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Introduction to Health Assessment unit-1
- 1. INTRODUCTION TO HEALTH ASSESSMENTCONCEPTS UNIT-1 Presented By Ms. Gulshan Umbreen M.Phil Epidemiology & Public Health Lecturer, SNC
- 2. UNIT OBJECTIVES: By theend of the unit, learners will be able to: • Discuss the need for health assessment in general nursing practice. • Explain the concepts of Health, Assessment, Data collection, and Diagnosis. • Identify types of Health Assessments • Document health assessment data using a Problem Oriented Approach.
- 3. INTRODUCTION TO HEALTH ASSESSMENT •The first assessment begin in (1992) by American medical association. • In (1995) Health Assessment considered as basic human right • Preventive health care divided in three categories, Primary, Secondary and Tertiary prevention.
- 4. Cont...... • Each levelof prevention is based on a thorough assessment of the client's health as status. • Periodic health assessment needed to be performed by a physician, or a nurse
- 5. NEED FOR HEALTHASSESSMENT IN GENERAL NURSING PRACTICE 1. Systematic and continuous collection of client data. 2. It focus on client responses to health problems. 3. The nurse carefully examine the client’s body parts to determine any abnormalities.
- 6. Cont.... 4.The nurse relieson data from different sources which can indicate significant clinical problems 5.Health assessment provides a base line used to plan the clients care. 6. Health assessment helps the nurse to diagnose client’s problem & the intervention
- 7. Cont.... 7. Complete healthassessment involves a more detailed review of client’s condition 8. Health assessment influence the choice of therapies & client's responses
- 8. Explain the conceptsof Health, Assessment, Data collection, and Diagnosis.
- 9. HEALTH • The conditionof being sound in body, mind, or spirit; especially freedom from physical disease or pain According to “WHO” Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
- 10. ASSESSMENT: • Assessment isdefined as “The systematic collection of all data and information relevant to the care of patients, their problems, and needs” (Taber’s, 2009). or Is the first step to determine heath status. It is gathering of information to have all the “necessary puzzle pieces” to make a clear picture of the person's health status
- 11. Cont... • Assessment: Themost critical step • Answers the questions: “What is happening?” (actual problem), or “What could happen?” (potential problem) • Involves collecting, organizing, and analysing information/data about the patient.
- 12. A healthassessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history
- 13. Cont.... • Data Collection: •Data collection is defined as the ongoing systematic collection, analysis, and interpretation of health data necessary for designing, implementing, and evaluating public health prevention programs.
- 14. Data Collection: AHolistic Approach Types of data • Subjective: “Symptoms” that the patient describes; e.g. “I can’t do anything for myself” Objective: Signs that can be observed, measured, and verified; e.g. swollen joints
- 15. Cont.... Sources of data Primary:The patient; is always the best source Secondary: Everything/everybody else.
- 16. Cont.... • Diagnosis: Nursing diagnoseis independent role of the nurse. Nursing diagnoses depends on the client's problems/response associated with specific disorder
- 17. Nursing Diagnosis • Astatement that describes a specific human response to an actual or potential health problem that requires nursing intervention. • A nursing diagnosis is a clinical judgment about individuals, families, or communities and their responses to actual and/or potential health problems or life processes (NANDA International, 2007).
- 18. Potentials for NursingDiagnosis • Safety – Confusion – History of falls • Skin integrity – Immobility • Pain – Fractured hip
- 19. Building A NursingDiagnosis: 1. PROBLEM 2. ETIOLOGY 3. SYMPTOMS
- 20. PES: PROBLEM P – Atrisk for impaired skin integrity RELATED TO (R/T) E – Immobilization AS EVIDENCED BY (AEB) S – Bed rest and traction
- 21. Nursing Diagnosis Statement •Potential for skin breakdown related to immobility as evidenced by bed rest and traction
- 22. Cont.... • Another NursingDiagnosis Statement • Pain related to fractured hip as evidenced by patient states pain level 8/10.
- 23. ASSESSMENT Is the systematicand continuous: • Collection • Organization – Validation • Documentation Of Data.
- 24. Collection of Data •Gathering Of Information About The Client • Includes Physical, Psychological, Emotion, Socio-cultural, Spiritual Factors That May Affect Client’s Health Status Includes Past Health History Of Client (Allergies, Past Surgeries, Chronic Diseases). Includes Current/Present Problems Of Client (Pain, Nausea, Sleep Pattern, Religious Practices, Medication Or Treatment The Client Is Taking Now)
- 25. Data Collection Methods 1.Observing: to observe is to gather data by using the senses. 2. Interviewing: an interview is a planned communication or conversation with a purpose. 3. Examining: Performance of a physical examination. The physical examination is often guided by data provided by the patient.
