1. conceptual overview.pptx

8/15/2019 1. conceptual overview.pptx

1/28


2/28

HEALTH

• State of complete physical,mental and social well-

being. (WHO,!"#$


3/28

HEALTH ASSESSMENT /

NURSING ASSESSMENT


4/28

ASSESS%E&T

• Systematic and contin'o'scollection, alidation, and

comm'nication of patientdata, whe)e data )e*ects howhealth f'nctioning is

enhanced by healthp)omotion o) comp)omised byillness


5/28

ASSESS%E&T

• Systematic and contin'o'scollection, alidation, and

comm'nication of patientdata, whe)e data )e*ects howhealth f'nctioning is

enhanced by healthp)omotion o) comp)omised byillness


6/28

ASSESS%E&T

• Systematic collection of dataabo't a client fo) the p')pose of

dete)mining the+. clients c'))ent and ongoinghealth stat's

. )edicting )is/ to health0. 1dentifying health-p)omoting

actiities.


7/28

ASSESS%E&T

• Attaining s'b2ectie andob2ectie data f)om p)ima)y

and seconda)y so')ces, toidentify and g)o'p signi3cantdata, and to comm'nicate

this info)mation to othe)membe)s of the health team


8/28

ASSESS%E&T

Primary Sources Or Direct Source. The client

.

Secondary sources. 4amily membe)s,

. ca)egie)s,

0. othe) membe)s of the health team

". %edical )eco)ds


9/28

ASSESS%E&T

• The data incl'des+

. physical ,

. social,0. c'lt')al,

". eni)onmental and

5. emotional facto)s•. That impact the oe)all well-beingof the client


10/28

ASSESS%E&T

• Efective communicationtechniques and the use ocritical thinking skills a)eessential in helping the n')se togathe) detailed , complete,)eleant, ob2ectie, s'b2ectie and

meas')able data needed tofo)m'late a plan of ca)e to meetthe need of the client.


11/28

ASSESS%E&T

• 6ende)s info)mationnecessa)y fo) clinical-

decision ma/ing


12/28

ASSESS%E&T

• Health assessment incl'des7

. The inte)iew

. hysical assessment0. 8oc'mentation

". And inte)p)etation of3ndings


13/28

ASSESS%E&T


. The inte)iew

•.S'b2ectie data is gathe)edwhich incl'des

A. health histo)y and9. foc'sed inte)iew


14/28

ASSESS%E&T


. hysical assessment

• Hands on e:amination of theclient

• ;omponents+

a. S')ey

b. e:amination of system


15/28

ASSESS%E&T

• Health assessment incl'des70. 8oc'mentation

8oc'mentation of data f)omthe health assessment c)eatesa client )eco)d o) becomes an

additional to e:isting )eco)ds


16/28

ASSESS%E&T


8oc'mentation of data f)omthe health assessment c)eatesa client )eco)d o) becomes an

additional to e:isting )eco)ds


17/28

ASSESS%E&T



18/28

ASSESS%E&T

All planning fo) ca)e isdi)ected by the

inte)p)etation of 3ndingsf)om the ob2ectie ands'b2ectie data gathe)ed.


19/28

ASSESS%E&T

S'b2ectie data

• 1nfo)mation that the client

e:pe)iences andcomm'nicates to the n')se7

E:amples+ pe)ception of pain.&a'sea, di==iness itchingsensations o) feeling ne)o's


20/28

ASSESS%E&T

S'b2ectie data• ;oe)t data(hidden$

• Symptoms –e)ceied by the client b't

can not be seen by othe)s


21/28

ASSESS%E&T

S'b2ectie data4amily membe)s o) ca)egie)s can)epo)t s'b2ectie data based on the

pe)ception of client sha)ed withthem

• 1f+ the client is e)y ill o) 'n able tocomm'nicate

• 6e>'i)ed if+ the client is infant o)child.


22/28

ASSESS%E&T

Ob2ectie 8ata• Obse)ed and meas')ed bythe p)ofessional n')se

• Oe)t 8ata o) Sign –8etected by the n')se

• ;an be seen, hea)d, felt andmeas')ed


23/28

ASSESS%E&T

Ob2ectie 8ata• &eeded to alidate

s'b2ectie data and tocomplete the data base


24/28

ASSESS%E&T

• Health assessment incl'des7". 1nte)p)etation of 3ndings

• %a/ing dete)mination abo'tall of the data collected datain the health assessment

p)ocess.


25/28

ASSESS%E&T


•

8ete)mine if the 3ndings fallwithin the no)mal ande:pected )anges in )elation

to the clients age, gende),and )ace


26/28

ASSESS%E&T


•

8ete)mine the signi3canceof the 3ndings in )elation tothe clients health stat's

and immediate and long)ange health )elated needs.


27/28

8atabase

• 1ncl'des all the pe)tinent patientinfo)mation collected by the n')seand othe) health ca)e

p)ofessionals• Enables a comp)ehensie and

e?ectie plan of ca)e to be

designed and implemented fo)the client


28/28

Assessment s. Eal'ation

Evaluation • 8ete)mines e?ectieness of

t)eatment o) ca)e

• t)eatment o) ca)e is )eiewed,the client@s )esponse tointe)ention identi3ed, and a

conside)ation as to whethe) theclient has achieed thep)edete)mined o'tcomes and

goals

1. conceptual overview.pptx

Documents