Meaning of Health Assessment
‘Health Assessment’ is defined as a two-step process, which helps the nurse to identify the individual’s health needs and health problems. The first step is ‘data gathering’ and the second step is making a ‘nursing diagnosis’ by analysing the data.Throughout this text individuals with health problems will be referred to as ‘clients’.
Let us now break the definition and understand the meaning of ‘Health Assessment’.‘Health’ reflects the condition of a person’s body, mind and spirit. That is, the body organs,which in normal condition help the person to perform his day-to-day activities without any difficulty. It also means the person’s capacity to adjust mentally or emotionally to the usual stress and strain of life. Spiritual health means to have faith in God or some ideals which give direction to all life of activities.
‘Assessment’ means to measure or find out the functioning capacity of the person’s body organs or systems and his/her ability to maintain emotional balance in all life situations. If there is any difficulty or deficiency in these abilities, a systematic examination can identify the cause and thus help in making a suitable plan of treatment and nursing care.
Principles of Health Assessment
Before we go further in discussion about Health Assessment, it is essential to remember certain points about it. These points when written in the form of statements, are called as ‘Principles’.These principles are evidence based and guide us in our every activity in Health Assessment.Over the years many leaders in health care areas have experimented with these points and have found them to be true. Therefore, principles are scientifically proved facts. These principles guide us in our every activity in Health Assessment.
The principles are:
a) Every individual has health problems and health needs, which are different from others.
b) All human beings, who are aware of his surroundings, need privacy.
c) Health Assessment is a systematic step-by-step process.
d) The well-being of body, mind and spirit of an individual has influence on each other.
e) The degree of wellness of an individuals continuously changes.
Steps of Health Assessment
Now let us discuss about the steps of Health Assessment.
Step One: Data Gathering or Data Collection.
Data gathering is gathering or collection of information about the client’s physical health,mental outlook, social circumstances, family and community life, his functioning abilities in day-to-day life, habits, interests etc.
Step Two: Nursing Diagnosis
‘Nursing Diagnosis’ is a statement showing the cause and effect relationship of a person’s health problem.Cause is the contributing factor leading to the development of health problem.
Effect is the person’s present and future health problems, e.g., alteration in comfort, abdominal pain, related to indigestion and gas formation.Here,
‘Indigestion and gas formation, is the Cause,
‘Alteration in comfort’ is the Effect, and
‘Abdominal pain’ is the Evidence of the relationship between the ‘cause’ and ‘effect’.
‘Nursing Diagnosis’ is different from ‘Medical Diagnosis’.
‘Medical Diagnosis’ identifies and describes the nature of the illness. e.g., inflammation,infection, burns etc.
‘Nursing Diagnosis’ identifies and describes the effects of illness on the individual, his family and community. e.g., altered comfort, altered body temperature, altered respiration.
Purposes of Health Assessment
The reasons that we need to collect information about the client’s health condition are the following to:
a) prepare a Data-Base.
b) understand the progress in client’s health condition as the treatment is going on.
c) estimate the effectiveness of nursing care from the clients changing health condition.
d) identify the client’s health problem/need, as it undergoes changes from time to time.
e) formulate Nursing diagnoses.
f) assist in making and confirming medical diagnoses.
Data-Base
The specific basic information, or facts when organised meaningfully, make a Data-Base. This Data-Base serves as a starting point for planning nursing care, as it helps in identifying important health prob1ems and health needs of the client.Data-gathering never stops with the Data-Base, it is a continuous process. Because, a person’s health condition keeps on changing every moment, so are the health needs.Remember that data-gathering does not include interpretation or analysis of the information gathered. That is done in the second step of Health Assessment.What is there in a Data-Base?
A typical Data-Base or basic information about the client includes the following:
a)A description of the person himself
‘Health Assessment’ is defined as a two-step process, which helps the nurse to identify the individual’s health needs and health problems. The first step is ‘data gathering’ and the second step is making a ‘nursing diagnosis’ by analysing the data.Throughout this text individuals with health problems will be referred to as ‘clients’.
Let us now break the definition and understand the meaning of ‘Health Assessment’.‘Health’ reflects the condition of a person’s body, mind and spirit. That is, the body organs,which in normal condition help the person to perform his day-to-day activities without any difficulty. It also means the person’s capacity to adjust mentally or emotionally to the usual stress and strain of life. Spiritual health means to have faith in God or some ideals which give direction to all life of activities.
‘Assessment’ means to measure or find out the functioning capacity of the person’s body organs or systems and his/her ability to maintain emotional balance in all life situations. If there is any difficulty or deficiency in these abilities, a systematic examination can identify the cause and thus help in making a suitable plan of treatment and nursing care.