- 26. • A head-to-toeapproach is frequently used to provide systematic approach that helps to avoid omitting important data
- 27. VALIDATING DATA Theinformation gathered during the assessment phase must be complete, factual, and accurate because the nursing diagnosis and interventions are based on this information. Validation is the act of "double-checking" or verifying data to confirm that it is accurate and factual.
- 28. Purposes of DataValidation • Ensure that data collection is complete • Ensure that objective and subjective data agree • Obtain additional data that may have been overlooked • Avoid jumping to conclusion
- 29. Data Requiring Validation Notevery piece of data you collect must be verified. For example: you would not need to verify or repeat the client’s pulse, temperature, or blood pressure unless certain conditions exist. Conditions that require data to be rechecked and validated include:
- 30. • Discrepancies orgaps between the subjective and objective data. For example, a male client tells you that he is very happy despite learning that he has terminal cancer.
- 31. Data Requiring Validation •Discrepancies or gaps between what the client says at one time and then another time. For example, your female patient says she has never had surgery, but later in the interview she mentions that her appendix was removed at a military hospital when she was in the navy
- 32. –Findings those arevery abnormal and inconsistent with other findings. For example, the client has a temperature of 104 o F degree. The client is resting comfortably. The client’s skin is warm to touch.
- 33. METHODS OF VALIDATION •Recheck your own data through a repeat assessment. • For example, take the client’s temperature again with a different thermometer. • Clarify data with the client by asking additional questions. • For example: if a client is holding his abdomen
- 34. • The nursemay assume he is having abdominal pain, when actually the client is very upset about his diagnosis and is feeling.
- 35. »Verify the datawith another health care professional. For example, ask a more experienced nurse to listen to the abnormal heart sounds you think you have just heard. »Compare you objective findings with your subjective findings to uncover discrepancies.
- 36. • For example,if the client state that she “never gets any time in the sun” yet has dark, wrinkled, suntanned skin, you need to validate the client’s perception of never getting any time in the sun
- 37. ORGANIZING DATA The nurseuses a written or computerized format that organizes the assessment data systematically. The format may be modified according to the client's physical status.
- 38. Documenting Data • Tocomplete the assessment phase, the nurse records client's data. • Accurate documentation is essential and should include all data collected about the client's health status. Data are recorded in a factual manner and not interpreted by the nurse. E.g.: the nurse record the client's breakfast intake as" coffee 240 mL. Juice 120 mL, 1 egg". Rather than as "appetite good".
- 39. Purposes of documentation •Provides a chronological source of client assessment data and a progressive record of assessment findings that outline the client’s course of care. • Ensures that information about the client and family is easily accessible to members of the health care team; provides a vehicle for communication; and prevents fragmentation, repetition, and delays in carrying out the plan of care. • Acts as a source of information to help diagnose new problems.
- 40. Guidelines for documentation •Document legibly or print neatly in unerasable ink • Use correct grammar and spelling • Use only abbreviations that are acceptable and approved by the institution • Avoid wordiness that creates redundancy • For example, do not record: “Auscultated gurgly bowel sounds in right upper, right lower, left upper, and left lower abdominal quadrants. Heard 36 gurgles per minute.” Instead record: • “Bowel sounds present in all quadrants at 36/minute.”
- 41. • Use phrasesinstead of sentences to record data • For example, avoid recording: “The client’s lung sounds were clear both in the right and left lungs.” Instead record: “Bilateral lung sounds clear.” • Record data findings, not how they were obtained For example, do not record: “Client was interviewed for past history of high blood pressure, and blood pressure was taken.” Instead record: “Has 3-year history of hypertension treated with medication. BP sitting right arm 140/86
- 42. • Write entriesobjectively without making premature judgments or diagnosis Use quotation marks to identify clearly the client’s responses. For example, record: “Client crying in room, refuses to talk, husband has gone home” instead of “Client depressed due to fear of breast biopsy report and not getting along well with husband.”
- 43. • Avoid recordingthe word “normal” for normal findings For example, do not record: “Liver palpation normal.” Instead record: “Liver span 10 cm in right MCL and 4 cm in MSL. No tenderness on palpation.” • Record complete information and details for all client symptoms or experiences For example, do not record: "Client has pain in lower back.” Instead record: “Client reports aching-burning pain in lower back for 2 weeks. Pain worsens after standing for several hours. Rest and ibuprofen used to take edge off pain.
