Dr. Jean Piaget was a genetic epistemologist (one who

studies the origin of knowledge).

• His theory is a description and an explanation of the growth

and development of intellectual structures.

• Cognition is the process of obtaining understanding about

one’s world.

• Piaget acknowledged the interrelationships of physical

maturity, social interaction, environmental stimulation and
experience in general were necessary for cognition to occur

Piaget’s Major Concept and Terms

• Schema – a unit of thought and a classification for a

phenomenon, behavior or event.

• Assimilation – an adaptive process whereby a stimulus or

information is incorporated into an already existing schema.

• Accommodation – the creation of a new schema or the

Erikson Theory of Psychosocial Development modification of an old one to differentiate more accurately a
stimulus or a behavior from an existing schema.

• Equilibrium – balance between assimilation and

 Erik Erikson was a psychoanalyst who adapted and accommodation.
expanded Freud’s psychosexual theory.

 Psychosocial – intrapersonal and interpersonal responses of

a person to external events.

 Societal, cultural, and historical factors as well as biophysical

processes and cognitive function influence personality
development.
 • He was most concerned with examining the reasoning a
person used to

make a decision, as opposed to the action that resulted after

the decision was made.

• Justice (or fairness) as the goal of moral judgment

Pain Assessment

•Pain is what the client says it is: it is subjective

and only the client knows what he or she feels.

Effects of Pain

•Can interfere with sleep, and sleep deprivation can

increase the sensitivity to pain.

•Interferes with life activities and results in stress

and anxiety.

Pain Assessment

•Clients do not/cannot always describe pain

accurately; therefore, careful assessment is
necessary.

Types of Pain

• Cutaneous

– Skin and subcutaneous tissue

• Deep somatic

– Ligaments, tendons, bones, blood vessels, and

nerves

• Visceral

– Cranial, thoracic, or abdominal cavities

Types of Pain

• Radiating pain

– Felt at site of problem but also in surrounding

areas

• Referred pain

– Pain felt in an area distant from the source of the

problem

Types of Pain

• Intractable pain

– Pain that is very difficult to relieve

• Neuropathic pain

– Results from damage to the nervous system

(ex., Phantom limb pain)

Acute vs. Chronic Pain

– Acute: < 6 months ( less than 6 months )

– Chronic: > 6 months (more than 6 months )

Acute Pain
Kohlberg Theory of Moral Development
• Sympathetic nervous system predominates:
• Lawrence Kohlberg, a psychologist, expanded Piagtet’s
thought on morality. – elevated VS, sweating, pupil dilation

• Kohlberg proposed, individual morality has been viewed as – client reports pain
a dynamic, process that extends over one’s lifetime, primarily – manifests signs of pain such as restlessness,
involving the affective and cognitive domain in determining
what is “right” and ”wrong”. anxiety, crying, guarding, or holding affected area.
Chronic Pain

• Parasympathetic nervous system predominates:

– Normal VS, warm, dry skin, normal or

constricted pupils

– appears depressed or withdrawn

– does not report pain unless asked

ASSESSING FOR VIOLENCE (lamps, radios, irons, etc.) or with common weapons (knives

DOMESTIC VIOLENCE or guns)

“ A pattern of abusive behavior in any 2. PSYCHOLOGICAL ABUSE

relationship that is used by one partner to gain • Involves the use of constant insults or criticism, blaming the
victim for things that are not the victim’s fault, threat to hurt
or maintain control over another intimate children or pets, isolation from supporters, deprivation,
partner” humiliation, stalking and intimidation and manipulation of
various kinds such as threats of suicide
FAMILY VIOLENCE
• Also known as EMOTIONAL ABUSE “any act including
“ Violent or threatening behavior or any other form of confinement, isolation verbal assault, humiliation,
behavior, that coerces or controls a family member or causes intimidation, or any other treatment which may diminish the
a family member to be fearful.” sense of identity, dignity and self-worth”
ABUSE CAN BE: 3. ECONOMIC ABUSE
• PHYSICAL : slapping, hitting, kicking, punching, burning • Preventing the victim from getting or keeping a job,
controlling money and limiting access to funds, spending the
• EMOTIONAL: threats of physical harm, financial harm, victim’s money and controlling knowledge of family finances.
harassment; insults and other verbal abuse; • Also known as FINANCIAL ABUSE, is the improper
isolation; intimidation; exploitation of another person’s personal assets, properties or
funds
• SEXUAL: incest or rape
4. SEXUAL ABUSE
TYPES OF FAMILY VIOLENCE
• Forcing the victim to perform sexual act against her or his
will, pursuing sexual activity after the victim has said no, using
1. PHYSICAL ABUSE violence during sex, and using weapons vaginally, orally and
anally
• Pushing, shoving, slapping, kicking, choking, punching and
• Assault and rape
burning
ASSESSING MENTAL STATUS
• May involve holding, tying or other methods of restraint.
(INCLUDING RISK FOR SUBSTANCE ABUSE)
• May also involve attacking the victim with household items
 • The perception that one’s worldview is the only

MENTAL STATUS acceptable truth, and that one’s beliefs, values and

Refers to a client’s level of cognitive functioning (thinking, sanctioned behaviors are superior to all others.
knowledge, problem solving) and emotional functioning
(feelings, mood, behavior, stability) ETHNICITY

MENTAL HEALTH • Exists when the person identifies with a “socially,

 Essential part of one’s total health and is more than just culturally and politically constructed group of
absence of mental disabilities or disorders. individuals that holds a common set of characteristics
 A state of well-being in which an individual realizes his or not shared by others with whom its members come in
her own abilities, can cope with normal stresses of life, contact.”
can work productively and is able to make contribution CULTURE- BASED TREATMENTS
to his or her community. (WHO) •ASIAN
FACTORS AFFECTING MENTAL HEALTH Cupping – involves placing heated glass jars on the skin
 Economic and social factors Coining – involves rubbing ointment into the skin with a
 Unhealthy lifestyle choices spoon or a coin.

