EXAM 1 REVIEW NURS 3320
CHAP 1: NURSE’S ROLES IN ASSESSMENT: COLLECTING AND ANALYZING DATAS
A. INTRODUCTION TO HEALTH ASSESSMENT IN NURSING
-Nursing as ―the protection, promotion, and optimization of health and abilities, prevention of illness and injury,
alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals,
families, communities, and populations.‖
-Emphasis is placed on ―diagnosis and treatment of human responses‖ based on ―accurate client assessments,‖ including
how effective nursing interventions are ―to promote health and prevent illness and injury.‖
- ―The registered nurse collects comprehensive data pertinent to the patient’s health or situation‖
To accomplish this pertinent and comprehensive data collection, the nurse:
• Collects data in a systematic and ongoing process
• Involves the patient, family, other health care providers, and environment, as appropriate, in holistic
data collection
• Prioritizes data collection activities based on the patient’s immediate condition, or
anticipated needs of the patient or situation
• Uses appropriate evidence-based assessment techniques and instruments in collectingpertinent
data
• Uses analytical models and problem-solving tools
• Synthesizes available data, information, and knowledge relevant to the situation to identify patterns
and variances
• Documents relevant data in a retrievable format (ANA, 2010, p. 21)
Standard 2 states, ―The registered nurse analyzes the assessment data to determine thediagnoses or
issues. To accomplish this, the registered nurse:
• Derives the diagnosis or issues based on assessment data
• Validates the diagnoses or issues with the client, family, and other health care providers when
possible and appropriate
• Documents diagnoses or issues in a manner that facilitates the determination of theexpected
outcomes and plan
B. NURSE’S ROLES IN HEALTH ASSESSMENT
Current focus on managed care and internal case management has had a dramatic impact on theassessment role o
the nurse
Current focus on managed care and internal case management has had a dramatic impact on theassessment role o
the nurse.
• The acute care nurse performs a focused assessment, and then incorporates assessment
findings with a multidisciplinary team to develop a comprehensive plan of care
• Critical care outreach nurses need enhanced assessment skills to safely assess critically ill clients
who are outside the structured intensive care environment
• Ambulatory care nurses assess and screen clients to determine the need for physicianreferrals.
• Home health nurses make independent nursing diagnoses and referrals for collaborativeproblems
as needed.
• Public health nurses assess the needs of communities, school nurses monitor the growth andhealth of
children, and hospice nurses assess the needs of the terminally ill clients and their families
In all settings, the nurse increasingly documents and retrieves assessment data through sophisticated
computerized information systems (Cowen & Moorhead, 2014). Nursing health assessment courses with
informatics content are becoming the norm in baccalaureate programs.
, BOX 1-1
EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT
The following factors will continue to promote opportunities for nurses with advanced assessment skills:
• Rising educational costs and increased focus on primary care that affect the numbers and
availability of medical students
• Increasing complexity of acute care
• Growing aging population with complex comorbidities
• Expanding health care needs of single parents
• Increasing impact of children and the homeless on communities
• Intensifying mental health issues
• Expanding health service networks
• Increasing reimbursement for health promotion and preventive care services
• Limited number of medical students pursuing practice in primary care settings
• Aging of the baby boomer generation
C. ASSESSMENT: STEP 1 OF THE NURSING PROCESS
Assessment is the first and most critical phase of the nursing process.
Health assessment is more than just gathering information about the health status of the client. It is analyzing
and synthesizing that data, making judgments about the effectiveness of nursing interventions, and evaluating
client care outcomes
I. FOCUS OF HEALTH ASSESSMENT IN NURSING
• Virtually every health care professional performs assessments to make professional judgmentsrelated to
clients. A comprehensive health assessment consists of both a health history and
physical examination.
