nurse's role in health assessment: 4 goals promote health
prevent illness
treat human responses to health or illness
advocate for individuals, families, communities, and
populations
types of assessment Emergency (center on immediate and highest priority
problem)
Comprehensive
General Survey
Focused
emergency assessment involves a life-threatening or unstable situation
A—Airway (with cervical spine protection if an injury is
suspected)
B—Breathing—rate and depth, use of accessory muscles
C—Circulation—pulse rate and rhythm, skin color
D—Disability—level of consciousness, pupils, movement
E—Exposure
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comprehensive assessment broad and complete; includes a complete health history and
physical assessment and all body systems and areas; a
patient's perception of health, strengths to build upon, risk
factors for illness, functional abilities, methods of coping, and
support systems
general survey assessment begins immediately upon meeting client and continues
throughout assessment; no measurements are done
-overall appearance, hygiene and dress, skin color, body
structure and development, behavior, facial expressions,
posture, ROM, gait, speech, LOC
focused assesssment based on the patient's health issues; usually involves one or
two body systems and is smaller in scope than the
comprehensive assessment, but more in-depth on the specific
issue or issues
example is a patient who presents to the clinic with a cough.
levels of intervention to promote healthy Primary prevention
change Secondary prevention
Tertiary prevention
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primary prevention involves strategies aimed at preventing problems and focuses
on people and groups. Examples: Immunizations, health
teaching, safety precautions, and nutrition counseling, family
planning services, providing poison-control information, and
accident-prevention education
secondary prevention focus on screening for early detection of disease with prompt
diagnosis and treatment
examples: Vision screening, Pap smears, BP screening, hearing
testing, scoliosis screening, and tuberculin skin testing
tertiary prevention focuses on preventing complications of an existing disease
and promoting health to the highest level
examples: Diet teaching, exercise programs, physical therapy,
medication, surgical treatment
what is health assessment? gathering information about the health status of the patient,
analyzing and synthesizing those data, making judgments
about nursing interventions based on the findings, and
evaluating patient care outcomes
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, [NSG 121 exam 1 Q&A]
health assessment includes healthy history and physical assessment
critical thinking in nursing -Purposeful, outcome-directed (result-oriented) thinking
-Is driven by patient, family, and community needs
-Is based on the nursing process, evidence-based thinking,
and the scientific method
-Requires specific knowledge, skills, and experience
-New nurses must question
-Guided by professional standards and ethic codes
-Is constantly reevaluating, self-correcting, and striving to
improve
health promotion the behavior of a person who is motivated by a personal
desire to increase well-being and health potential
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