Health Assessment (Prelims)

Nursing

is an art of applying scientific principles in a humanitarian way to care of people

nursing process

serves as the organizational framework for the practice of nursing

Nursing Process

Is a systematic method by which nursing: plans and provides care for patients

Nursing Process

This involves a problem-solving approach that enables the nurse to identify patient problems and potential at-risk needs (problems) and to plan, deliver, and evaluate nursing care in an orderly, scientific manner

Assessment, Diagnosis, Planning, Implementation, Evaluation

A = Assessment

D = Diagnosis

P = Planning

I = Implementation

E = Evaluation

Collection, Organization, Validation, Documentation

1. Assessment – is the continuous and systematic…

Collection

Organization

Validation

Documentation of data

Assessment

The nurse gathers information to identify the health status of the patient.

Assessment

Assessments are made initially and continuously throughout patient care.

validity, completeness

The remaining phases of the nursing process depend on the validity and completeness of the initial data collection

Establish the data base of the patient

The purposes of assessment is to:

1. Establish the data base of the patient

Nursing Health History, Physical Assessment, Result of Diagnostic and Laboratory Tests, Previous Medical Records

The purposes of assessment is to:

1. Establish the data base of the patient

• Nursing Health History

• Physical Assessment

• Results of Diagnostic and Laboratory Tests

• Previous Medical Records

Provides the basis of effective and holistic nursing care

The purposes of assessment is to:

2. Provides the basis of effective and holistic nursing care

Allows clinical judgement in the form of nusing diagnosis

The purposes of assessment is to:

3. Allows clinical judgement in the form of nusing diagnosis

Plan and implement appropriate nursing interventions

The purposes of assessment is to:

4. Plan and implement appropriate nursing interventions

Sets the standard for the evaluation of outcomes of nursing care

The purposes of assessment is to:

5. Sets the standard for the evaluation of outcomes of nursing care

Initial comprehensive assessment

Problem-focused Assessment

Emergency Assessment

Time-lapsed assessment

Types of Assessment (4)

Initial Comprehensive Assessment

Also called an admission assessment, is performed when the client enters health care from a health care agency.

Initial Comprehensive Assessment

The purposes are to evaluate the client's health status, to identify functional health patterns that are problematic, and to provide an in-depth, comprehensive database, which is critical for evaluating changes in the client's health status in subsequent assessments.

Problem-Focused Assessment

Collects data about a problem that has already been identified. This type of assessment has a narrower scope and a shorter time frame than the initial assessment.

Problem-Focused Assessment

nurses determine whether the problem still exists and whether the status of the problem has changed (i.e. improved, worsened, or resolved). This assessment also includes the appraisal of any new, overlooked, or misdiagnosed problems.

Problem-focused Assessment

In intensive care units, may perform focus assessment every few minutes.

Emergency Assessment

Takes place in life-threatening situations in which the preservation of life is the top priority. Time is of the essence rapid identification of and intervention for the client's health problems.

Emergency Assessment

Often the client's difficulties involve airway, breathing and circulatory problems (the ABCs). Abrupt changes in self-concept (suicidal thoughts) or roles or relationships (social conflict leading to violent acts) can also initiate an emergency.

Emergency Assessment

Emergency assessment focuses on few essential health patterns and is not comprehensive.

Time-Lapsed Assessment

takes place after the initial assessment to evaluate any changes in the clients functional health. Nurses perform time-lapsed reassessment when substantial periods of time have elapsed between assessments

Collection of Data

Gathering of information about the client which includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client's health status

Collection of Data

includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods)

Collection of Data

includes current/present problems of client (pain, nausea, sleep pattern, religious practices, medication or treatment the client is taking now)

Subjective Data

are the verbal statements provided by the Patient. Statements about nausea and descriptions of pain and fatigue are examples of subjective data.

Subjective Data

Symptoms or Covert Data

Objective Data

are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelt, and they are obtained by observation or physical examination.

Objective Data

Signs or Overt Data

Health History

a description of a patient's symptoms and how they developed. A complete history will serve as a guide to help identify potential or underlying illnesses or disease states.

respectful & culturally-sensitive

Communication during history and physical education must be respectful and performed in a culturally-sensitive manner

posture, language, tone

Privacy is vital, and the healthcare professional needs to be aware of posture, body language, and tone of voice while interviewing the patient

Biographical Data

Name, Age, S*x, Address, Nationality, Religion, Marital Status, Occupation

Chief Complaint

a brief statement of clients problems for which clients need cae

History of Present Illness

is a chronological description of the development of the patient’s present illness from the first sign/or syptom or from the previous encounter to the present

Location

Quality

Severity

Duration

Timing

Context

Modifying factors

Associated Signs and Symptoms

What is the LQSDT,CM,ASS of HPI

Present Health Status

Obtaining information about a patient's present health status allows the nurse to investigate current complaints.