Principles of Health Assessment
Before we go further in discussion about Health Assessment, it is essential to remember certain points about it. These points when written in the form of statements, are called as ‘Principles’.These principles are evidence based and guide us in our every activity in Health Assessment.Over the years many leaders in health care areas have experimented with these points and have found them to be true. Therefore, principles are scientifically proved facts. These principles guide us in our every activity in Health Assessment.
The principles are:
a) Every individual has health problems and health needs, which are different from others.
b) All human beings, who are aware of his surroundings, need privacy.
c) Health Assessment is a systematic step-by-step process.
d) The well-being of body, mind and spirit of an individual has influence on each other.
e) The degree of wellness of an individuals continuously changes.
Steps of Health Assessment
Now let us discuss about the steps of Health Assessment.
Step One: Data Gathering or Data Collection.
Data gathering is gathering or collection of information about the client’s physical health,mental outlook, social circumstances, family and community life, his functioning abilities in day-to-day life, habits, interests etc.
Step Two: Nursing Diagnosis
‘Nursing Diagnosis’ is a statement showing the cause and effect relationship of a person’s health problem.Cause is the contributing factor leading to the development of health problem.
Effect is the person’s present and future health problems, e.g., alteration in comfort, abdominal pain, related to indigestion and gas formation.Here,
‘Indigestion and gas formation, is the Cause,
‘Alteration in comfort’ is the Effect, and
‘Abdominal pain’ is the Evidence of the relationship between the ‘cause’ and ‘effect’.
‘Nursing Diagnosis’ is different from ‘Medical Diagnosis’.
‘Medical Diagnosis’ identifies and describes the nature of the illness. e.g., inflammation,infection, burns etc.
‘Nursing Diagnosis’ identifies and describes the effects of illness on the individual, his family and community. e.g., altered comfort, altered body temperature, altered respiration.
Purposes of Health Assessment
The reasons that we need to collect information about the client’s health condition are the following to:
a) prepare a Data-Base.
b) understand the progress in client’s health condition as the treatment is going on.
c) estimate the effectiveness of nursing care from the clients changing health condition.
d) identify the client’s health problem/need, as it undergoes changes from time to time.
e) formulate Nursing diagnoses.
f) assist in making and confirming medical diagnoses.
Data-Base
The specific basic information, or facts when organised meaningfully, make a Data-Base. This Data-Base serves as a starting point for planning nursing care, as it helps in identifying important health prob1ems and health needs of the client.Data-gathering never stops with the Data-Base, it is a continuous process. Because, a person’s health condition keeps on changing every moment, so are the health needs.Remember that data-gathering does not include interpretation or analysis of the information gathered. That is done in the second step of Health Assessment.What is there in a Data-Base?
A typical Data-Base or basic information about the client includes the following:
a)A description of the person himself
- Name
- Gender
- Age
- Address
- Observed physical and mental condition (e.g., Thin man, looks anxious).
b)A description of the person’s
- Education
- Occupation
- Family members
- Other important people in his life
- His involvement in socio-cultural activities.
c) His present health condition and health problems, if any as prescribed by him.
d) His past health history: This includes information about all minor discomforts and major health problems, also treatment taken, hospitalization etc.
e) Family health history: includes information about the health condition of his family members and causes of death.
d) His past health history: This includes information about all minor discomforts and major health problems, also treatment taken, hospitalization etc.
e) Family health history: includes information about the health condition of his family members and causes of death.
f) His relationship with his family members, friends and other people. The way he communicates with all others.
g) His abilities for activities of daily living, i.e., (ADL)
g) His abilities for activities of daily living, i.e., (ADL)
- Personal cleanliness
- Wearing dresses
- Sleep pattern
- Safety practices
- Movement
- Working
- Ability to maintain nutritional requirements
- Maintaining elimination.
h)His mental and emotional condition, i.e. How he reacts to stressful situations
- Mood changes
- What he thinks about his body, mind and personality
- Mental maturity
- Thought process (organised, meaningful)
- Special interests, motivations
- Willingness to take risk
- Non-verbal behaviour (posture, limb movements)
- Awareness of feelings of happiness, sadness, fear, apprehension, hatred, jealousy and the way he manages these feelings.
j)Awareness to environment
- Knows what is happening around him
- Keeps environment clean
- Reacts normally to extreme heat, cold, noise etc. physical discomforts.
What he thinks about his illness. What he expects and wants from the health care personnel.The data gathering for a child is similar to that of the adult. The additional information will be:
- The parent-child relationship
- The child’s adjustment to school
- His relationship with his friends
- Information about his physical growth and development
- Information about his mental growth and development.
Types of Data
As you have already studed of BNS-101. The data gathered/collected are of two kinds:
i) Subjective data: What the client says about himself.
ii) Objective data: What the health practitioner observes about the client.