- 44. • Include additionalassessment content when applicable(e.g., include information about the caregiver or last physician contact). • Support objective data with specific observations obtained during the physical examination • For example, when describing the emotional status of the client as depressed, follow it with a description of the ways depression is demonstrated such as “dressed in dirty clothing, avoids eye contact, unkempt appearance, and slumped shoulders.”
- 47.
- 48. INITIAL COMPREHENSIVE ASSESSMENT An initialassessment, also called an admission assessment, is performed when the client enters a health care from a health care agency. • The purposes are to evaluate the client’s health status, to identify functional health patterns that are problematic, and to provide an in-depth, comprehensive database, which is critical for evaluating changes in the client’s health status in subsequent assessments.
- 49. PROBLEM-FOCUSED ASSESSMENT A problemfocus assessment collects data about a problem that has already been identified. This type of assessment has a narrower scope and a shorter time frame than the initial assessment. In focus assessments, nurse determine whether the problems still exists and whether the status of the problem has changed (i.e. improved, worsened, or resolved).
- 50. • This assessmentalso includes the appraisal of any new, overlooked, or misdiagnosed problems. In intensive care units, may perform focus assessment every few minute.
- 51. EMERGENCYASSESSMENT Emergency assessment takesplace in life- threatening situations in which the preservation of life is the top priority. Time is of the essence rapid identification of and intervention for the client’s health problems. Often the client’s difficulties involve airway, breathing and circulatory problems (the ABCs). Emergency assessment focuses on few essential health patterns and is not comprehensive
- 52. Time-lapsed assessment orOngoing assessment • Time lapsed reassessment, another type of assessment, takes place after the initial assessment to evaluate any changes in the clients functional health. • Nurses perform time-lapsed reassessment when substantial periods of time have elapsed between assessments
- 53. • (e.g., periodicoutput patient clinic visits, home health visits, health and development screenings)
- 54. Frequency of assessment •The persons under (35) years every (4-5) years. • The persons from (35-45) every (2-3) years. • Persons from (45-55) years of age undergo a thorough health assessment every year. • Persons over (55) years may needs assessment every 6 months or less. 54
- 55. HEALTH ASSESSMENT • Twocomponents of the health assessment – Health History – Physical Assessment
- 56. Methods of Assessment •The Primary Methods are • Observing • Interviewing • Examining
- 57. Document health assessmentdata using a Problem Oriented Approach. Health History: • 8/25/12 11:00 am • Mrs. N is a pleasant, 54-year-old widowed saleswoman residing in Karachi • Referral. None • Source and Reliability. Self-referred; seems reliable. • Chief Complaint: “My head aches.”
- 58. Cont… • Present Illness: Forabout 3 months, Mrs. N has had increasing problems with frontal headaches. These are usually bifrontal, throbbing, and mild to moderately severe. She has missed work on several occasions because of associated nausea and vomiting. Headaches now average once a week, usually are related to stress, and last 4 to 6 hours.
- 59. • They arerelieved by sleep and putting a damp towel over the forehead. There is little relief from aspirin. No associated visual changes, motor-sensory deficits, or paresthesias. • She thinks her headaches may be like those in the past but wants to be sure, because her mother died following a stroke.
- 60. • She isconcerned that they interfere with her work and make her irritable with her family. She eats three meals a day and drinks three cups of coffee a day and tea at night. • Medications. Aspirin, 1 to 2 tablets every 4 to 6 hours as needed. “Water pill” in the past for ankle swelling, none recently. • *Allergies. Ampicillin causes rash. • Tobacco. About 1 pack of cigarettes per day since age 18 (36 pack-years). • Alcohol/drugs. No illicit drugs.
- 61. Past History: • ChildhoodIllnesses. Measles, chickenpox. No scarlet fever or rheumatic fever. • Adult Illnesses. Medical: Pyelonephritis, 1998, with fever and right flank pain; treated with ampicillin; developed generalized rash with itching several days later. Reports x-rays were normal; no recurrence of infection. • Surgical: Tonsillectomy, age 6; appendectomy, age 13. Sutures for laceration, 2001, after stepping on glass.
- 62. • Ob/Gyn: 3-3-0-3,with normal vaginal deliveries. Three living children. Menarche age 12. Last menses 6 months ago. Little interest in sex, and not sexually active. No concerns about HIV infection. • Psychiatric: None. • Health Maintenance. Immunizations: Oral polio vaccine, year uncertain; tetanus shots × 2, 1991, followed with booster 1 year later; flue vaccine, 2000, no reaction. • Screening tests: Last Pap smear, 2008, normal. No mammograms to date.
