Nursing-Health-Assessment-101

NURSING HEALTH ASSESSMENT

• Course: NCM101

• Instructor: MA. CARMELA ANDREA N. CEQUEÑA, RN, MANC

STEPS OF HEALTH ASSESSMENT

• Collection of Subjective Data through interview and health history.

  • Integral part of nursing health history includes:

    • Sensations or symptoms

    • Feelings

    • Perceptions

    • Desires

    • Preferences

    • Beliefs

    • Ideas

    • Values

    • Personal information

Subjective Data

• Provides clues to possible physiological, psychological, and sociologic problems.

  • Reveals:

    • Client’s risk for complications

    • Areas of strengths for client

• Obtained through effective interviewing skills, crucial for accurate data collection.

INTERVIEWING

• Requires professional, interpersonal, and interviewing skills.

• Focuses on:

  1. Establishing rapport and trusting relationship for accurate information.

  2. Gathering detailed information on client’s status across several domains:

  • Developmental

  • Psychological

  • Physiological

  • Sociocultural

  • Spiritual

PHASES OF INTERVIEW

Preintroductory Phase

• Review medical record before client interaction.

Introductory Phase

• Introduce self and explain interview purpose:

  • Discuss types of questions

  • Explain note-taking reasons

  • Assure confidentiality

• Ensure client's comfort and privacy:

  • Conduct at eye level for respect and equality.

  • Develop trust and rapport using verbal and nonverbal communication.

WORKING PHASE

• Elicit client comments about:

  • Major biographical data

  • Reasons for seeking care

  • History of present health concern

  • Past health history

  • Family history

  • Review of body systems for current health problems

  • Lifestyle and health practices

  • Developmental level

• Listen and observe cues.

• Use critical thinking to interpret and validate information.

• Collaborate with client to identify problems and goals.

SUMMARY AND CLOSING PHASE

• Summarize information gathered during the interview.

• Validate problems and goals with the client.

• Discuss potential plans to address concerns.

• Ask if there are further questions or concerns.

COMMUNICATION DURING THE INTERVIEW

Non-Verbal Communication

• Equally important as verbal communication;

  • Influences client perceptions through:

    • Appearance

    • Demeanor

    • Posture

    • Facial expressions

    • Attitude

• Facilitate eye-level contact.

Verbal Communication

• Effective verbal skills are crucial.

• Aim to gather maximum data regarding health status.

TYPES OF QUESTIONS AND TECHNIQUES

• Open-Ended Questions

• Closed-Ended Questions

• Laundry List

• Rephrasing

• Well-Placed Phrases

• Inferring

• Providing Information

SPECIAL CONSIDERATIONS DURING INTERVIEW

• Gerontologic Variations in Communication

• Cultural Variations in Communication

• Emotional Variations in Communication

COMPLETE HEALTH HISTORY

• Begins assessment process, laying foundation for clinical judgment.

• Identifies:

  • Nursing problems, areas of focus, and need for detailed physical exams.

• Provides insights into:

  • Client strengths

  • Limitations in lifestyle and health status.

8 SECTIONS OF HEALTH HISTORY

1. Biographical data

2. Reasons for seeking health care

3. History of present health concern

4. Personal health history

5. Family health history

6. Review of Systems (ROS) for current health problems

7. Lifestyle and health practices profile

8. Developmental level

HISTORY OF PRESENT HEALTH CONCERN

• Utilize COLDSPA mnemonic:

  • Character: Description of symptoms

  • Onset: Timing and progression

  • Location: Specific site of symptoms

  • Duration: Timeliness and recurrence

  • Severity: Pain scale rating

  • Pattern: Influencing factors

  • Associated factors: Other accompanying symptoms.

PQRST PAIN ANALYSIS MNEMONIC

• P: Provocative/palliative - triggers or reducers

• Q: Quality - describe pain characteristics

• R: Radiates - check if pain spreads

• S: Severity - rate the pain

• T: Timing - frequency and duration of pain occurrences.

COLLECTING OBJECTIVE DATA: PHYSICAL EXAM TECHNIQUE

• Complete nursing assessment incorporates:

  • Collection of subjective and objective data.

• Objective data includes:

  • What is directly observed and gathered during physical examination.

PREPARING FOR PHYSICAL EXAMINATION

• Proficiency in physical examination requires knowledge of:

  • Equipment operation and types (e.g., otoscope, sphygmomanometer)

  • Preparation of setting, self, and client for exam

  • Four examination techniques:

    • Inspection

    • Palpation

    • Percussion

    • Auscultation

PREPARING THE PHYSICAL SETTINGS

• Ensure examination settings meet conditions:

  • Comfortable room temperature

  • Private and interruption-free area

  • Quiet environment

  • Adequate lighting

  • Appropriate examination surface height

  • Availability of equipment holder.

PREPARING ONESELF

• Ensure thorough preparation as an examiner to collect objective data.

  • Reflect on personal feelings and anxiety before client assessment.

  • Practice examination techniques to build confidence.

• Prevent transmission of infections using standard precautions:

  • Based on risk assessment and use of personal protective equipment.