Provocative or Palliative

Quality

Region or Radiation

Severity

Timing

What is PQRST of Present Health Status

Past Health History

Should elicit information about the patient's childhood illnesses and immunizations, accidents or traumatic Injuries, hospitalizations, surgeries, psychiatric or mental illnesses, allergies, and chronic illnesses. For women, include history of menstrual cycle, how many pregnancies and how many births

Childhood Illnesses

Accidents or Traumatic injuries

Hospitalization

Surgeries

Psychiatric or mental illnesses

Allergies

What are the component of Past Health History? CAHSPA

Family history

Chronic Illnesses or known diseases with genetic components should also be screened for. Chronic illness or disease can include cancer, diabetes, autoimmune disorders, cholesterol, heart disease, hypertension, renal disease, and mental illness, among others

Family Tree/ Genogram

Diagrammatic representation of family members. Three generation has to donate in the family tree. It is used to recognize hereditary patterns over generations

3

How many generations should be in a genogram?

Family Tree & Family Composition

(2) Components of Family History

Occupational and Environmental History

includes client’s job area and environment of their workplace

Personal History

It includes clients personal details such as dietary pattern, sleep pattern, activity level alcoholism, smoking habit etc

Socioeconomic History

Collecting data regarding clients life style, working environment personal relationship with other human beings, monthly or annual income or housing facility.

Current Health Status

Information collected should also include details about your patient's personal habits such as smoking or drinking, nutrition, cholesterol, and if there is a history of heart disease or hypertension.

Medications

Obtain a list of current medications, including dose and frequency, as well as reason for taking them. Remember to ask the patient about over the counter medications, vitamins, and herbal supplements

Observing, Interviewing, Examining

Data collection methods:

1. Observing: to observe is to gather data by using the senses.

2. Interviewing: an interview is a planned communication or conversation with a purpose.

3.Examining: Performance of a physical examination. The physical examination is often guided by data provided by the patient. A head-to-toe approach is frequently used to provide systematic approach that helps to avoid omitting important data

Observation

Interview Techniques

Physical Examination

Laboratory Tests

Review of the records, books and related literature

Methods/Techniques in Data Collection:

1. Observation - using the senses to observe or gather data

2. Interview technique – It is an organized conversation with the client or family members to obtain the current health information regarding the patient. 

3. Physical examination 

4. Laboratory tests 

5. Review of the records, books & related Literature

Interview technique

It is an organized conversation with the client or family members to obtain the current health information regarding the patient.

Orientation phase, working phase, termination phase

(3) Phases of interview

Orientation phase

It begins with the nurse's introduction with client which includes the nurse's name, position and explanation of purpose of the interview. The nurse client relationship is enhanced by the professionalism and competence conveyed by the nurse's attitude, Manner & appearance

Working Phase

In this phase, nurse gather information about the client's health status. Nurse use variety of communication strategies as listening, paraphrasing, focusing, summarizing & clarifying to facilitate communication and ensure that nurse & client clearly understood each other.

Termination Phase

This phase also require skill on the part of the interview. The client should be given a clue that the interview is coming to an end. This approach also gives the client an opportunity to ask questions. The interview terminated in a friendly manner

Open Ended Questions

Types of Interview Technique:

Open Ended Questions: It prompts clients to describe a situation in more that one or two words. This questions give chance to client to speak freely

Close Ended Questions

Types of Interview Technique:

Close ended questions: Prompts client to give answer in only one or more words (typically yes or no)

Review of Systems

Is a systematic approach in collecting subjective information about the presence and absence of health-related issues per body system

Appearance

In physical health exam, what is the aligned subject for:

• Age, skin color, facial features

• Body Structure - Stature, nutrition, posture, position, symmetry

• Mobility - Gait, ROM

Behavior

In physical health exam, what is the aligned subject for:

• Facial expression, mood/affect, speech, dress, hygiene

Cognition

In physical health exam, what is the aligned subject for:

• Level of Consciousness and Orientation (x4)

Diet

Body System Approach:

• Appetite, likes and dislikes, restrictions, written dairy of food intake 

Skin, hair, and nails

Body System Approach:

