Health Assessment

Module 1 – Introduction to Health Assessment

Key Terms and Concepts

Health Assessment
Biomedical model Western view is that health is the absence of disease. Biomedical focus is on
diagnosis and treatment of pathogens and curing of the disease.
Critical thinking The means by which we learn to assess and modify before acting. Required for
sound diagnostic reasoning and clinical judgment. Enables us to:
 Analyze complex data about patients
 Make decisions about the patients problems and alternate possibilities
 Evaluate each problem to decide which applies
 Decide on the most appropriate interventions for the situation
Data objective What we observe from the PE
subjective What the patient says they feel
Database Complete – Complete health history and full physical exam; current and past
health state; forms a baseline; yields the first diagnosis.
Episodic – for a limited or short term problem; “mini” database, smaller in scope
and more focused; mainly only one problem, one cue complex, or one body
system.
Follow up – problems evaluated at regular intervals; assess changes, is it getting
better or worse, coping strategies.
Emergency – rapid collection of the data compiled concurrently with lifesaving
measures.
Diagnosis Nursing diagnosis – clinical judgments Medical diagnosis – identification of a
about a person’s response to an actual disease from its symptoms. Evaluates
or potential health state. Evaluates the the cause and etiology. Focuses on the
person as a whole. function or malfunction of an organ.
Health Promotion A set of positive acts we can take, such as teaching and helping the consumer
choose a healthier lifestyle. Based on risk factors.
Heritage Gather data that is accurate and meaningful; intervene with culturally sensitive
assessment and appropriate care.
Holistic health Consideration of the whole person: mind, body, spirit – interdependent and
function as a whole.
Nursing process Assessment –
 Collect data: review the clinical record, interview, health history, PE,
functional assessment, consultation, review of the literature
Diagnosis –
 interpret data: ID clusters of cues, make inferences;
 validate inferences;
 compare clusters of cues with definition and defining characteristics;
 ID related factors;
 document the diagnosis
Outcome identification-
 ID expected outcomes;
 individualize to the person;
  realistic and measurable;
 include a time frame
Planning –
 establish priorities;
 develop outcomes;
 set time frames for outcome;
 ID interventions;
 document plan of care
Implementation-
 review the planned interventions;
 schedule and coordinate the person’s total health care;
 collaborate with other team members;
 supervise implementation of the care plan by delegating appropriate
responsibilities;
 counsel the person and significant others;
 involve the person in the health care plan;
 refer individuals who require cont. care;
 document the care provided
Evaluation –
 refer to established outcomes
 evaluate the individual’s condition and compare actual outcomes with
expected outcomes
 summarize the results of the evaluation
 Identify reasons for the person’s failure, if indicated, to achieve expected
outcomes stated in the plan of care.
 Take corrective action to modify the plan of care as necessary
 Document the evaluation of the person’s achievement of outcomes and
modifications, if any, in the plan of care.
Prevention Link between health and personal behavior. Counseling designed to change
unhealthy behaviors. I.e. Counseling on smoking, alcohol, drug use, lack of
exercise, poor nutrition, injuries, STDs.
Priority problems Used when there is more than one diagnosis.
 1st level: emergent, life threatening. ABCs.
 2nd level: require prompt intervention to stop further deterioration. Ex:
mental status, acute pain, urinary elimination problems, risks of infection.
 3rd level: important to health but can be addressed after the urgent
problems.
Validation Checking the accuracy and reliability of data.
Wellness A move toward optimal functioning. Optimal health = high level wellness. It is a
dynamic process, moving in the direction of progress. Health care professionals
try to maximize the person’s potential to grow towards high level wellness.

