1) Nursing health history
2) Physical examination
Purposes of health assessment:
· To plan strategies, to encourage continuation of healthy pattern, to prevent potential health problems & alleviate or manage existing health problems.
· To get holistic view of the client
· To evaluate the physiologic outcomes/progress
· Identify and confirm nursing diagnosis
· To help, formulate a conclusion or problem statement.
· to establish a database
· physical, psychosocial, and emotional health in order to identify health promoting behaviours as well as actual and/or potential health problems
· To get a clear picture of the clients health status and health related problems.
· Ascertain the client’s level of health and physiological function
· Identify factors placing the client at risk and to determine areas of preventive nursing
· Confirm alterations, disease, or inability to perform the activities of daily living
· Identify the need for additional testing or examination
· Evaluate the outcomes of treatment and therapy
· determines the client’s functional abilities and the absence or presence of dysfunction
· The client’s normal routine for activities of daily living and lifestyle patterns
· Identification of the client’s strengths
· complete picture of the client’s physiological functioning
· Database to direct decision making.
· Provides an opportunity for the nurse to form a therapeutic interpersonal relationship with the client
· the client is provided an opportunity to discuss health care concerns and goals with the nurse
ü Collection and analysis of data that are used in formulating nursing diagnoses
ü Identifying outcomes and planning care, and developing nursing interventions
The health assessment is conducted in a systematic and efficient manner that results in the fewest position changes for the client.
Elements of the assessment process
• Data collection
• Data verification
• Data organization
• Data interpretation
• Data documentation
Types of health assessment
ü Initial assessment
ü Problem focused assessment
ü Emergency assessment
ü Time lapsed assessment
TYPES OF ASSESSMENT
Comprehensive- includes a complete health history to determine needs of the client, include assessment of physical and psychosocial aspects of the client’s health, the client’s perception of health, the presence of health risk factors, the client’s coping patterns.
Focused- focus on a particular need or health care problem or potential health care risks.
Assessments are not as detailed as comprehensive assessments for purposes of screening for specific problems or risk
Ongoing assessment- is an assessment that includes systematic monitoring and observation related to specific problems allows the nurse to broaden the database or to confirm the validity of the data obtained during the initial assessment. Systematic monitoring and observations allow the nurse to determine the response to nursing interventions to identify any emerging problems.
An emergency Assessment: Is a type of rapid focused assessment conducted to determine potentially fatal situation.
Frame work for health assessment
1. Functional health frame work;evaluates the effects of mind, body & environment in relation to a person’s ability to perform the task of daily living.
2. Head to toe frame work; - is system for collecting data in an organized manner starting from the head and proceeding systematically downwards to the toe. This is also known as cephalocaudal framework
3. Body system frame work: - focuses on the patho- physiology involved within the specific body system. Also known as system wise frame work.
Types of Data
· Data from the client’s point of view and include feelings, perceptions and concerns. (Also referred to as symptoms)
· Obtained through interviews with the client.
· They are called subjective because they rely on the feelings or opinions of the person experiencing them and cannot be readily observed by another.
Objective data –
· Observable and measurable (quantitative) data that are obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing.
· These data (also called signs)
· Can be seen, heard, or felt by someone other than the person experiencing them.
· Comprehensive and accurate
SOURCES OF DATA
· Family/significant other
· Other health care professionals
· Medical records
· Interdisciplinary conferences, rounds, and
· Results of diagnostic tests
· Relevant literature
Methods of Data Collection
o Health history
o Symptom analysis
o Physical examination
o Laboratory and diagnostic data.
· The health history is a review of the client’s functional health pattern
· Responses to changes in health status, and alterations in lifestyle.
· The health history is also used in developing the plan of care and formulating nursing interventions
Health assessment begins with a general survey that involves Observation- client’s general appearance, body build, hygiene and posture
Measurements of vital signs, height and weight
1. Appearance and mental status
Appearance and behaviour must be assessed in relation to culture, educational level, socioeconomic status, and current circumstances. E.g. - loss of loved one in recent past may appear depressed.
Deviation from normal
Observe body build, height & weight
Proportionate varies with life style
Excessively thin /obese
Observe the clients posture & gait, standing, sitting & walking
Relaxed, erect posture, coordinated movements
Tense. Slouched, bent posture, uncoordinated movements
Overall hygiene & grooming
Dirty and unkept
Body & breath odor in relation to activity level
No body odor / minor body odor r/t work / exercise, no breath odor
Foul body odor, ammonia, acetone breath odor,& foul breath
Observe for signs of distress in posture & facial expression
Bending over because of abdominal pain, wincing or labored breathing
Note obvious signs of health / illness e.g skin color or breathing
Pallor, weakness obvious illness
Assess the clients attitude
Negative, hostile/ withdrawn
Note the clients affect, mood & response
Appropriate to situation
inappropriate to situation
Listen for quantity of speech –quality, inflection & coherence
Understandable, moderate pace, exhibits thought association
Rapid / slow pace, uses generalization, lacks association
2. Vital signs: are measure to establish base line data against which to compare future measurements. To detect actual & potential health problems
3. Height& weight: the measure of height and weight provides general measure of health & also provides idea of self-image
I. Components of nursing health history:
I. HEALTH HISTORY
b) Patient’s profile:
Gender: Male / Female
Religion: Hindu/ Muslim/ Christian/ Sikh / Any other
Marital status: Married/ Single/ Widow
Date and time of admission:
Date of surgery (if any):
c) Chief complaints with duration (on the day of admission X duration):
Eg. Headache x 2 days
fever x 5 days
d) History of Present Illness: presenting signs and symptoms/ onset/ duration/ progress/ aggravating and relieving factors/ treatment taken
History of present illness:-
When the symptoms started
Whether the onset of symptoms was sudden or gradual
How often the problem occurs
Exact location of the distress
Character of the complaint (e.g. intensity of pain or quality of sputum, emesis or discharge)
Activity in which the client was involved when the problem occurred
Phenomena or symptom associated with the chief complaint
Factors that aggravate or alleviate the problem
History of past illness
Childhood illnesses – such as chickenpox, mumps, measles, rubella rheumatic fever etc
Allergies to drugs, animals, insects or other environmental agents
Accidents and injuries: how, when, and where the incident occurred, type of injury, treatment received and any complications
Hospitalization for serious illnesses – date, type of surgery performed, course of recovery, and any complications.
