Telehealth Improves Access to Care Source:

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Homes; and the home is becoming a primary setting for assessing and delivering health services due in large measure to telehealth. The Veterans Administration is a major player in funding, developing, and using telehealth. As technology improves and cost decreases, telehealth is likely to have an even greater impact on health care (Figure 4–4). Three points are spurring adoption of telehealth:

• Governmentalsupportandintegrationintoaccountablecareorganizations

• Consumerdemand

• Technologicalinnovation

NURSING Frame Works FOR HEALTH Assessment

Health assessment performed by the nurse is a collaborative partnership with the client that pro- motes mutual input into decision making and planning to improve the client’s health and well- being. The initial assessment provides a valuable baseline to compare subsequent assessments.

The desired outcomes describe the following:

1. Health assets

2. Health problems

3. Health-related lifestyle strengths

4. Key health-related beliefs

5. Health behaviors that put the client at risk

6. Changes that improve the quality of life

Nursing frameworks are available for nurses to assess and diagnose health and health behaviors. Nursing assessment is the systematic collection of data about a client’s health status, beliefs, and behaviors relevant to developing a health promotion-prevention plan, whereas nurs- ing diagnosis is the identification and enhancement of assessment to maximize health status.

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Nursing diagnostic classification systems (taxonomies) primarily focus on the individual and aspects of illness. Hence, positive health states (or strengths) of the individual, family, or community are not always adequately addressed in these taxonomies. As health promotion and prevention knowledge expands, taxonomies continue to include new definitions supportive of a health promotion/wellness perspective.

The North American Nursing Diagnosis International (NANDA-I) nursing diagnosis tax- onomy responds to the nine human response patterns: exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling (National Association of Nursing Diagnosis-International, 2013). The defining characteristics of each diagnosis, as well as related factors and risk factors, provide guidance about the critical assessment areas for the diagnosis. The NANDA-I classification provides a way to diagnose and intervene in selected health promo- tion and wellness processes and problems across the span of nursing practice (Popkess-Vawter, 2008). For example, stress overload occurs when the client presents feelings of tension and pres- sure that interfere with effective decision making, resulting in physical or psychological distress. Potential interventions, including active listening and decision-making support, address the stress overload diagnosis (Lunney, 2008).

Other examples of wellness nursing diagnoses/processes (client strengths) include the following:

1. Nutrition adequate to meet or maintain body requirements

2. Exercise level appropriate to maintain wellness state

3. Strength derived from one’s spirituality

Case studies and sample care plans are available to illustrate how diagnostic statements provide direction for health promotion-prevention care planning.

Gordon (2009) grouped the NANDA-I diagnoses into 11 functional health patterns to assist in classifying nursing diagnoses:

1. Health perception–health management

2. Nutritional–metabolic

3. Elimination

4. Activity–exercise

5. Sleep–rest

6. Cognitive–perceptual

7. Self-perception–self-concept

8. Role–relationship

9. Sexuality–reproductive

10. Coping–stress tolerance

11. Value–belief

Gordon provides guidelines to conduct a nursing history and examination to assess clients’ functional health patterns. As assessment proceeds, diagnostic hypotheses generate targeted or more detailed data collection. Refer to Gordon’s Manual of Nursing Diagnosis for recommended formats to assess functional health patterns in infants and young children, adults, families, and communities (Gordon, 2009).

The Omaha Visiting Nurse Association System is a useful guide for community health nurs- ing practice, a method of documentation, and a framework for community management. The Omaha System incorporates the needs of individuals and families in the categories of environ- ment, psychosocial, physiological, and health behavior needs. These categories use key words such as individual, family, or health promotion in the individual and family categories. Nurse research- ers have shown the usefulness of the Omaha System in quantifying nursing practice in community health, rural nursing practice, primary care, and wellness centers. A difficulty in developing nurs- ing classification systems for communities is that nursing diagnoses/problem classifications focus on nursing practice, whereas community problems focus more on interdisciplinary practice.

Nursing Interventions Classification (NIC), a system that generates standardized nursing actions and interventions for providing care, is relevant for community health because nursing services are categorized and linked to direct reimbursement (Bulechek, Butcher, Dochterman, & Wagner, 2013). However, NIC does not have categories for the health behaviors of communities. The Nursing Outcomes Classification (NOC) system measures the responses of an individual, family, and community behavior/perception to a nursing intervention and is useful in all settings with individuals, families, and communities (Moorhead, Johnson, Maas, & Swanson, 2013).

