Health assessment

Health assessment

Components

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

Goal

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

ü  Ongoing

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

Subjective 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

·         Client

·         Family/significant other

·         Other health care professionals

·         Medical records

·         Interdisciplinary conferences, rounds, and

·         consultations

·         Results of diagnostic tests

·         Relevant literature

Methods of Data Collection

o   Observation

o   Interview

o   Health history

o   Symptom analysis

o   Physical examination

o   Laboratory and diagnostic data.

Health History

·         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

General Survey

Health assessment begins with a general survey that involves Observation- client’s general appearance, body build, hygiene and posture

 Mental status

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.

Assessment	Normal finding	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	Clean, neat	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	No distress	Bending over because  of abdominal  pain, wincing or labored breathing
Note obvious signs of health / illness e.g skin color or breathing	Healthy appearance	Pallor, weakness obvious illness
Assess the clients attitude	Cooperative	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

a) Introduction:

b) Patient’s profile:

Name:

Hospital No:

Age:     Years

Gender: Male / Female

Address:

Religion: Hindu/ Muslim/ Christian/ Sikh / Any other

Marital status: Married/ Single/ Widow

Date and time of admission:

Ward/Bed No:

Diagnosis: Medical/Surgical

Date of surgery (if any):

Informant:

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

Support system

Neighborhood relationship

Involvement in social activities, if applicable

ii) Economic status:

Education

Occupation

 Family income/ month

Type of house and ventilation

Toilet facility

Water source

h) Nearest health care facilities: PHC / clinics/ hospitals/ others

i)  Personal history:

Immunization history:

Dietary history: Vegetarian / Non vegetarian

                              No. of meals / Day

                            Food preference:

                             Fluid Intake:___________glasses/day                                                                  Beverages: __________glasses/day

Personal hygiene: Oral hygiene:  Frequency

                              Bath:  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

Habits/ hobbies

         Substance use: Tobacco/ Alcohol/ Drugs/Any other

amount, frequency, and duration of substance use (alcohol, coffee, tobacco, cola, tea, illicit recreational drugs etc.

Elimination:

          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

Female:

 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.

Physical examination

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

Draping

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

Gloves

Lubricant -To ease insertion of instruments (e.g., vaginal speculum)

Tongue blades (depressors) to depress the tongue during assessment of the mouth

Laryngeal mirror

Disposable pads

Stethoscope

BP apparatus

Thermometers

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

position	description	Areas assessed
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
Prone position	Lies on abdomen with head turned to the side, with or without a small pillow	Posterior thorax, hip joint movement
Sim’s position	Side lying position with lowermost arm behind the body, uppermost leg flexed at hip& knee, upper arm flexed at shoulder and elbow	Rectum & vagina
Sitting position	A seated position back unsupported & legs hanging freely	Head, neck, posterior and anterior thorax, lungs, heart, vital signs upper and lower extremities etc.
Lithotomy position	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.