Medications: all currently used prescriptions
f) Family history (3 generation genogram with key):
Type: Joint/ nuclear
Number of members:
Any illness: TB/ DM/ HT/Hereditary illness/ any other
Genogram (Family tree) - representing ages of siblings, current state of health, diseased death, cause of death,
health risk factors like DM, CVS disorders, cancers, alcoholism, mental disorders etc.
g) Socio-economic status:
i) Social aspect:
Who makes decision on health matters
Involvement in social activities, if applicable
ii) Economic status:
Family income/ month
Type of house and ventilation
h) Nearest health care facilities: PHC / clinics/ hospitals/ others
i) Personal history:
Dietary history: Vegetarian / Non vegetarian
No. of meals / Day
Fluid Intake:___________glasses/day Beverages: __________glasses/day
Personal hygiene: Oral hygiene: Frequency
Sleep and rest:
Hours at night
Uninterrupted / interrupted
Drugs used for sleeping:
Day time naps: ________ hours/ day
Sleep/ rest patterns:- sleep& wake times, difficulties in sleeping, remedies used in difficulties.
Restrictions in Activities of daily living
Instrumental activities of daily living
Activity and exercise:
Daily walking /any other
Nature of work: Sedentary/
Mild/ Moderate/ Heavy
Substance use: Tobacco/ Alcohol/ Drugs/Any other
amount, frequency, and duration of substance use (alcohol, coffee, tobacco, cola, tea, illicit recreational drugs etc.
Bowel: Frequency Regular/ Irregular/ Constipation
Bladder: Frequency at night / Day
j) Marital /Sexual history:
Married or Widow/ Widower
Unmarried or Unmarried Mother
Spouse general health; Good/Fair/ Bad
Spouse job status: Working/ Not working
Staying together: Yes / No
Relationship with spouse: satisfactory/ unsatisfactory
Menstrual history: Age at menarche/ duration and frequency / any irregularities
Age at menopause/ post-menopausal problem, if any specify
Male: Anything Specific
II. Physical Assessment
A physical health assessment is conducted to assess the function and integrity of the clients’ body part.
A physical health assessment is conducted to assess the function and integrity of the clients’ body part.
A test of the body to find out its state of health, using any or all of the means of testing. The physical examination, medical history, and first laboratory tests are the basis on which a diagnosis is made and on which treatment is decided.
Preparation for physical examination
1) Preparing the Client-explanation of the physical examination
· Reassure during the examination by explanations at each step
· The nurse should explain when and where the examination will take place, why it is important, and what will happen.
· Information gathered and documented during the assessment is kept confidential
· Assist the client to undress and put on a gown
· Clients should empty their bladders before the examination
2) Preparation of environment
· The time for the physical assessment should be convenient to both the client and the nurse
· The environment needs to be well lighted
· The equipment should be organized for efficient use
· The room should be warm enough
· Infection control
· Use Additional personal protective equipment's
· Isolation gown, Eye shield
· Hand hygiene
· The room needs to be quiet, warm, without drafts, and adequately lit.
· Ensure privacy
Area to be assessed is exposed and other body areas are covered.
Drapes provide not only a degree of privacy but also warmth.
Drapes are made of paper, cloth, or bed linen.
Instruments used in physical examination
Aromatic substances (vanilla, coffee) - Test first cranial nerve (olfactory)
Flashlight or penlight - assist viewing of the pharynx and cervix or to determine the reactions of the pupils of the eye
Nasal speculum - permit visualization of the lower and middle turbinates;
Ophthalmoscope A lighted instrument to visualize the interior of the eye
Otoscope- A lighted instrument to visualize the eardrum and external auditory
Percussion (reflex) hammer- An instrument with a rubber head to test reflexes
Tuning fork - A two-pronged metal instrument used to test hearing acuity and vibratory sense
Vaginal speculum- assess the cervix and the vagina
Cotton applicators - To obtain specimens
Lubricant -To ease insertion of instruments (e.g., vaginal speculum)
Tongue blades (depressors) to depress the tongue during assessment of the mouth
Instrumentation – all equipment’s required for the health assessment should be clean, and in good working condition and readily accessible.
Positioning for a Physical Examination
Dorsal recumbent position
Back lying position with knees flexed hips externally rotated
Head & neck, axillae, anterior thorax, lungs, breast, heart, extremities, peripheral pulses, vital signs, & vagina
Supine (horizontal position)
Back lying position with legs extended with / without pillow under the head
Head & neck, axillae, anterior thorax, lungs, breast, heart, extremities, peripheral pulses
Lies on abdomen with head turned to the side, with or without a small pillow
Posterior thorax, hip joint movement
Side lying position with lowermost arm behind the body, uppermost leg flexed at hip& knee, upper arm flexed at shoulder and elbow
Rectum & vagina
A seated position back unsupported & legs hanging freely
Head, neck, posterior and anterior thorax, lungs, heart, vital signs upper and lower extremities etc.
Back lying position with feet supported in stirrups: the hips should be in line with the edge of the table.
Female genitals, rectum, & female reproductive tract.