The next phase of knowledge generation in nursing is the integration of terminologies into EHR information systems to support standards of care across settings worldwide. Integration will make it easier to describe and share interventions that work or do not work to help people be healthy and reduce costs. Research using data from information systems embedded with nursing standards and terminology builds nursing knowledge and documents the contribution of nursing to health care.

Guidelines For Preventive serviced And screenings

An increasing emphasis on the prevention of disease has resulted in the development of varying sets of guidelines for the delivery of preventive services to individuals, families, and communities across the life span. These guidelines focus on clinical care directed toward prevention of specific diseases such as HIV disease and behavioral morbidity such as substance abuse.

The Guide to Clinical Preventive Services (U.S. Preventive Services Task Force, 2012) is an authoritative source for making decisions about preventive services. In 2009, the U.S. Preventive Services Task Force (USPSTF) recommended limiting the use of screening mammography. The recommendation garnered the media’s attention and, according to one study, the percentage of women screened the year following the recommendation declined by 4.3%, suggesting that the recommendation had a chilling effect on the willingness of women to get mammograms. How- ever, Block and colleagues examined data from the Behavioral Risk Factor Surveillance Study and observed no change in rates among women who had mammograms the previous year, but did observe lower rates of mammogram use among women who reported no mammogram in the previous year (Block, 2013).

Other experts report 1.3 million overdiagnosed breast cancers over 30 years, meaning that their screening detected tumors that would never lead to clinical symptoms (Bleyer & Welsh, 2012). However, the American Cancer Society and the American Radiology Association continue to recommend that women undergo a yearly mammogram beginning at age 40.

Screening is not right for everyone or every health problem. Screenings to detect particular, unrecognized health problems in individuals who are members of at-risk groups reduce false alarms. However, data are not sufficient to address all the uncertainties of general screenings.

Screenings uncover health problems in an efficient and economically feasible manner when the following factors are present:

1. The specific population has a high prevalence of the disease or health problem.

2. Treatment is available if the condition is identified.

3. Screening instruments are valid and reliable.


The cost of conducting screenings bears on the decision to offer large-scale screenings. For example, conducting a screening to detect osteoporosis requires special equipment, and the cost may be high due to the number of machines needed to screen in a timely, efficient manner. In addition to cost, targeted screenings should consider race/ethnicity, age, and low income and how these factors relate to increased or decreased willingness to participate in screenings, along with the risks and benefits (Kressin, Manze, Russell, Katz, Claudio, Green, & Wang, 2010).

Elective Preventive Services Selector (ePSS) is a quick, hands-on tool available to pri- mary care providers to identify screening services that are appropriate for particular clients based on the recommendations of the U.S. Preventive Services Task Force, and can be searched by client characteristics, such as age, sex, and behavioral risk factors. ePSS is available as Web and Mobile applications for the iPhone, iPad, and other mobile devices. Through these appli- cation nurses and other clinicians have preventive information—recommendations, clinical considerations, and selected practice tools—available at the point of care (U.S. Preventive Ser- vices Task Force, 2012). Guide to Clinical Preventive Services (U.S. Department of Commerce Census, 2012) and Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (Hagan, Shaw, & Duncan, 2008) also are important guidelines for nurses to be familiar with and use to ensure that clients across the life span benefit from state-of-the-art preventive services.


Assessment of the individual client in the context of health promotion extends beyond physical assessment to include a comprehensive examination of other health parameters and health behaviors. The purpose of the assessment, setting, culture, and age determine the components of health assessment. The components are as follows:

• Functionalhealthpatterns

• Physicalfitness

• Nutrition

• Lifestress

• Spiritualhealth

• Socialsupportsystems

• Healthbeliefsandlifestyle

Functional assessment of health patterns comprises a health history, including hereditary and family characteristics, and physical assessment. Assessment components focus on individu- als and have particular relevance for health promotion and prevention.

Physical Fitness

Physical activity is an important part of personal health status (see Chapter 6). Determining one’s level of physical fitness is a critical part of the nursing assessment. A sedentary lifestyle, for many individuals, begins early in childhood and continues into adulthood. The assess- ment is applicable to clients of all ages, with restrictions on some components for physically compromised individuals. Skill-related physical fitness and health-related physical fitness focus on different qualities.

Skill-related fitness focuses on qualities that contribute to successful athletic performance: agility, speed, power, and reaction time. Health-related fitness focuses on qualities that contribute

Chapter4 • AssessingHealthandHealthBehaviors 85 to general health and include cardio-respiratory endurance (aerobic capacity); muscular endurance, strength, and flexibility; and body composition.

