Introduction into Health Assessment Health History Clinical Judgement Process

Health Assessment Overview

General Survey

Immediate observational overview of a patient’s overall health and physical condition.

• Can help identify major signs of distress

• Physical appearance, behavior/ mood, body structure/ mobility

Health Assessment

• A health assessment involves the collection, clinical judgment, and evaluation of data to plan and deliver patient-centered care while accounting for the client's preferences, goals, and needs.

• The health assessment identifies the needs of the client that will be addressed by the health care team to assist the client in achieving their highest level of health possible.

Comprehensive

• Head-to-toe (10 min bedside assessment)

Focused

• Core (vital) organs + relevant based on complaints

What is NORMAL? What is ABNORMAL?

• Occurs naturally, quickly (usually faster than you can say out loud)

• Starts developing your clinical judgment

Types of Data

Subjective

• information from the patient’s point of view, complaints, including feelings, perceptions, and concerns

• Difficulty breathing

• Chest Pain

• Feel depressed

Objective

• observable and measurable data (“signs”) obtained through observation, physical examination, and lab + diagnostic findings

• HR 120 bpm

• RR 30 bpm

• BP 145/99

• Excessive sweating

• Tachycardia

• Flat affect: no facial expression

Assessment Techniques

• Use ALL the senses—sight, smell, touch, and hearing—to gather data during physical examination

Skills performed one at a time:

• Inspection: what I see

• Auscultation: what I hear

• Palpitation: What I feel

• Percussion: What I hear

Inspection

• “Concentrated watching”

• Begins the moment you meet the person, developing general survey

• Always comes first in the assessment sequencing

• Always maintain modesty

• Train eyes to inspect each body system, comparing left to right (symmetry) and identifying abnormalities

• Notice skin tone, rashes, bruising, breathing patterns, wounds

• Observe for affect and mood

• Tools: penlight, otoscope, tongue depressor

Palpation

• use hands to feel for data.

• Ulnar surface (vibration), dorsal surface back of hand (temp), fingertips

Percussion

• tapping to hear difference

Auscultation

• stethoscope listening on skin

• doppler

Health History

Key elements – use PLEASE acronym:

P • Past medical history

L • Last oral intake

E • Events leading to illness/injury

A • Allergies & reaction

S • Symptoms & chief complaint

E • Each prescribed medication, OTC med, and herbal supplements

Health History

• Reason for seeking care (chief complaint)

• Brief statement in the patient’s own words that describes the reason for their visit – always place in quotations if patient able to verbalize.

• EX: “Chest pain x2 hours”

• Includes:

• History of present illness (HPI):

• O - Onset

• L – Location

• D – Duration

• C – Characteristics

• A – Aggravating and alleviating factors

• R – Related symptoms

• T – Treatment

• S – Severity

Social determinants of health

• Financial stability

• Education

• Social & community aspects

• Access to health care

• Neighborhood & environment in which client lives & works

Medical History (PMH)

• Childhood illnesses,

• Major injuries

• Chronic illnesses

• Prior hospitalizations

• Immunizations

• Health maintenance (dental, vision, annual visits/labs,

screenings),

Past Surgical History

• List of any prior surgeries

Allergies

• Environmental

• Medications

• Foods

Current Medications

• Prescription

• OTC

• Supplements

Family history

• Trying to highlight diseases and conditions for which a patient may be at increased risk

• Typically inquire about immediate family (mother, father, siblings, paternal and maternal grandparents), noting alive or deceased – cause of death and age of death

• Of significance can include:

• cancers

• heart disease

• neurological disease

• genetic conditions

• diabetes

Activities of Daily Living

• Functional assessment of activities of daily living

(ADLs)

• Measures a person’s self-care ability in the areas of general physical health

• ADLs include bathing, dressing, toileting, eating, walking

• Instrumental ADLs include housekeeping, shopping,

cooking, doing laundry, using the telephone, managing

finances, nutrition, social relationships, self-concept and

coping, and home environment

Nursing Process

• Assessment- Gather information, collect subjective and objective data

• Analysis- Examine subjective and objective data, identify both actual and potential problems

• Planning- Prioritize outcomes and develops interventions

• Implementation- Carry out interventions, monitor progress towards achieving goals

• Evaluation- Evaluate effectiveness of goals andconsider the possibility of revising the plan of care.

Clinical Reasoning Cycle

Therapeutic Communication

• Intentional communication process in which

healthcare staff uses listening skills, empathy, and a

desire to build a professional relationship with the

client to provide holistic and patient-centered care.

• Open-ended questions

• Restating

• Reflection

• Active listening

• AVOID: Dismissing, false reassurance, giving advice