Intro Health Assessment

Assessment of Client Data

• Definition of Data Types

  • Objective Data:

  • Collected through direct assessment of a client.

  • Methods of collection:

    • Inspection

    • Percussion

    • Palpation

    • Auscultation

  • Subjective Data:

  • Information reported by the client in response to assessment questions.

• Purpose of Data Collection:

  • Enables clinical judgments about the client's health needs.

  • Assists in planning client goals and determining appropriate nursing interventions.

Findings During Assessment

• Expected Findings:

  • Symmetrical facial features and movements (e.g., a smiling man or woman).

  • When conducting a general survey of a client, the nurse should assess three things

    • Speech

    • Gait

    • Level of consciousness

• Information to collect during general survey

  • Use of assistive devices

  • Height and weight

  • Behavior and mode

• Unexpected Findings:

  • Expressionless or mask-like face.

  • Asymmetrical facial features (e.g., drooping eyelid, drooping side of the mouth).

  • Involuntary facial movements (e.g., twitching, excessive blinking).

  • Other related features: swelling, lesions, and frowning expressions, indicating emotional distress.

Emotional State Assessment

• Evaluation of Emotional State:

  • Can be assessed through a quick survey of client's behavior and statements.

  • Expected Findings:

  • Relaxed posture, smiling, and responsiveness indicate calmness.

  • Unexpected Findings:

  • Restlessness, grimacing, or quietness may indicate pain, anxiety, or sadness (anger, distrust, depression).

Eye Contact and Level of Consciousness Assessment

• Expected Findings:

  • Appropriate eye contact; however, cultural differences or shyness can affect this.

• Unexpected Findings:

  • Avoidance of eye contact may indicate confusion or anxiety.

  • Penetrating stares may convey negative emotions.

• Level of Consciousness:

  • Determine if client is alert and oriented to person, place, time, and situation.

  • Assess through responses to greeting and questions.

• Unexpected Findings:

  • Confusion, lethargy, stupor, and coma.

Skin and Behavioral Assessment

• Skin Assessment:

  • Expected Findings:

  • Intact, warm, evenly toned skin.

  • Unexpected Findings:

  • Cool, hot, sweaty, diaphoretic skin, or variations in color (e.g., cyanosis, jaundice, erythema).

• Behavioral Assessment:

  • Observe speech, mood, and affect.

  • Speech Assessment:

  • Look for fluency, articulation, and clarity.

  • Difficulty in finding words may indicate disorders such as aphasia.

  • Mood Assessment:

  • Observe verbal and nonverbal expressions of emotions, including tone of voice.

  • Affect Assessment:

  • Evaluate if physical expressions match spoken emotional states.

Personal Hygiene Assessment

• Hygiene Evaluation:

  • Include observations of grooming, body, and breath odors, and dental hygiene.

  • Grooming Assessment:

  • Clean, appropriate clothing.

  • Well-maintained hair and nails.

  • Mismatched clothing or lack of grooming may indicate depression or cognitive disorders.

  • Odor Evaluation:

  • Expected: Neutral or pleasant body and breath odors.

  • Unexpected: Halitosis, fruity breath (diabetes), musty odors (liver disease), and others.

Body Structure and Mobility Assessment

• Body Structure Assessment:

  • Posture:

  • Expected: Upright posture with body parts aligned.

  • Unexpected: Slumped or rigid posture, fidgeting.

  • Overall Build:

  • Observe height and symmetry; assess nutritional status.

  • Expected: Well-nourished, symmetrical build.

  • Unexpected: Height deviations, weight distribution indicating endocrine disorders.

• Mobility Assessment:

  • Observe gait, range of motion, and involuntary movements.

  • Expected: Smooth, steady movements, free arm movement.

  • Unexpected: Difficulty walking, localized pain, reduced mobility.

Vital Signs Measurement

• Overview of Vital Signs:

  • Includes temperature, pulse, respirations, blood pressure, and pulse oximetry.

  • Establishes baseline for ongoing health assessments.

Temperature Assessment

• Definition:

  • Core temperature range: 36°C to 38°C (96.8°F to 100.4°F).

  • Regulated through thermoregulation by the hypothalamus.

  • Methods include oral, rectal, temporal, axillary, tympanic.

• Expected Findings:

  • Oral: 36°C to 38°C (average 37°C).

  • Rectal: 0.5°C to 0.9°C higher than oral.

  • Axillary: 0.5°C to 0.9°C lower than oral.

• Unexpected Findings:

  • Hyperthermia, hypothermia, negative factors affecting temperature measurement (recent food/drink, activity, etc.).

Pulse Assessment

• Definition:

  • Palpable like contraction resulting from blood flow; assessed at pulse sites (e.g., radial, apical).

• Expected Findings:

  • Normal range: 60 to 100 beats per minute with regular rhythm.

  • Unexpected Findings:

  • Bradycardia (<60 bpm), tachycardia (>100 bpm), dysrhythmia (irregular heartbeat).

Respiratory Assessment

• Definition:

  • Evaluates the exchange of oxygen and carbon dioxide.

  • Measured by rate, depth, rhythm; expected range is 12 to 20 breaths per minute.

• Unexpected Findings:

  • Dyspnea, tachypnea, and apnea.

  • Depth irregularities observed through chest movements.

Blood Pressure Assessment

• Definition:

  • Measures the force of blood against arterial walls; systolic (contracting) and diastolic (resting) pressures noted.

• Expected Findings:

  • Normal systolic <120 mmHg, diastolic <80 mmHg.

  • Unexpected Findings:

  • Hypotension, hypertension (stages 1 & 2 categorized for severity).

Pulse Oximetry Assessment

• Definition:

  • Measures pulse oxygen saturation (SpO2) via a pulse oximeter.

  • Expected range is 95% to 100%; <90% indicates hypoxia requiring immediate response.

Pain Assessment

• Definition:

  • Pain is subjective; assessed using the PQRST method and numeric scale (0-10). - Sources include visceral, somatic, and referred categories with acute vs. chronic classification stated.

• Expected Findings:

  • Appropriate patient responses to pain assessments.

  • Unexpected Findings:

  • Discrepant reports regarding pain; signs of discomfort in the absence of admission.

Conclusion

• Comprehensive Nursing Assessment:

  • Essential to collect an extensive range of client data to formulate effective nursing care and interventions.