• The purpose of a nursing health assessment is to collect holistic subjective and objective datato
determine a client’s overall level of functioning in order to make a professional clinical judgment. The
nurse collects physiologic, psychological, sociocultural, developmental, and
spiritual data about the client. Thus the nurse performs holistic data collection
• The mind, body, and spirit are considered to be interdependent factors that affect a person’slevel of
health. The nurse, in particular, focuses on how the client’s health status affects activities of daily
living (ADL) and how those ADL affect the client’s health. For example, a
client with asthma may have to avoid extreme temperatures and may not be able to enjoy recreational
camping. Walking to work in a smoggy environment may adversely affect thisperson’s asthma.
• In addition, the nurse assesses how clients interact within their family and community, and how the
clients’ health status affects the family and community. For example, a diabetic clientmay not be able
to eat the same foods that the rest of the family enjoys. If this client develops complications of
diabetes and has an amputation, the client may not be able to carry out the family responsibility of
maintaining the yard. The client may no longer be able to work in the community as a bus driver. The
nurse also assesses how family and community affect the individual client’s health status. A
supportive, creative family may find alternative ways of cooking tasteful foods that are healthy for the
entire family. The community may or may not have a diabetic support group for the client and the
family.
• In contrast, the physician performing a medical assessment focuses primarily on the client’s
physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.
Similarly, a physical therapist would focus primarily on the client’s musculoskeletal system and the
effects on ability to perform ADL.
, II. FRAMEWORK OF HEALTH ASSESSMENT
• The framework used to collect nursing health assessment data differs from that used by other
professionals. A nursing framework helps to organize information and promotes the collection of
holistic data. This, in turn, provides clues that help to determine human
responses.
• The book is organized around a head-to-toe assessment of body parts and systems. In each chapter,
the nursing health history is organized according to a ―generic‖ nursing history framework, which is
an abbreviated version of the complete nursing health history detailedin Chapter 21. The questions
asked in each physical system’s chapter focus on that particular body system and are broken down
into four sections:
• History of present health concern
• Personal health history
• Family history
• Lifestyle and health practices
• Following the health history and health promotion sections (see the Using Evidence to Promote
Health and Prevent Disease section), the physical assessment section providesthe procedure,
normal findings, and abnormal findings for each step of examining a
particular body part or system.
• Thus the end result of a nursing assessment is the formulation of nursing diagnoses (health
promotion, risk, or actual) that require nursing care, the identification of collaborative
problems that require interdisciplinary care, the identification of medical
problems that require immediate referral, or client teaching for health promotion.
III. USING EVIDNECE TO PROMOTE HEALTH AND PREVENT DISEASE
• In order to participate in health promotion and disease prevention, the nurse needs knowledgeof
physiology as well as factors affecting a client’s risk of developing a disease and factors affecting
client behavior.
• There are many models used to analyze health promotion and disease prevention. Two of themajor
models are the Health Belief Model and the Health Promotion Model
• The Health Belief Model is based on three concepts: the existence of sufficient motivation; the
belief that one is susceptible or vulnerable to a serious problem; and the belief that changefollowing a
health recommendation would be beneficial to the individual at a level of acceptable cost
• In Pender’s Health Promotion Model, there are three focuses of the model: individual
characteristics and experiences, behavior-specific cognitions and affect, and behavioral outcomes
• Healthy People 2020 is a model developed by the U.S. Department of Health and Human Services
(DHHS) aiming to increase the life span and improve the quality of health for allAmericans. The
progress toward this goal is evaluated every 10 years,
• Many tools are available for nurses to use to screen clients for health risks through the National
Center for Chronic Disease Prevention and Health Promotion. Screening tools for
risks are also available through organizations such as the American Cancer Society (ACS), American He
Association (AHA), American Diabetic Association (ADA), Centers for Disease
, Control and Prevention (CDC), and the American Academy of Ophthalmology (AAO), amongothers
• Another resource for the nurse to consider is the U.S. Preventive Services Task Force (USPSTF),
which determines risk versus benefit in screenings. According to its website, the
USPSTF ―is an independent panel of non-Federal experts in prevention and evidence-basedmedicine and
composed of primary care providers
IV. TYPES OF ASSESSMENT
The four basic types of assessment are:
• Initial comprehensive assessment
• Ongoing or partial assessment
• Focused or problem-oriented assessment
• Emergency assessment
1. Initial Comprehensive Assessment
An initial comprehensive assessment involves collection of subjective data about the client’s
perception of his or her health of all body parts or systems, past health history, family history, and
lifestyle and health practices (which include information related to the client’s overall functioning) as
well as objective data gathered during a step-by-step physical examination.
