HEALTH ASSESSMENT

DEFINITION

®     An evaluation of the health status of an individual by performing a physical examination after obtaining a health history.

2 ASPECTS OF HEALTH ASSESSMENT

1.      NURSING HEALTH HISTORY

-        A review of the client’s functional health patterns prior to the current contact with a health care agency.

-        It is the systematic collection of subjective and objective data, ordering and a step by step process inculcating detailed information in determining client’s history, health status, functional and coping pattern.

-        This vital information provide a conceptual baseline data utilized in developing nursing process application as a whole.

-        It is the first part and one of  most significant aspects in case studies.

PURPOSE:

o    Provide the subjective database

o    Identify client’s strengths

o    Identify client health problems, both        actual and potential

o    Identify supports

o    Identify teaching needs

o    Identify discharge needs

o    Identify referral needs

TYPES:

o    Complete Health History

-        Biographical data

-        Client’s name, age, gender, birthdate, birthplace, marital status, race, religion, address, education, occupation, contact person, and health insurance/SSS no.

-        Source of the health history and his or her reliability,

-        Who referred the client

o    Focused Health History

-        Focused on an acute problem

-        Includes all data that are found in complete health history.

-        Indicated when the patient’s condition is UNSTABLE or when TIME constraints are an issue.

2.      PHYSICAL EXAMINATION

TYPES:

o    Complete Assessment

o    Exam of the Body System

o    Exam of the Body Area

COMPONENTS OF HEALTH HISTORY

1.      Biographical Data

2.      Reason for Seeking Care: CHIEF COMPLAINTS

3.      Current Health Status

4.      Past Health History

5.      Family History

6.      Psychosocial Profile

4 BASIC TYPES OF ASSESSMENT

1.      Initial Comprehensive Assessment

-        Collecting data about patients perception of her health of all body parts, past health family hx,etc.

2.      Ongoing or Partial Assessment

-        It occurs after comprehensive database is established. Performed whenever the nurse encounter the client.

3.      Focused or Problem-oriented Assessment

-        Performed when comprehensive database exist. Done when the patient comes with a specific concern. Focused on a particular problem, does not cover areas not related to the problem.

4.      Emergency Assessment

-        Rapid assessment done in life threatening situation.

ASSESSMENT PROCESS INVOLVES 4 CLOSELY RELATED ACTIVITIES:

1.      Collecting Data

-        Process of gathering information about a client’s health status.

-        Must be systematic and continuous to prevent the omission of significant  data and reflect  a client’s changing health status.

-        Involves: collecting the SUBJECTIVE and OBJECTIVE data.

2.      Organizing Data

-        The act of using format that arranges the assessment data systematically. (E.g nursing health history)

3.      Validating Data

-        Is the act of double checking or verifying data to confirm that it is correct and factual.

-        This is where the nursing diagnosis and intervention are based on this information.

4.      Documenting Data

-        To complete the assessment phase, the nurse records the client data.

-        Data are recorded in a factual manner and not interpreted by the nurse.

PRINCIPAL METHODS USED TO COLLECT DATA

1.      Observing

-        Is conscious, deliberate skill that is develop through effort and with organized approach.

-        To gather by using senses (vision, smell, hearing and touch).

-        Distinguishing the data in a meaningful way.

2.      Interviewing

-        It is a planned communication or conversation with a purpose.

APPROACHES TO INTERVIEW:

o    Directive Interview

o    Non-Directive Interview

STAGES OF AN INTERVIEW:

o    The Opening

-        Establish rapport and orientation.

-        Includes the: purpose, nature of interview, length, what information is needed, what is expected.

o    The Body

-        The use of therapeutic communication and the client communicate what he or she thinks, feel, knows or perceives in response to nurse’s questions.

o    The Closing

-        The nurse terminates the interview when needed information has been obtained.

3.      Examining

-        It is a systematic data collection method  that  uses  observation to detect health problems.

-        Techniques commonly used:

a)     Inspection

b)     Auscultation

c)     Palpation

d)     Percussion

PHYSICAL ASSESSMENT

DEFINITION

®     It is a comprehensive orderly manner of examining a client.

®     The part of health assessment representing a synthesis of information obtained in a physical examination.

®     The history and the physical exam provide much of the information known about the patient's health status. As a practical nurse, you may be called upon to assist the physician or other health care providers during a physical examination. You should know the basics of the examination in order to have the appropriate equipment and supplies on hand, and so that you may place the patient in the proper position and drape him correctly.

