Nursing Health Assessment Fundamentals

Principles and Definitions of Health Assessment

Definition of Health: Health is recognized as more than just physical findings. It is the general condition of the body as reported by the client. Assessment must consider what factors external or internal affect health.
Purpose of Nursing Health Assessment: The primary objective is to determine a patient’s health status, identify risk factors, and establish the need for education. This assessment acts as the foundation for developing a nursing plan of care.
The Puzzle Metaphor: Health assessment is described as opening a puzzle box and dumping out the pieces. Each piece of the history and physical examination data represents a different aspect of a patient's life. When assembled, these pieces form a complete picture of who the patient is.

Types of Assessment

Comprehensive (Admission): This occurs when a patient enters or is admitted into the healthcare system (e.g., a hospital admission).
Focused (Problem-Based): This is usually system-specific and targeted toward a specific complaint (e.g., assessing leg pain).
Time-Lapse (Follow-up): This is conducted to follow up on a previously identified health problem (e.g., monitoring Hypertension/HTN).
Emergency: This involves the rapid identification of life-threatening problems (e.g., assessing chest pain).

Data Collection Categories

Subjective Data: These are symptoms. It is what the patient tells the nurse, including the patient's history, Chief Complaint, and Review of Systems (ROS).
Objective Data: These are signs. These include the nurse’s observations, physical examination findings, vital signs, and laboratory or test results.
Data Sources in Nursing Assessment: - Subjective Assessment Components: Past Medical History (PMH), Past Surgical History (PSH), Family History, Social/Personal History, and Review of Systems (ROS). - Objective Assessment Components: Vital Signs, Physical Assessment, General Survey, and Lab/Test Results.

Therapeutic Communication Skills

Successful information retrieval during an interview depends on specific therapeutic communication skills:

Active Listening: Engaging fully with the patient's narrative.
Guided Questions: Using prompts to elicit specific details.
Nonverbal Communication: Being mindful of body language and cues.
Empathy: Demonstrating understanding of the patient's perspective.
Validation: Acknowledging the patient's feelings or concerns as valid.
Reassurance: Providing comfort to the patient.
Summarizing: Recapping information to ensure accuracy.
Transitions: Using clear statements when moving from one part of the assessment to another.
Empowering the Patient: Encouraging the patient to take an active role in their care.

Detailed Subjective Data Components

Past Medical History (PMH): Covers acute and chronic issues relating to body systems. Key elements include: - Allergies - Medications - Childhood Illnesses - Adult Illnesses - OB/GYN History - Health Maintenance activities
Family History (FH): Focuses on the presence or absence of diseases with a genetic predisposition. This includes grandparents, parents, siblings, spouse, and children. Identifying these issues helps in early/routine screening and suggesting diet or lifestyle changes. Key conditions to track include: - Hypertension (HTN) - Heart Disease - Cancer - Cerebrovascular Accidents (CVAs) - Diabetes - Tuberculosis (TB) - Asthma - Anemia - Mental Illness - Alcoholism
Personal and Social History: Investigates how lifestyle contributes to health through the lens of Social Determinants of Health (SDOH). Categories include: - Economic Stability (e.g., financial resources) - Education Access and Quality - Health Care Access and Quality - Neighborhood and Built Environment - Social and Community Context
Review of Systems (ROS): A series of questions organized by body systems used to determine normal or abnormal function. It helps identify the reason for seeking healthcare and specific complaints.

The Eight Dimensions of a Symptom (OLDCART-M)

While some texts use seven dimensions (OLDCART), the model used here includes an eighth dimension, "Meaning" (OLDCART-M).

Onset: When the symptom began. - Sample Questions: "When did it start?" "What were you doing when it happened?"
Location: Where the symptom is located. - Sample Questions: "Where is it?" (Ask patient to point). "Does it spread or radiate?"
Duration: How long the symptom has been persisting. - Sample Questions: "How long does it last?" "How often does it occur?" "Does it change over time?"
Characteristic Symptoms: The quality, severity, and description of the symptom. - Sample Questions: "What is it like/how does it feel?" "What is the scale of the symptom (rate $0-10$ )?" "Character?" "Intensity?"
Associated Manifestations: Other symptoms that occur simultaneously. - Sample Questions: "Are you feeling any other symptoms?" "Does anything else happen when you get the described symptom?" (Following the answer, the nurse should offer three related symptoms to confirm).
Relieving and Exacerbating Factors: Things that make the symptom better or worse. - Sample Questions: "What makes it better (non-pharmacological)?" "Positioning?" "Heat/ice?" "Resting?" "What makes this worse?"
Treatment: Interventions previously tried. - Sample Questions: "Medications (prescribed, OTC, herbal)?" "How much?" "How often?" "Seen a provider?" "Holistic approach (chiropractic, acupuncture)?" (Note: Always clarify if the treatment was effective).
Meaning: The patient's perspective on the symptom. - Sample Questions: "What do you think might be going on?" "How has this affected your daily life?" "Impact on work, school, sleep, eating, exercise?"