.Aerobic capacity is the most important component of fitness. Fitness reflects the ability of the CR system to efficiently adjust to and recover from exercise. Research shows that individuals with an acceptable aerobic capacity have a reduced risk of obesity, diabetes, high blood pressure, and other health problems.

 The goal of muscular endurance, strength, and flexibility tests is to determine the functional health status of the musculoskeletal system. It is important to have strong muscles that maintain body structure and endurance. The strength and endurance of the upper body muscles are good indicators of overall fitness. Flexibil- ity, the ability to move muscles and joints through their maximum range of motion, also is an important component of physical fitness. Flexibility decreases with age and chronic illness. The lack of ability to flex or extend muscles or joints often reflects poor health habits, such as seden- tary lifestyle, poor posture, or faulty body mechanics. Loss of flexibility greatly decreases one’s ability to move about with ease and comfort.

The increased prevalence of overweight and obesity in children and adults in the United States is a concern for both the public and private sectors. The availability of high-fat and low-cost fast foods and the decline in levels of physical activity contribute to these trends. Increased levels of body fat are associated with cardiovascular disease, diabetes, and stroke in adults; and diabetes, hypertension, and increased cholesterol levels occur more frequently in overweight and obese children.

Estimates of body fat include underwater weighing, bioelectrical impedance, skin fold measures, and other anthropometry measures such as the Body Mass Index (BMI). Each method has limitations leading to measurement errors of 2% to 3% for estimates of body fat, with the BMI error rate as great as 6% because body weight includes bone and muscle mass and not just fat composition.

Bioelectrical impedance analysis (BIA) provides a measure of body fat when a small, safe electrical current passes through the body, carried by water and electrolytes of the fluid spaces. Impedance is greatest in fat tissue, which contains only 10 to 20% water, while muscle tissue, which contains 70 to 75% water, allows the signal to pass more easily. Height and weight, body type, gender, age, fitness level, and BIA are measures used to calculate percentage of body fat, muscle mass, and hydration level (American College of Sports Medicine, 2009).

BIA is useful in healthy, young, normally hydrated teens and adults, and for monitoring these groups for changes in body fat composition over time. Body fat scales (similar to bathroom scales) and handheld body fat analyzers, both available at reasonable cost, also provide a measure of BIA. While technology is improving, it is difficult to get an accurate body fat composition from commercially available body fat analyzers.

Anthropometric (measures of body fat) methods are simple, convenient, and inexpensive. Skin fold estimates, conducted while maintaining standards and using high-quality skin fold calipers, provide an accurate measure of body fat and compare favorably with bioelectrical impedance. The combination of weight, anthropometric methods, and BIA is an excellent predic- tor of total body fat composition.

A physical fitness assessment is an essential component of health assessment. Careful atten- tion to assessment will optimize the fit of the exercise prescription to the physical capabilities of

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the client. The Presidential Youth Fitness Program adopted FITNESSGRAM, a research-based assessment developed by the nonprofit Cooper’s Institute, and recommends implementation in all public schools. The FITNESSGRAM program assesses cardiovascular fitness, body composi- tion, muscle strength, muscular endurance, and flexibility in children 4 to 17 years of age. The American College of Sports Medicine (ACSM) Resource Manual for Guidelines for Exercise Testing and Prescription (American College of Sports Medicine, 2013) is an excellent guide for physical fitness assessment tools for adults.


Good nutrition is one of the primary determinants of good health. Effective planning for health promotion requires an assessment of the nutritional status of the client to establish a baseline. Anthropometrical measurements and/or BIA analysis, laboratory values, and dietary history are useful assessment tools.

Anthropometrics assessment measures include height and weight, circumference of various areas of the body, and skin-fold thickness. BMI is the best method to assess healthy weight (American College of Sports Medicine, 2013). BMI does not assess body fat composi- tion or fat distribution, but it is a useful screening tool for overweight or obesity. It has been determined that childhood BMI is associated with adult adiposity. The classification of over- weight and obesity by BMI, waist circumference, and associated disease risks standards for adults is available in Table 4–2.

Healthy and unhealthy weight guidelines are in Table 4–3. The waist-to-hip ratio assesses the amount of fat distributed in the abdomen versus fat distributed below the waist. The ratio is the waist circumference over the hip circumference. The higher the value of the waist-to-hip ratio, the greater the potential that health problems are present or will occur (American College of Sports Medicine, 2013; WHO Expert Consultation, 2008).