For example, in a hospital setting the physician usually performs a total physical examination when the
client is admitted (if this was not previously done in the physician’s office). In this setting, the nurse
continues to assess the client as needed to monitor progress and client outcomes. A physical therapist
may perform a musculoskeletal examination, as in the case of a stroke patient, and a dietitian may take
anthropometric measurements in addition to doing a subjective nutritional assessment. In a community
clinic, a nurse practitioner may perform the entire physical examination. In the home setting, the nurse
is usually responsible for performing most of the physical examination
Regardless of who collects the data, a total health assessment (subjective and objective data
regarding functional health and body systems) is needed when the client first enters a health care
system and periodically thereafter to establish baseline data against which future health status
changes can be measured and compared.
2. Ongoing or Partial Assessment
An ongoing or partial assessment of the client consists of data collection that occurs after the
comprehensive database is established. This consists of a minioverview of the client’s body systems
and holistic health patterns as a follow up on health status. Any problems that were initially detected
in the client’s body system or holistic health patterns are reassessed to determine any changes
(deterioration or improvement) from the baseline data (Fig. 1-4). In addition, a brief reassessment of
the client’s body systems and holistic health patterns is performed to detect any new problems. This
type of assessment is usually performed whenever and wherever the nurse or another health care
professional has an encounter withthe client, whether in the hospital, community, or home setting.
For example, a partial assessment of a client admitted to the hospital with lung cancer requires
frequent assessment of respiratory rate, oxygen saturation, lung sounds, skin color, and capillary refill.
A total assessment of skin would be performed less frequently, with the nurse focusing on the color
and temperature of the extremities to determine level of oxygenation.
CHAP 1: NURSE’S ROLES IN ASSESSMENT: COLLECTING AND ANALYZING DATAS
A. INTRODUCTION TO HEALTH ASSESSMENT IN NURSING
-Nursing as ―the protection, promotion, and optimization of health and abilities, prevention of illness and injury,
alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals,
families, communities, and populations.‖
-Emphasis is placed on ―diagnosis and treatment of human responses‖ based on ―accurate client assessments,‖ including
how effective nursing interventions are ―to promote health and prevent illness and injury.‖
- ―The registered nurse collects comprehensive data pertinent to the patient’s health or situation‖
To accomplish this pertinent and comprehensive data collection, the nurse:
• Collects data in a systematic and ongoing process
• Involves the patient, family, other health care providers, and environment, as appropriate, in holistic
data collection
• Prioritizes data collection activities based on the patient’s immediate condition, or
anticipated needs of the patient or situation
• Uses appropriate evidence-based assessment techniques and instruments in collectingpertinent
data
• Uses analytical models and problem-solving tools
• Synthesizes available data, information, and knowledge relevant to the situation to identify patterns
and variances
• Documents relevant data in a retrievable format (ANA, 2010, p. 21)
Standard 2 states, ―The registered nurse analyzes the assessment data to determine thediagnoses or
issues. To accomplish this, the registered nurse:
• Derives the diagnosis or issues based on assessment data
• Validates the diagnoses or issues with the client, family, and other health care providers when
possible and appropriate
• Documents diagnoses or issues in a manner that facilitates the determination of theexpected
outcomes and plan
B. NURSE’S ROLES IN HEALTH ASSESSMENT
Current focus on managed care and internal case management has had a dramatic impact on theassessment role o
the nurse
Current focus on managed care and internal case management has had a dramatic impact on theassessment role o
the nurse.
