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Health Assessment

HEALTH ASSESSMENT

Myung-Hee Pak, RN, MSN, CNS

Health Assessment
n Incorporates

critical thinking
n Includes knowledge of
developmental stages through the
life cycle
n Health assessment includes,
physical & mental along with
assessment for domestic violence
and child abuse

Cultural Assessment
Brief History of the cultural group patient
identifies with
n Communication
n Values
n Cultural Sanctions/Restrictions and Health
related beliefs/practices
n

(Include nutrition, socioeconomic


considerations, educational background and
religious affiliation)

nIs

Data Collection and Data


Analysis
nUtilizes the Nursing process
nIs essential in diagnosing
medical and nursing problems,
provides insight into beliefs
and perceptions.

Health Assessment
nRequires

proficient
communication skills and
interviewing techniques

nConsiders
n

cultural aspects

Cultural Competency

Cross-Cultural
Communication
n Cultural

perspectives on professional
interactions
n Etiquette
n Space and distance
n Cultural considerations on gender
and sexual orientation

Techniques of
Communication
n

(cont.)

Health Assessment
n Begins

Nonverbal skills
n

Physical appearance

Posture

Gestures

Facial expression

Eye contact

Voice

Touch

with reason for seeking care


(chief complaint is previously used
term) & health history
n Document using the patients own
words
n Elicit a complete description from
patient
n Document duration of complaint
n What aggravates condition, what
may alleviate it?

Types of Health Histories

History Taking

nComplete

n Well

nInterval
nProblem

focused or chief
complaint

Complete Health History


n Biographical

n Review

of
systems
n Reason for
seeking health n Psychological
care
n Functional
Assessment
n Present health/
Illness
n Perception of
n Past health
health
n Family health

developed interview skills and


careful documentation
n Environment conducive to privacy
and comfort
n Is the client a good historian?
n Reasons for seeking health care
n Interview- intro, working,
termination phases

Reason for Seeking Care


n Symptom
n Subjective

sensation

n Sign
n Objective

abnormality
on physical exam or in
laboratory reports

n Detectable

Present Health/Illness

Past Health History

n Onset,

duration, precipitating
factors.
n Frequency, duration
n Associated symptoms i.e. N/V
n Alleviating/ aggravating factors
n ROS re: CC
n Relevant family, occupational or
recreational history.

n Past

Current Health

Family History

n Allergies
n Habits
n Meds

(including OTC/Herbal/
Vitamins)
n Exercise
n Sleep

Genogram:see also page 813

general health
illnesses
n Accidents/ injuries
n Hospitalizations/surgeries
n Acute and chronic illnesses
n Immunizations
n Allergies, medications, transfusions
n Childhood

n Important

to know to determine
risks
n Spouse/significant other
n Children
n Cultural considerations

Review of Systems: ROS


nReviews

past and present


health status of each body
system.
nReviews health maintenance.
nHead to toe
nMay elicit new information

Psychological Function
nCognitive

Functional Assessment

memory,
comprehension
nResponse to illness and
health
nPsych history, meds,
anxiety?
nCultural considerations

n ADLs

Perception of Health

Physical Examination (PE)

nHow

one defines health


nViews on ones health status
nWhat are ones expectations
pertaining to health and
health care

Techniques of PE
n Four

components used in specific


order:
n Inspection
n Palpation
n Percussion
n Auscultation

n Sleep/rest
n Nutrition/problems

with diet,
weight
n Alcohol problems /Substance
abuse
n Coping difficulties
n Domestic/child abuse

nGoal

is to identify variations
form normal.
nExplain procedure first
nHead to Toe
nUnaffected areas before
affected

Techniques of PE
n Inspection-

First techniques used.


What examiner sees, hears and
smells. Observe symmetry.

n Palpation-

Second technique using


fingers and hands to touch. Light
palpation first then deep palpation

Palpation Technique
The RN must utilize different parts of the hand
One hand or bimanual (2 hands)
n
n
n
n

fingertips - assess texture, swelling, pulse or


lumps
Fingers and thumb in a grasp - assess position
and shape of organs
Dorsa (back) of hands - assess temperature
Base of hand - assess vibration

Techniques of PE
n Methods
n Direct-

of Percussion

used over sinuses.

n Indirect-

used over thorax and


abdomen.
n Fist Percussion- used over kidneys

Techniques of PE
n Auscultation-Usually

last technique
during PE (*exception abdomen,
its the 2nd technique after
inspection)
n Use stethoscope to block sounds not
magnify
n Diaphragm-firmly against skin
n Bell- lightly against skin

Techniques of PE
Percussion- Third techniquestapping
on skin surface which creates a vibration
of underlying structures. The vibration
produces a sound, may aid in diagnosis.
n Resonant- normal lung.
n Hyperresonant- Childs lung or
emphysema.
n Tympany- Air filled organ, e.g., stomach
or intestine.
n Dull- Dense organ, e.g., liver or spleen.
n Flat- No air present, e.g., bone.
n

Techniques of PE
n Uses

for Percussion: Mapping out


location and size of an organ
n Determining density (air, fluid, solid) of
a structure
n Detecting superficial mass (up to 5 cm
deep)
n Eliciting pain if underlying structure is
inflamed
n Eliciting a DTR using a percussion
hammer

Techniques of PE
n Description

of sounds heard
n Pitch- frequency of sound vibrations,
high or low.
n Intensity- loudness of sound: loud or
soft (amplitude)
n Duration- length of sound: short, long
n Quality- subjective terms- harsh,
tinkling, etc

Physical Exam

Summary

nUtilize

nHealth

4 techniques
nProper setting
nEquipment
nClean/ safe environment
nRemember client comfort

SOAP note
Subjective - info given by pt
(health history)
n Objective - PE finding using IPPA
n Assessment - therapeutic ideas,
nsg dx
n Plan - diagnostic, therapeutic or
educational interventions
to work toward problem solving.
n

Objective data
the RN observes
the PE is performed you must
identify the normal and abnormal
findings

n What
n As

Pertinent positives
and
Significant negatives

assessment
includes:
nComplete health history
nROS
nPhysical Exam

Subjective Data
n
n
n

Statements made by patient


Their feelings about symptomotology
Patient denies any history of skin disease
or problems. States he has a receding
hairline since his mid 30s. Admits to
nail biting only when studying for
nursing exams.

Assessment
After you collect the data then you must
interpret the results
n Written as a NANDA diagnosis
Actual health problem
Risk diagnosis
Wellness diagnosis
n Remember the 2 and 3 part statements
n PES format
n Problem r/t etiology AEB S&S
n

Plan
n

List of interventions that will aim to resolve the problem(s)


Educational
Therapeutic
Diagnostic
Referral to specialist
Use of active verbs to state nursing interventions
Instruct
Discourage
Encourage
Advise
Teach
But never..TELL !!!!!