• rash or eruption, itching, color or texture change, excessive sweating, abnormal nail or hair growth 

Musculoskeletal

Body System Approach:

• Joint stiffness, pain, restricted motion, swelling, redness, heat, deformity

Eyes

Body System Approach:

• visual acuity, blurring, diplopia, photophobia, pain, recent change in 

Ears

Body System Approach:

• Hearing loss, pain, discharge, tinnitus, vertigo 

Nose

Body System Approach:

• Sense of smell, frequency of colds, obstruction, epistaxis, sinus pain, or postnasal discharge 

Throat and Mouth

Body System Approach:

• Hoarseness or change in voice, frequent sore throat, bleeding o swelling, of gums, recent tooth abscesses or extractions, soreness of tongue or mucosa.

Endocrine and genital reproductive

Body System Approach:

• Thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change, polyuria, polydipsia, changes in distribution of facial hair;

Males

Body System Approach:

• Puberty onset, difficulty with erections, testicular pain, libido, infertility

Females

Body System Approach:

• Menses onset, regularity, duration and amount}, Dysmenorrhea, last menstrual period, frequency of intercourse, age at menopause, pregnancies {number, miscarriage, abortions} type of delivery, complications, use of contraceptives; breasts (pain, tenderness, discharge, lumps)

Chest and lungs

Body System Approach:

• Pain related to respiration, dyspnea, cyanosis, wheezing, cough, sputum {character, and quantity}, exposure to tuberculosis (TB), last chest X-ray 

Heart and blood vessels

Body System Approach:

Chest pain or distress, precipitating causes, timing and duration, relieving factors, dyspnea, orthopnea, edema, hypertension, exercise tolerance

Gastrointestinal

Body System Approach:

: Appetite, digestion, food intolerance, dysphagia, heartburn, nausea or vomiting, bowel regularity, change in stool color, or contents, constipation or diarrhea, flatulence or hemorrhoids 

Genitourinary

Body System Approach:

• Dysuria, flank or suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, loss in force of stream, edema, sexually transmitted disease

Neurological

Body System Approach:

• Syncope, seizures, weakness or paralysis, abnormalities of sensation or coordination, tremors, loss of memory 

Psychiatric

Body System Approach:

• Depression, mood changes, difficulty concentrating nervousness, tension, suicidal thoughts, irritability. 

Pediatrics

Body System Approach:

along with systemic approach in case of pediatrics, measure anthropometric measurement and neuromuscular assessment.

Inspection

Assessment Technique:

• Close and careful visualization of the person as a whole and of each body system

• Ensure good lighting

• Perform at every encounter with your client

Palpation

Assessment Technique:

• Temperature, Texture, Moisture

• Organ size and location

• Rigidity or spasticity

• Crepitation & Vibration

Palpation

Palpation is a method of feeling with the fingers or hands during a physical examination

Palpation

Assessment Technique

• Position & Size

• Presence of lumps or masses

• Tenderness, or pain

Palpation

Assessment Technique

• Position & Size

• Presence of lumps or masses

• Tenderness, or pain

Light & Deep

(2) Palpation Techniques

Percussion

Assessment Technique that assesses underlying structures for location, size, density of underlying tissue

Inspection, Palpation, Percussion, Ausc

(4) assessment techniques

Direct

• Direct Percussion -  helps assess an adult's sinuses for tenderness and elicits sounds in a child's thorax

Indirect

• Indirect Percussion - helps reveal the size and density of underlying thoracic and abdominal organs and tissues

Blunt

• Blunt percussion - aims to elicit tenderness over organs, such as the kidneys, gallbladder, or liver

Resonance

Percussion Sounds:

• Resonance: A hollow sound. (ex. normal lung)

Hyper Resonance

Percussion Sounds:

• Hyper resonance: A booming sound. (Ex. Lung with emphysma)

Tympany

Percussion Sounds:

• Tympany: A musical sound or drum sound like that produced by the stomach

Dullness

Percussion Sounds:

• Dullness: Thud sound produced by dense structures such as the liver, and enlarged spleen, or a full bladder.

Flatness

Percussion Sounds:

• Flatness: An extremely dull sound like that produced by very dense structures such as muscle or bone

Auscultation

Assessment technique that involves listening to sounds produced by the body

Stethoscope, Diaphgram, Bell

 Auscultation

• Listening to sounds produced by the body

• Instrument: stethoscope (to skin)

• Diaphragm–high pitched sounds (Heart, Lungs, Abdomen)

• Bell–low pitched sounds (Blood vessels)