- 63. • Family History: •Father died at age 43 in train accident. Mother died at age 67 from stroke; had varicose veins, headaches. • One brother, 61, with hypertension, otherwise well; second brother, 58, well except for mild arthritis; one sister, died in infancy of unknown cause. • Husband died at age 54 of heart attack. • Daughter, 33, with migraine headaches, otherwise well; son, 31, with headaches; son, 27, well. • No family history of diabetes, tuberculosis, heart or kidney disease, cancer anemia, epilepsy, or mental illness.
- 64. • Personal andSocial History: Born and raised in Las Cruces, finished high school, married at age 19. Worked as sales clerk for 2 years, then moved with husband to Islamabad had 3 children. Returned to work 15 years ago because of financial pressures. Children all married. Four years ago, Mr. N died suddenly of a heart attack, leaving little savings. Mrs. N has moved to small apartment to be near her daughter, Isabel. Isabel’s husband, John, has an alcohol problem.
- 65. Cont… • Exercise anddiet. Gets little exercise. Diet high in carbohydrates. Safety measures. Uses seat belt regularly. Uses sunblock. Medications kept in an unlocked medicine cabinet. Cleaning solutions in unlocked cabinet below sink. Mr. N’s shotgun and box of shells in unlocked closet upstairs.
- 66. • Review ofSystems: • General. *Has gained about 10 lbs in the past 4 years. • Skin. No rashes or other changes. • Head, Eyes, Ears, Nose, Throat (HEENT). See Present Illness. No history of head injury. Eyes: Reading glasses for 5 years, last checked 1 year ago. No symptoms. • Ears: Hearing good. No tinnitus, vertigo, infections. Bickly, L. S. (2012).
- 67. • Nose, sinuses:Occasional mild cold. No hay fever, sinus trouble. • Throat (or mouth and pharynx): Some bleeding of gums recently. Last dental visit 2 years ago. Occasional canker sore. • Neck. No lumps, goiter, pain. No swollen glands. • Breasts. No lumps, pain, discharge. Does breast self-exam sporadically. • Respiratory. No cough, wheezing, shortness of breath. Last chest x-ray, 1986, St. Vincent’s Hospital; unremarkable.
- 68. • Cardiovascular. Noknown heart disease or high blood pressure; last blood pressure taken in 2006. No dyspnea, orthopnea, chest pain, palpitations. Has never had an electrocardiogram (ECG). • Gastrointestinal. Appetite good; no nausea, vomiting, indigestion. Bowel movement about once daily, *though sometimes has hard stools for 2 to 3 days. when especially tense; no diarrhea or bleeding. No pain, jaundice, gallbladder or liver.
- 69. • Urinary. Nofrequency, dysuria, hematuria, or recent flank pain; nocturia × 1, large volume. *Occasionally loses some urine when coughs hard. • Genital. No vaginal or pelvic infections. No dyspareunia. • Peripheral Vascular. Varicose veins appeared in both legs during first pregnancy. • For 10 years, has had swollen ankles after prolonged standing; wears light elastic pantyhose; tried “water pill” 5 months ago, but it didn’t help much; no history of phlebitis or leg pain.
- 70. • Musculoskeletal. Mild,aching, low back pain, often after a long day’s work; no radiation down the legs; used to do back exercises but not now. No other joint pain. • Psychiatric. No history of depression or treatment for psychiatric disorders. See also Present Illness and Personal and Social History. • Neurologic. No fainting, seizures, motor or sensory loss. Memory good.
- 71. • Hematologic. Exceptfor bleeding gums, no easy bleeding. No anemia. • Endocrine. No known thyroid trouble, temperature intolerance. Sweating average. No symptoms or history of diabetes.
- 72. Physical Examination: • Mrs.N is a short, overweight, middle-aged woman, who is animated and responds quickly to questions. She is somewhat tense, with moist, cold hands. Her hair is well-groomed. Her color is good, and she lies flat without discomfort. • Vital Signs. Ht (without shoes) 157 cm (5′2″ ). Wt (dressed) 65 kg (143 lb). BMI 26. BP 164/98 right arm, supine; 160/96 left arm, supine; 152/88 right arm, supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18. Temperature (oral) 98.6°F.
- 73. References: • Bickly, L.S. (2017). Bates’Guide to Physical Examination and History Taking (12th ed). Philadelphia: J. B. Lippincott. • Thompson B. (1991). Clinical manual of health assessment (4th ed). St. Louis: Mosby. • Weber, J. R. (2001). Nurses handbook of health assessment (4th ed). Philadelphia: J. B. Lippincott.