Nursing Health Assessment

1. Nursing Health Assessment Dr. Bashir Ibrahim Alhajjar BSN, MSDS, MSP, PhDMHC, PhDMHN, PhDNE Faculty of Nursing-IUG

2. Faculty of Nursing-IUG Chapter (1) Introduction of Health Assessment

3. The first assessment began in (1992) by American medical association. • In (1995) health assessment considered as basic human right. • Preventive health care divided in three categories, primary, secondary and tertiary prevention. Each level of prevention is based on a thorough assessment of the client's health as status. • Periodic health assessment needed to be performed by a physician, or a nurse.

4. Objectives of health assessment • Surveillance of health status, identification of occult disease, screening, and follow-up care. • The periodic assessment, at regular intervals. • Increasing client participation in health care. • Accurately define the health and risk care needs for individuals. • Health assessment is shared with the client in a clearly and understandable manner. • The client must share in decision making for his own care.

5. Types of Assessment • Comprehensive assessment: is usually the initial assessment it very thorough and includes detailed health history and physical examination and examine the client's overall health status. • Focused assessment : is problem oriented and may be the initial assessment or an ongoing assessment.

6. Frequency of assessment • The persons under (35) years every (4-5) years. • The persons from (35-45) every (2-3) years. • Persons from (45-55) years of age undergo a thorough health assessment every year. • Persons over (55) years may needs assessment every 6 months or less.

7. Importance of nursing health assessment 1. Systematic and continuous collection of client data. 2. It focus on client responses to health problems. 3. The nurse carefully examine the client’s body parts to determine any abnormalities. 4. The nurse relies on data from different sources which can indicate significant clinical problems. 5. Health assessment provides a base line used to plan the clients care

8. 6. Health assessment helps the nurse to diagnose client’s problem & the intervention. 7. Complete health assessment involves a more detailed review of client’s condition. 8. Health assessment influence the choice of therapies & client's responses.

9. Purposes of health assessment 1. To Gather data. 2. To confirm or refuse data obtained in the health history. 3. To identify nursing diagnoses. 4. To make clinical judgments about client's changing health status. 5.To evaluate bio-psycho-social & spiritual outcomes of care.

10. Nursing and medical diagnosis • There is a big Difference between both because: • Nursing diagnose is independent role of the nurse. • Nursing diagnoses depends on the client's problems/response associated with specific disorder. • Any problem in nursing diagnosis must notice from a holistic view e.g. bio-psycho-social and spiritual relations.

11. Medical diagnoses • Depends on clinical picture and laboratory findings. • The specialist doctor has a right to diagnose not else. Example: - DM is medical diagnoses (hypo or hyperglycemia). - Nursing diagnoses in this case e.g. Impaired skin integrity R/T poor circulation, Knowledge deficit about the effects of exercise on needs of insulin.