• The acute care nurse performs a focused assessment, and then incorporates assessment
findings with a multidisciplinary team to develop a comprehensive plan of care
• Critical care outreach nurses need enhanced assessment skills to safely assess critically ill clients
who are outside the structured intensive care environment
• Ambulatory care nurses assess and screen clients to determine the need for physicianreferrals.
• Home health nurses make independent nursing diagnoses and referrals for collaborativeproblems
as needed.
• Public health nurses assess the needs of communities, school nurses monitor the growth andhealth of
children, and hospice nurses assess the needs of the terminally ill clients and their families
In all settings, the nurse increasingly documents and retrieves assessment data through sophisticated
computerized information systems (Cowen & Moorhead, 2014). Nursing health assessment courses with
informatics content are becoming the norm in baccalaureate programs.
, BOX 1-1
EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT
The following factors will continue to promote opportunities for nurses with advanced assessment skills:
• Rising educational costs and increased focus on primary care that affect the numbers and
availability of medical students
• Increasing complexity of acute care
• Growing aging population with complex comorbidities
• Expanding health care needs of single parents
• Increasing impact of children and the homeless on communities
• Intensifying mental health issues
• Expanding health service networks
• Increasing reimbursement for health promotion and preventive care services
• Limited number of medical students pursuing practice in primary care settings
• Aging of the baby boomer generation
C. ASSESSMENT: STEP 1 OF THE NURSING PROCESS
Assessment is the first and most critical phase of the nursing process.
Health assessment is more than just gathering information about the health status of the client. It is analyzing
and synthesizing that data, making judgments about the effectiveness of nursing interventions, and evaluating
client care outcomes
I. FOCUS OF HEALTH ASSESSMENT IN NURSING
• Virtually every health care professional performs assessments to make professional judgmentsrelated to
clients. A comprehensive health assessment consists of both a health history and
physical examination.
• The purpose of a nursing health assessment is to collect holistic subjective and objective datato
determine a client’s overall level of functioning in order to make a professional clinical judgment. The
nurse collects physiologic, psychological, sociocultural, developmental, and
spiritual data about the client. Thus the nurse performs holistic data collection
• The mind, body, and spirit are considered to be interdependent factors that affect a person’slevel of
health. The nurse, in particular, focuses on how the client’s health status affects activities of daily
living (ADL) and how those ADL affect the client’s health. For example, a
client with asthma may have to avoid extreme temperatures and may not be able to enjoy recreational
camping. Walking to work in a smoggy environment may adversely affect thisperson’s asthma.
• In addition, the nurse assesses how clients interact within their family and community, and how the
clients’ health status affects the family and community. For example, a diabetic clientmay not be able
to eat the same foods that the rest of the family enjoys. If this client develops complications of
diabetes and has an amputation, the client may not be able to carry out the family responsibility of
maintaining the yard. The client may no longer be able to work in the community as a bus driver. The
nurse also assesses how family and community affect the individual client’s health status. A
supportive, creative family may find alternative ways of cooking tasteful foods that are healthy for the
entire family. The community may or may not have a diabetic support group for the client and the
family.
• In contrast, the physician performing a medical assessment focuses primarily on the client’s
physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.
Similarly, a physical therapist would focus primarily on the client’s musculoskeletal system and the
effects on ability to perform ADL.
, II. FRAMEWORK OF HEALTH ASSESSMENT
• The framework used to collect nursing health assessment data differs from that used by other
professionals. A nursing framework helps to organize information and promotes the collection of
holistic data. This, in turn, provides clues that help to determine human
responses.
• The book is organized around a head-to-toe assessment of body parts and systems. In each chapter,
the nursing health history is organized according to a ―generic‖ nursing history framework, which is
an abbreviated version of the complete nursing health history detailedin Chapter 21. The questions
asked in each physical system’s chapter focus on that particular body system and are broken down
into four sections:
• History of present health concern
• Personal health history
• Family history
• Lifestyle and health practices
• Following the health history and health promotion sections (see the Using Evidence to Promote
Health and Prevent Disease section), the physical assessment section providesthe procedure,
normal findings, and abnormal findings for each step of examining a
particular body part or system.