Infection Control: WHO 5 Moments for Hand Hygiene

Hand hygiene is critical to protecting both the patient and the healthcare environment.

Before touching a patient: To protect the patient against harmful germs carried on hands.
Before clean/aseptic procedures: To protect the patient against harmful germs (including their own) from entering the body.
After body fluid exposure risk: To protect yourself and the environment from harmful patient germs; must be done after glove removal.
After touching a patient: When leaving the patient's side.
After touching patient surroundings: Clean hands even if the patient was not touched, but objects or furniture in their immediate surroundings were.

Physical Examination Preparation and General Survey

Physical Exam Tips: - Assure client privacy. - Check for comfort (temperature levels). - Provide courteous, clear instructions. - Use appropriate body mechanics (nurse should be at eye level with the patient).
Supplies Needed: - Hand sanitizer/Soap & Water - Gloves - Gown (if necessary) - Thermometer - Watch with a second hand - Sphygmomanometer - Stethoscope - Pulse oximeter - Paper and pen or computer for data recording
General Survey (Immediate Observations): - Apparent state of health or illness - Level of Consciousness (LOC) - Facial Expression - Posture, Gait, Motor Activity, and Speech - Skin Color and Obvious Lesions - Odors of the body and breath - Dress, Grooming, and Personal Hygiene - Signs of distress

Vital Signs and Anthropometric Measurements

Anthropometric Measurements: - Height and Weight: Usually recorded in Metric units. - Body Mass Index (BMI).
Temperature: Measured using clinical thermometers (infrared/tympanic/temporal options shown in visuals).
Pulse/Heart Rate (HR): - Auscultate the chest for $60\,\text{seconds}$ . - Note the Rate and Rhythm. - If the rhythm is irregular, listen at the Apex of the heart for another $60\,\text{seconds}$ .
Pulse Oximetry: - Measures arterial oxygen saturation, or $SpO_2$ . - It compares light emitted to light absorbed to calculate the percentage of oxygen saturation.
Blood Pressure (BP): - Systolic (Top number): Pressure in arteries when the heart pumps. - Diastolic (Bottom number): Pressure in arteries when the heart rests between beats; this is when the heart fills with blood and receives oxygen. - Cuff Size and Procedure Errors: - Falsely High: Cuff is too small; wrapping the cuff unevenly; deflating the cuff too slowly. - Falsely Low: Cuff is too large; not pumping the cuff high enough; releasing the valve too fast; arm held above heart level.
Respiratory Rate (RR): - Auscultate breath for $60\,\text{seconds}$ . - Can observe the rise and fall of the chest or abdomen. - Note Rate, Rhythm, Depth, and Effort. - Alternatively, inspect/observe for $30\,\text{seconds}$ and multiply by $2$ .

Pain Assessment

Subjective Nature: Pain is a subjective finding.
Scales: - 0/10 Scale: Most common ( $0$ = no pain, $10$ = worst pain in life). - FACES Scale: Used for patients who may have difficulty with numerical scales.
Non-Verbal Pain Assessment: Used if the patient cannot communicate. Tools include the Non-Verbal Pain Scale (NVPS) and the Critical Care Pain Observation Tool. - Indicators and Scoring: - Facial expression: Relaxed ( $0$ ), Tense ( $1$ ), Grimacing ( $2$ ). - Body movements: Absence of movements ( $0$ ), Protection/Slow cautious moves ( $1$ ), Restlessness/Thrashing/Fighting commands ( $2$ ). - Muscle tension: Relaxed ( $0$ ), Tense/Rigid ( $1$ ), Very tense or rigid ( $2$ ). - Compliance with Ventilator (Intubated): Tolerating ( $0$ ), Coughing but tolerating ( $1$ ), Fighting ventilator ( $2$ ). - Vocalization (Extubated): Normal tone/no sound ( $0$ ), Sighing/Moaning ( $1$ ), Crying out/Sobbing ( $2$ ).

Physical Examination Techniques and Nursing Process

Examination Techniques: - Inspection: Use of vision to examine and observe the patient. - Palpation: Use of touch using hands and fingers to feel size, texture, and other qualities. - Auscultation: Use of hearing (typically with a stethoscope) to detect movement or sounds. - Percussion: Use of hearing and touch to detect density and specific sounds.
Health Promotion: Aimed at assisting patients to change behaviors and lifestyles for optimal health via education, asking questions, and knowing the patient.
The Nursing Process (Five-Step Process): 1. Assessment: Focus of NUR362 (Data gathering). 2. Diagnosis: Nursing-specific diagnosis. 3. Planning/Outcome: Setting goals. 4. Implementation: Carrying out the plan. 5. Evaluation: Determining the effectiveness of the interventions.