Health History
The Interview
Active listening Complete attention so you understand. Listen to what the person says
and the way they say it.
Closed/direct question
Communication
Confrontation
Empathy
Etiquette
External factors
Facilitation
Internal factors
Interpretation
Nonverbal communication
Open-ended questions
Reflection
Silence
Subjective
Verbal communication
The Complete Health History
Activities of daily living
(ADL)
Disease burden
Functional assessment
Instrumental activities of
daily living (IADL)
Ask for specific information. Limiting. Want a short, one or two word
answer. Cold facts. Limits rapport and leaves interaction neutral.
Exchanging information so that each person clearly understands the
other.
Includes your own thoughts and feelings. Focus the person’s attention
on a specific action, feeling, or statement. Give your honest feedback.
Use with discrepancies or inconsistencies in the story.
Viewing the world from the other person’s inner frame of reference
while remaining yourself. Recognize and accept another person’s
feelings without criticism. This response recognizes a feeling and puts
it into words, helping the patient feel accepted and deal with the
feeling openly. Allows the person to express without embarrassment.
Conventional code of good manners that governs behavior and varies
cross culturally.
Physical setting. Ensure privacy, refuse interruptions, physical
environment (room temp, lighting, noise level, personal space), dress
(patient in street clothes, nurse appears professional), note taking, tape
and video recording.
Responses that encourage the patient to say more or continue with the
story (aka general leads). Shows the person you are interested and will
listen further. “Yes, go on.” “Uh-huh.”
What the examiner (you) bring to the interview: Liking others,
empathy, and the ability to listen.
Based on your inference or conclusion. Links events, makes
associations, or implies cause. There is risk of making the wrong
inferences.
Body language – posture, gestures, facial expressions, eye contact, foot
tapping, touch.
Asks for narrative information. General. Used to begin the interview,
introduce a new topic, or new section of questions. Unbiased, the
person can answer however he/she wants. Elicits feelings, opinions,
and ideas. Builds rapport.
Response that echoes the patients words or reflects feelings. Repeat
part of what the patient just said. Helps the person elaborate on the
problem.
Use with open-ended questions. Silent attentiveness gives the patient
time to think and organize what he’s going to say.
What the person tells you they are feeling, what they say about
themselves.
The words you speak, vocalizations, tone of voice.
Part of a functional assessment to measure a person’s self-care ability
in general physical health. Bathing, dressing, toileting, eating, walking,
The impact of health problems in an area.
Measures a person’s self-care ability in the areas of general physical
health or absence of illness; ADLs, IADLs, nutrition, social
relationships and resources, self-concept and coping, and home
environment.
Needed for independent living: Housekeeping, shopping, cooking,
laundry, using the telephone, managing finances.
Sign An objective abnormality that you as the examiner could detect on a
physical exam or in lab reports.
Symptom A subjective sensation that the person feels from the disorder

Physical Examination
Amplitude Intensity. A loud or soft sound.
Auscultation Listening to the sounds produced by the body. Heart, blood vessels,
lungs, abdomen. Use a stethoscope to hear/evaluate sounds.
Bell Best for soft, low-pitched sounds – extra heart sounds, murmurs.
Diaphragm Best for high pitched sounds – breath, bowel, and normal heart
sounds.
Doppler sonometer
Duration Length of time a note lingers.
Fetoscope
Goniometer
Inspection Concentrated watching. Individual as a whole, then each body
system. Begins the moment you meet the person and develop a
“general survey.” Always comes first. Need good lighting, adequate
exposure, and occasional use of special instruments.
Nosocomial infection Infection acquired during hospitalization. Transmitted between
patients or patient and examiner. MRSA, VRE, tuberculosis.
Ophthalmoscope Illuminates the internal eye structures.
Otoscope Funnels light down the ear canal and onto the tympanic membrane.
Palpation Applies your sense of touch to assess texture, temperature, moisture,
organ location and size, swelling, vibration or pulsation, rigidity or
spasticity, crepitation, presence of lumps or masses, and presence of
tenderness or pain. Follows/confirms points noted from inspection.
 Fingertips: skin texture, swelling, pulsation, lumps
 Grasping action: position, shape, consistency of an organ or
mass.
 Dorsa (backs) of hands and fingers: determine temperature
 Base of fingers: vibration
Technique should be slow and systematic
Pelvimeter
Percussion Tapping the person’s skin with short, sharp strokes to assess
underlying structures. A characteristic sound will tell you location,
size, and density of the underlying organ.
 Maps out the location and size of an organ – percussion note
changes at borders of organs
 Signaling the density of a structure
 Detecting an abnormal mass if it’s fairly superficial. (<5cm
deep)
 Eliciting pain if the structure is inflamed
 Eliciting deep tendon reflex using the percussion hammer.
Pitch Frequency. The number of vibrations per second, written as “cps”
cycles per second. Rapid vibrations produce a high pitch tone. Slower
vibrations yield a low pitch tone.
Quality Timbre.
Resonance Low pitched, clear, hollow sound that predominates in health lung
tissue in the adult.
Standard precautions Intended for use with all patients regardless of their risk or presumed
infection status. Apply to:
1) Blood.
2) All body fluids, secretions, excretions.
3) Nonintact skin.
4) Mucous membranes.
 Wash hands
 Wear clean gloves
 Wear a mask and eye protections
 Wear a gown
 Take care with used patient care equipment
 Design and follow adequate hospital procedures
 Take care with used linen
 Prevent injuries due to blood borne pathogens
 Place in a private room
Stethoscope Blocks out room sounds so you can hear body sounds.
Transmission based Intended for use with patients with documented or suspected
precautions transmissible infections, in addition to standard precautions.
Airborne, droplet, contact.
Tympany A low pitched resonant, drum like sound obtained by percussing the
surface of a large air containing space.