PURPOSES FOR PERFORMNING PHYSICAL EXAMINATION

1.      Gather baseline data about the client’s health.

2.      Supplement, confirm or refute data obtained in the nursing history.

3.      Confirm and identify nursing diagnoses.

4.      Make clinical judgements about a client’s changing health statis and management.

5.      Identify area of health promotion and disease prevention.

6.      Evaluate physiologic outcomes of health care.

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PREPARATION GUIDELINES IN PHYSICAL ASSESSMENT

a.      Preparing Physical Setting or Environment

o    Comfortable Room Temperature

o    Door/Curtain should be closed: free of interruptions.

o    Quiet Area: Free of distractions

o    Adequate lighting

o    Firm and adjustable examination table

o    Bedside table tray

b.     Preparing Oneself

o    Assess your own feelings and anxieties.

o    Wash hands before and after examination

o    Wear mask or gloves if necessary

c.      Preparing Equipment

o    List equipment necessary for each part of the exam.

o    Equip yourself on how to use each equipment.

o    Gather necessary equipment

d.     Approaching and Preparing the Client

1.      Physiologic Preparation

2.      Physical Preparation

3.      Positioning

e.      Order of Examination

1.      General Survey

o    Includes observation of general appearance and behavior, vital signs, height and weight measurement

2.      Review of Systems

3.      Head to Toe Examination

PHYSICAL ASSESSMENT TECHNIQUES

PHYSICAL ASSESSMENT TECHNIQUES

INSPECTION

®     Involves senses to detect abnormal findings.

®     Starts from the time you meet the client and continues throughout the examination.

®     Precedes other techniques.

®     Room needs to have comfortable temperature.

®     Good lighting

®     Proper exposure of body part inspected.

®     Compare appearance of symmetric body parts.

®     Deliberate, purposeful, and systematic visual examination

®     Moisture, color, texture of body surfaces

®     Shape, position, size, symmetry of the body

®     To detect normal characteristics or significant physical signs. To inspect body parts accurately the nurse observes the following principles:

o    Make sure good lighting is available

o    Position and expose body parts so that all surface can be viewed

o    Inspect each areas for size, shape, color, symmetry, position and abnormalities

o    If possible, compare each area inspected with the same area of the opposite side of the body

o    Use additional light (for example, a penlight) to inspect body cavities

PALPATION

®     The position of the hand for light palpation.

®Deep palpation using the lower hand to support the body while the upper hand palpates the organ.

®     Uses parts of the hand to touch and feel.

®     the hands can make delicate and sensitive measurements of specific physical signs, so palpation is used to examine all accessible parts of the body. The nurse uses different parts of the hand to detect characteristics such as texture, temperature, and the perception of movement.

NOTE FOR:

·       Consistency

·       Temperature

·       Moisture

·       Mobility

·       Degree of Tenderness

FINGERPADS:

-        Fine discriminations:

o    Strength of pulses

o    Texture

o    Size

o    Shape

o    Crepitus

DORSAL (BACK):

-        Temperature

ULNAR/PALMAR:

-        Vibrations

-        Thrills

-        Fremitus

4 TYPES OF PALPATION:

1.      Light Palpation

2.      Moderate Palpation

3.      Deep Palpation

4.      Bi manual Palpation

PERCUSSION

®Direct percussion - Using one hand to strike the surface of the body.

®Indirect percussion - Using the finger of one hand to tap the finger of the other hand.

®     Examination by striking the body’s surface with a finger, vibration and sound are produced. This vibration is transmitted through the body tissues and the character of the sound depends on the density of the underlying tissue.

®     Involves tapping the body parts.

®     Assess underlying structures.

3 TYPES OF PERCUSSION:

1.      Direct Percussion – Direct tapping using 1 or 2 fingers.

2.      Indirect Percussion – Tapping the middle finger.

3.      Blunt Percussion – Pounding the other hand flat on body surface.

USED FOR:

1.      Eliciting pain

2.      Determines location

3.      Determine density

4.      Detecting abnormalities

5.      Eliciting reflexes

PALPATION

®     Is listening to sound created in body organs to detect variations from normal. Some sounds can be heard with the unassisted ear, although most sounds can be heard only through a stethoscope:

o    Bowel sounds

o    Breath sounds:

§  Vesicular

§  Bronchovesicular

§  Bronchial

®     It requires the use of stethoscope to:

o    Listen to heart sounds

o    Movement of blood

o    Movement of bowel

o    Movement of air

®     Assess for the:

o    Intensity – loud or soft

o    Pitch – high or low

o    Duration - length

o    Quality – musical, raspy, crackling

POSITIONING A PATIENT FOR EXAMINATION OR TREATMENT

®     Patients are put in special positions for examination, for treatment or test, and to obtain specimens. You should know the positions used, how to assist the patient, and how to adjust the drapes.

1.      Horizontal Recumbent Position

-        Used for most physical examinations. Patient is on his back with legs extended. Arms may be above the head, alongside the body or folded on the chest.

2.      Dorsal Recumbent Position

-        Patient is on his back with knees flexed and soles of feet flat on the bed. Fold sheet once across the chest. Fold a second sheet crosswise over the thighs and legs so that genital area is easily exposed.

3.      Dorsal Lithotomy Position

-        Used for examination of pelvic organs. Similar to dorsal recumbent position, except that the patient's legs are well separated and thighs are acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over thighs and legs so that genital area is easily exposed. Keep patient covered as much as possible.

4.      Fowler’s Position

-        Used to promote drainage or ease breathing. Head rest is adjusted to desired height and bed is raised slightly under patient's knees.

5.      Prone Position

-        Used to examine spine and back. Patient lies on abdomen with head turned to one side for comfort. Arms may be above head or alongside body. Cover with sheet or bath blanket.