 Exposure to violence Moxibustion – attachment of smoldering herbs to the end of

acupuncture needles or the placement of herbs on the skin
 Personality factors

 Spiritual factors

 Cultural factors

 Changes or impairment in the structure and

function of the neurologic system

 Psychosocial development level and issues

SUBSTANCE ABUSE

 Harmful or hazardous use of psychoactive substances

including alcohol and illicit drugs.

Thoracic and Lung Assessment
 The abuse may lead to a dependence syndrome which
•Thorax: portion of body extending from base of neck
manifest itself in a cluster of behavior, cognitive and superiorly to level of diaphragm inferiorly;

physiologic phenomena that developed after repeated – outer structure = thoracic cage;

substance use. – inner structure = thoracic cavity

ASSESSING CULTURE •Thoracic Cage

• Culture affects so many aspects of life, including – Constructed of sternum and 12 pairs of ribs, 12 thoracic
vertebrae, muscles and cartilage
health related definitions, health outcomes and
•Thoracic cavity
health practices
– Mediastinum: trachea, esophagus, heart, great vessels
CULTURE
– Lungs:
• Shared system of values, beliefs and learned patterns of
•Right: 3 lobes
behavior.
•Left: 2 lobes
• The totality of socially transmitted behavioral patterns,
•Thoracic cavity
arts, beliefs, values, customs, lifeways and all other
– Pleura: parietal and visceral
products of human work and thought characteristic of a
– Pleural space
population or people that guide their world view and
•Trachea and bronchi
decision making. (Purnell)
– Respiratory dead space
VALUES
– Lined with cilia
• Learned beliefs about what is held to be good or bad
Sequence for Palpating the Posterior Thorax
NORMS
•What to use:
• Learned behaviors that are perceived to be appropriate
• Fingers  for sensation, lumps and lesions
or inappropriate
•Palm  tactile fremitus
ETHNOCENTRISM
Starting Position for Assessing the Symmetry of Lung Peripheral Vascular Assessment
Expansion
•Peripheral vascular system
• Level of T9 or T10
– Components for assessment
•Deep breath
•Arteries and veins of arms, legs
•Thumbs should move
•Lymphatic system
5-10 cm apart
•Capillaries
SYMMETRICALLY
– Understanding of fluid exchange
Diaphragmatic Excursion
•Arteries’ attributes:
• Done on both left and right sides
– Carry oxygenated, nutrient-rich blood to capillaries
• Normal:
– High pressure system
– Equal and bilateral
– Thick, layered walls
– 3-5 cm in adults
– Pulse = force of blood against arterial walls felt with heart
– 7-8 in well-conditioned clients beat

•Veins’ attributes

– Carry deoxygenated, nutrient-depleted, waste-laden blood

from the tissues back to the heart

– No force that propels blood flow

– Low pressure system

Major arteries of the arm

– Brachial, radial, ulnar

• Major arteries of the leg

– Femoral, popliteal, dorsalis pedis, posterior tibialis

Lymphatic system attributes

– Primary function: drain excess fluid and plasma protein from

bodily tissue and return them to venous system

•Prevents edema

•Produces lymph

Lymphatic system attributes, continued

– Second function: major part of immune system

– Third function: absorb fats (lipids) from small intestine

•Capillaries attributes

– Release of oxygen to tissue via interstitial fluid and pick-up

of waste products

– Hydrostatic (pushing) pressure

– Osmotic (pulling) pressure (also called oncotic pressure)

 Joints:

– Places where 2 or more bones meet

– Classified as:

•fibrous (sutures of skull),

•cartilaginous (joints between vertebrae),

•synovial (shoulders, wrists, hips, knees, ankles)

Knee Inspection

• Knock knees (genu valgum)

• Bowed legs (genu varum)

Arterial Vs. Venous Insufficiency • Tendernes: synovitis

• Arterial insufficiency

– Pallor when elevated

– Rubor when dependent

– Loss of hair

– Cold to touch

– Weak or absent touch

• Venous insufficiency

– Cyanosis when dependent

– Rusty or brownish pigmentation around ankles

– Warm to touch

Homan's sign test also called dorsiflexion sign test is a

physical examination procedure that is used to test for

Deep Vein Thrombosis (DVT).

• Homans Sign is a screening test used to check for deep

vein thrombosis (DVT) which causes calf pain. It's

sometimes called dorsiflexion sign.

Ankle-Brachial Index (ABI)

• Formula:

– ABI = Ankle / Brachial Systolic Pressure

• Interpretation:

– 1 = Normal

– 0.5 – 0.95 = Moderate arterial

insufficiency

– 0.25 or lower = Severe ischemia

Musculoskeletal Assessment

Musculoskeletal System

– Components: bones, muscles, joints

– Control and innervation by central nervous system (CNS)

•Number of bones:

– 206 bones make up axial skeleton (head and trunk) and

appendicular skeleton (extremities, shoulders, hips)

Skeletal muscle:

– 650 voluntary skeletal (voluntary) muscles; made up of long

muscle fibers (fasciculi) arranged together in bundles and
joined by connective tissue