• Thus the end result of a nursing assessment is the formulation of nursing diagnoses (health
promotion, risk, or actual) that require nursing care, the identification of collaborative
problems that require interdisciplinary care, the identification of medical
problems that require immediate referral, or client teaching for health promotion.
III. USING EVIDNECE TO PROMOTE HEALTH AND PREVENT DISEASE
• In order to participate in health promotion and disease prevention, the nurse needs knowledgeof
physiology as well as factors affecting a client’s risk of developing a disease and factors affecting
client behavior.
• There are many models used to analyze health promotion and disease prevention. Two of themajor
models are the Health Belief Model and the Health Promotion Model
• The Health Belief Model is based on three concepts: the existence of sufficient motivation; the
belief that one is susceptible or vulnerable to a serious problem; and the belief that changefollowing a
health recommendation would be beneficial to the individual at a level of acceptable cost
• In Pender’s Health Promotion Model, there are three focuses of the model: individual
characteristics and experiences, behavior-specific cognitions and affect, and behavioral outcomes
• Healthy People 2020 is a model developed by the U.S. Department of Health and Human Services
(DHHS) aiming to increase the life span and improve the quality of health for allAmericans. The
progress toward this goal is evaluated every 10 years,
• Many tools are available for nurses to use to screen clients for health risks through the National
Center for Chronic Disease Prevention and Health Promotion. Screening tools for
risks are also available through organizations such as the American Cancer Society (ACS), American He
Association (AHA), American Diabetic Association (ADA), Centers for Disease
, Control and Prevention (CDC), and the American Academy of Ophthalmology (AAO), amongothers
• Another resource for the nurse to consider is the U.S. Preventive Services Task Force (USPSTF),
which determines risk versus benefit in screenings. According to its website, the
USPSTF ―is an independent panel of non-Federal experts in prevention and evidence-basedmedicine and
composed of primary care providers
IV. TYPES OF ASSESSMENT
The four basic types of assessment are:
• Initial comprehensive assessment
• Ongoing or partial assessment
• Focused or problem-oriented assessment
• Emergency assessment
1. Initial Comprehensive Assessment
An initial comprehensive assessment involves collection of subjective data about the client’s
perception of his or her health of all body parts or systems, past health history, family history, and
lifestyle and health practices (which include information related to the client’s overall functioning) as
well as objective data gathered during a step-by-step physical examination.
For example, in a hospital setting the physician usually performs a total physical examination when the
client is admitted (if this was not previously done in the physician’s office). In this setting, the nurse
continues to assess the client as needed to monitor progress and client outcomes. A physical therapist
may perform a musculoskeletal examination, as in the case of a stroke patient, and a dietitian may take
anthropometric measurements in addition to doing a subjective nutritional assessment. In a community
clinic, a nurse practitioner may perform the entire physical examination. In the home setting, the nurse
is usually responsible for performing most of the physical examination
Regardless of who collects the data, a total health assessment (subjective and objective data
regarding functional health and body systems) is needed when the client first enters a health care
system and periodically thereafter to establish baseline data against which future health status
changes can be measured and compared.
2. Ongoing or Partial Assessment
An ongoing or partial assessment of the client consists of data collection that occurs after the
comprehensive database is established. This consists of a minioverview of the client’s body systems
and holistic health patterns as a follow up on health status. Any problems that were initially detected
in the client’s body system or holistic health patterns are reassessed to determine any changes
(deterioration or improvement) from the baseline data (Fig. 1-4). In addition, a brief reassessment of
the client’s body systems and holistic health patterns is performed to detect any new problems. This
type of assessment is usually performed whenever and wherever the nurse or another health care
professional has an encounter withthe client, whether in the hospital, community, or home setting.
For example, a partial assessment of a client admitted to the hospital with lung cancer requires
frequent assessment of respiratory rate, oxygen saturation, lung sounds, skin color, and capillary refill.
A total assessment of skin would be performed less frequently, with the nurse focusing on the color
and temperature of the extremities to determine level of oxygenation.
