weber health assessment in nursing

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WeberHealth Assessment in Nursing

WeberHealth Assessment in Nursing

Chapter 01: Nurse’s Role in Health Assessment: Collecting

and Analyzing Data


AssessmentAssessment

• 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


Phases of the Nursing ProcessPhases of the Nursing Process


Initial Comprehensive AssessmentInitial Comprehensive Assessment

• Collection of subjective data about the client’s perception of health of all body parts or systems

• Past medical history

• Family history

• Lifestyle and health practices


Types of AssessmentTypes of Assessment

• Ongoing or partial assessment: consists of data collection that occurs after the comprehensive data base is established

• Focuses on problem-oriented assessment: consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem

• Emergency assessment: very rapid assessment performed in life-threatening situations


QuestionQuestion

Is the following statement True or False?

A partial assessment is done when the client first enters a health care facility.


AnswerAnswer

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.


Steps of Health AssessmentSteps of Health Assessment

• Preparing for the assessment

– Review client’s record

– Review client’s status with other health care team members

– Educate about client’s diagnosis and tests performed


Collection of Subjective DataCollection of Subjective Data

• Biographical information

• Physical symptoms related to each body part or system

• Past health history

• Family history

• Health and lifestyle practices


Collection of Objective DataCollection of Objective Data

• Physical characteristics

• Body functions

• Appearance

• Behavior

• Measurements

• Results of laboratory testing


Comparing Subjective and Objective DataComparing Subjective and Objective Data


QuestionQuestion


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.


AnswerAnswer

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.


Steps of Health AssessmentSteps of Health Assessment

• Validating assessment data

• Documenting data


Analysis Phase of Nursing Process 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.


QuestionQuestion


A nurse is not supposed to draw inferences and identify problems during data analysis.


AnswerAnswer

False.

A nurse is supposed to draw inferences and identify problems during data analysis after identifying abnormal data and strengths and clustering data.


• 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 education

• Advanced practice nurses

Evolution of the Nurse’s Role in Health Assessment: PastEvolution of the Nurse’s Role in Health Assessment: Past

Jerry Ralya

A word is probably missing between "and" and "education"--maybe "graduate"? (I don't have the book.)


• 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: PresentEvolution of the Nurse’s Role in Health Assessment: Present


Evolution of the Nurse’s Role in Health Assessment: FutureEvolution 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

weber health assessment in nursing

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