Fundamentals of Nursing I

Introduction:

Health Assessment is the first phase of the nursing process and probably the most vital as nursing assessment directs the rest of the process. It does not matter what nursing outcomes and goals as when the assessment is wrong the entire nursing intervention will be incorrect.

 

Topic Learning Outcome (TLOs):

By the end of this topic, you should be able to:

1. Explain the purpose of health assessment in today’s context.
2. Describe the roles of the professional nurse in health assessment.
3. Discuss the different levels of preventive care.

Nursing Assessment in Today’s Context

Nursing assessment is the process of collecting, validating, and clustering data. It is the first and most important step in the nursing process. The assessment phase sets the tone for the rest of the process, and the rest of the process flows from it. Assessment identifies a patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process. After performing initial assessment, you establish your baseline, identify nursing diagnoses, and develop a plan. Then, as you implement your plan, you also assess your patient’s response. Finally, you assess the effectiveness of your plan of care for your patient.

 

The purpose of assessment is to collect data pertinent to the patient’s health status, to identify deviations from normal, to discover the patient’s strengths and coping resources, to pinpoint actual problems, and to spot factors that place the patient at risk for health problems. Assessment requires at least these skills; cognitive, problem-solving, psychomotor, affective/interpersonal, and ethical skills. Cognitive skills are needed for critical thinking, creative thinking, and clinical decision making. With experience, you will develop your problem-solving skills. Do not limit yourself to one method; instead, select the method that best suits your patient’s needs. Assessment is “doing.” Psychomotor skills are needed to perform the four techniques of physical assessment: inspection, palpation, percussion, and auscultation. Affective skills are needed to practice the “art” of nursing. Affective skills are essential in developing caring, therapeutic nurse-patient relationships. The data collected through assessment is used to plan the patient’s care, but it is important to remember that the data are the patient’s information. Therefore, you are responsible and accountable for your practice following the code of practice for nurses.

The Role of the Nurse in Assessment

The role of the nurse has changed drastically over the years. The importance of assessment can be traced to the beginning of modern nursing. Florence Nightingale (1859) stressed the importance of observation and experience as essential in maintaining or restoring one’s state of health. The scope of assessment has also expanded from simple observation to a holistic view of the patient that includes biophysical, psychosocial, developmental, and cultural assessments. Therefore, major roles are firstly direct and indirect caregiving, such as restore health for ill patients; assist patient and family to cope with disability and as a designers/coordinators/manager of care. Then advocates for the patient and the profession. For examples, patient’s safety; communicates patient’s needs; identifies side effects of treatment and finds better options; help patients understand their diseases and treatments. Besides, nurse takes responsibility to protect the legal and ethical rights of patients by based on professional values: Altruism (unselfishness); Human dignity; Autonomy; Integrity and Social justice. Lastly, professional nursing practice is grounded in best practice, critical inquiry and skilled questioning that involve research. Knowledge of patient care technologies and information systems is essential in the management of care through health assessment.

Level of Preventive Care

Health promotion and disease prevention are necessary to improve health at both the individual and the population level. Nurses have a vital role in all three levels of health care, and assessment skills are needed at all levels. Preventive healthcare can be classified as primary, secondary, and tertiary.

 

In Primary Preventive Care, nurses use assessment skills to screen and identify patient education needs about wellness and the risk factors for health problems. Mainly focuses on health promotion and guards against health problems. Examples include: health fairs, immunizations, and nutritional instructions.

In Secondary Preventive Care, accurate assessment is crucial to establish the patient’s baseline and to continually monitor his or her condition and response to treatment. Mainly focuses on early detection prompt intervention, and health maintenance for patients with health problems. Examples include: acute health problems seen with inpatient hospitalization.

In Tertiary Preventive Care, although the patient’s health status is generally more stable than in secondary care, patients usually have a chronic illness. Assessment skills are needed to continually monitor health status. Mainly focuses on rehabilitative or extended care. Examples include: skilled nursing care facilities; rehabilitative hospitals; long-term care facilities; home care; Hospice.