‘Subjective data’ are what the client says about what he feels, sees, hears, thinks, and all his experiences about himself and his environment, e.g.,
“I feel pain here”
“I can’t see the writings properly”
“I have no hunger”
“I am afraid of darkness”
“I hear strange sounds”
What the client’s relatives or friends say about the client are also subjective data, e.g.,
“He is not responding to our calls”
“He says he feels pain here”
“She does not eat well”
Subjective data are not observable and its measurement is difficult.Subjective data are usually collected when the client comes in contact with the health professional, first time. It is also obtained during daily contacts with him.When recording subjective data it is essential to write exactly what the client says.e.g., “The client says, I feel very depressed” (correct) “The client looks depressed”(Incorrect).
The later is what you think about the client, may not be what he feels. ‘Objective data’ are the information about the client obtained by the health care practitioners by using the senses, i.e., visual observations; listening through stethoscope; touching the body parts; feeling the skin for warmth, dryness; smelling of breath for odor etc. The objective data may be recorded as:
“He opens his eyes when called”
“His speech is slurred”
“His body temperature is 38°C
“His pulse is bounding.”
Objective data are observable and measurable, and are gathered during the physical examination or functional assessment. However, objective data gathering is also a process. It requires daily, sometimes hourly or even minute-to-minute assessment, depending on the
client’s health condition.
Data Validation
It is essential to validate or check the authenticity of both subjective and objective data.
Example
As you have already studed of BNS-101. The data gathered/collected are of two kinds:
i) Subjective data: What the client says about himself.
ii) Objective data: What the health practitioner observes about the client.
‘Subjective data’ are what the client says about what he feels, sees, hears, thinks, and all his experiences about himself and his environment, e.g.,
“I feel pain here”
“I can’t see the writings properly”
“I have no hunger”
“I am afraid of darkness”
“I hear strange sounds”
What the client’s relatives or friends say about the client are also subjective data, e.g.,
“He is not responding to our calls”
“He says he feels pain here”
“She does not eat well”
Subjective data are not observable and its measurement is difficult.Subjective data are usually collected when the client comes in contact with the health professional, first time. It is also obtained during daily contacts with him.When recording subjective data it is essential to write exactly what the client says.e.g., “The client says, I feel very depressed” (correct) “The client looks depressed”(Incorrect).
The later is what you think about the client, may not be what he feels. ‘Objective data’ are the information about the client obtained by the health care practitioners by using the senses, i.e., visual observations; listening through stethoscope; touching the body parts; feeling the skin for warmth, dryness; smelling of breath for odor etc. The objective data may be recorded as:
“He opens his eyes when called”
“His speech is slurred”
“His body temperature is 38°C
“His pulse is bounding.”
Objective data are observable and measurable, and are gathered during the physical examination or functional assessment. However, objective data gathering is also a process. It requires daily, sometimes hourly or even minute-to-minute assessment, depending on the
client’s health condition.
Data Validation
It is essential to validate or check the authenticity of both subjective and objective data.
Example
- “I feel hot, may be I have got fever” (Subjective data).
- Oral temperature recording shows body temperature 100.2°F, i.e., above normal (Objective data)
Data validation may be done by checking one’s own observation also.
Sources of Data
There are two major sources of data as described in BNS-101 unit 1.
a) The primary source is the client himself/herself
b) The secondary sources are the following:
i) The client’s family, friends, colleagues and other close persons.
ii) Hospital and clinic records
Sources of Data
There are two major sources of data as described in BNS-101 unit 1.
a) The primary source is the client himself/herself
b) The secondary sources are the following:
i) The client’s family, friends, colleagues and other close persons.
ii) Hospital and clinic records
- Admission history
- Progress record
- Discharge summary, etc.
iii) Laboratory reports
iv) Other members of the health team — the doctor, other nurses, physiotherapist, etc.
v) Books and journals on health care matters.
Two points must be considered about data sources.
First, most people will give information about themselves frankly, if they are convinced that the information will be kept confidential. So, we must guarantee that his privacy will be respected.
Second, we must always consider the factor of human bias. Client’s fear, anxiety etc. emotions may influence the objectivity of his information. Also health professionals “feelings, personal experiences and understanding about the client may influence their judgement about client’s health condition.
iv) Other members of the health team — the doctor, other nurses, physiotherapist, etc.
v) Books and journals on health care matters.
Two points must be considered about data sources.
First, most people will give information about themselves frankly, if they are convinced that the information will be kept confidential. So, we must guarantee that his privacy will be respected.
Second, we must always consider the factor of human bias. Client’s fear, anxiety etc. emotions may influence the objectivity of his information. Also health professionals “feelings, personal experiences and understanding about the client may influence their judgement about client’s health condition.
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