6.      Knee-Chest Position

-        Used for rectal and vaginal examinations and as treatment to bring uterus into normal position. Patient is on knees with chest resting on bed and elbows resting on bed or arms above head. Head is turned to one side. Thighs are straight and lower legs are flat on bed.

7.      Sim’s Position

-        Used for rectal examination. Patient is on left side with right knee flexed against abdomen and left knee slightly flexed. Left arm is behind body; right arm is placed comfortably.

PURPOSES FOR DRAPING THE PATIENT DURING THE PE

WHY SHOULD THE PATIENT BE DRAPED?

®     To provide comfort and privacy during   examination.

®     To prevent unnecessary exposure of the patient's body.

®     To help the patient relax—a patient who is embarrassed will be tense and less cooperative.

®     To prevent chilling — the drapes will provide warmth.

WHAT IS THE PROPER WAY OF DRAPING WHILE
STANDING?

®     Place the double folded sheet around the body passing it under the axillae by securing it with a safety pin leaving one side open.

1.      HORIZONTAL RECUMBENT

Draping:

-        Cover the client from shoulder to foot part.

Areas Assessed:

-        Head

-        Neck

-        Axillae

-        Thorax

-        Breast

-        Heart

-        Lungs

-        V/S

-        Peripheral Pulses

-        Extremities

-        Abdomen

Caution:

-        Contraindicated for patients with cardiovascular and respiratory problems.

2.      DORSAL RECUMBENT

Draping:

-        Place the sheet diagonally by folding the top corner over the chest.

-        Feet flat on bed.

Areas Assessed:

-        Female genitals

-        Rectum

-        Female reproductive tract.

Caution:

-        Contraindicated for patients with cardio-pulmonary problems.

3.      DORSAL LITHOTOMY

Draping:

-        Place the sheet diagonally by folding the top corner over the chest.

-        Elevate legs using stirrups.

Areas Assessed:

-        Female genitals

-        Rectum

-        Female reproductive tract.

Caution:

-        Contraindicated for patients with cardio-pulmonary problems.

4.      FOWLER’S POSITION

Draping:

-        Head 45 degrees.

-        Cover client from shoulders to foot part.

Areas Assessed:

-        Head

-        Neck

-        Axillae

-        Thorax

-        Breast

-        Heart

-        Lungs

-        V/S

-        Peripheral Pulses

-        Extremities

-        Abdomen

Caution:

-        Patients with cardio-pulmonary problems to facilitate breathing.

5.      PRONE POSITION

Draping:

-        Lies on abdomen.

-        Cover client from shoulders to foot part.

Areas Assessed:

-        Posterior Thorax Hip Joint Movement

Caution:

-        Contraindicated for patients with cardio-pulmonary problems and elders.

6.      KNEE-CHEST POSITION

Draping:

-        On prone while kneeling.

-        Cover client from waist

Areas Assessed:

-        Rectum

-        Vaginal and Gynecological Condition

Caution:

-        Contraindicated for patients with cardio-pulmonary problems and elders. 

7.      TRENDELBERG POSITION

Draping:

-        On left side, while lying on one side.

-        Cover client from shoulder to footpart diagonally.

Areas Assessed:

-        Head

-        Neck

-        Axillae

-        Thorax

-        Breast

-        Heart

-        Lungs

-        V/S

-        Peripheral Pulses

-        Extremities

-        Abdomen

Caution:

-        Contraindicated for patients with cardio-pulmonary problems and elders.

Ideal For:

-        Shock

-        Postural Drainage

-        Surgical/Postural Drainage

PAINT ASSESSMENT (COLDSPA)

®Character – How does it feel, look, sound, smell? Describe please.

®Onset - When did it begin?

®Location - Where is it? Does it radiate?

®Duration - How long does it last? Does it recur?

®Severity - How bad is it?

®Pattern - What makes it better? What makes it worse?

®Associated Factors - What other symptoms that occur with it?

PQRST

1.      P = PRECIPITATING/PALLIATIVE FACTORS

ASK:

·       What were you doing when the problem started? 

·       Does anything make it better, such as medications or certain positions?

·       Does anything make it worse, such as movement or breathing?

2.      Q = QUALITY/QUANTITY

ASK:

·       Can you describe the symptom?

·       What does it feel like, look like, or sound like? 

·       How often are you experiencing it?

·       To what degree does this problem affect your ability to perform your usual daily activities?

3.      R = REGION/RADIATION/RELATED SYMPTOMS

ASK:

·       Can you point to where the problem is?

·       Does it occur or spread anywhere else?  (Take care not to lead your client.) 

·       Do you have any other symptoms?  (Depending on the chief complaint, ask about related symptoms. 

For example:

-        If the client has chest pain, ask if he or she has breathing problems or nausea.

4.      S = SEVERITY

ASK:

·       Is the symptom mild, moderate, or severe? 

·       Grade it on a scale of 0 to 10, with 0 being no symptom and 10 being the most severe. 

·       (Grading on a scale helps objectify the symptom)

5.      T = TIMING

ASK:

·       When the symptoms started?

·       Is the symptoms sudden or gradual?

·       How often the problem occurs?