Health Assessment-LEC/RLE PRELIM EXAM

NCM 201 | COLLEGE OF NURSING REVIEWER

SAN PEDRO COLLEGE TRANSCRIBER: PATHAY, ANTONIETTE

INTRODUCTION TO HEALTH ASSESSMENT  Modify the assessment as the client’s status changes
 Report assessment as needed to other members of the
HEALTH ASSESSMENT health care team.
OVERVIEW/ REVIEW OF THE NURSING PROCESS
 a systematic, rational method of planning and providing
nursing care.
 an essential nursing functions which provides foundation
for quality nursing care and intervention  ADOPIE/ADPIE
 refers to a critical investigation and evaluation of client
status ASSESSMENT
 involves formation of database on the individual’s health
 process of collecting, validating, clustering, and
state.
documenting data a continuous process carried out
 Health assessment forms the foundation of all nursing
during all phases of the nursing process most critical &
care
crucial
 evaluation of the health status by performing a physical
exam after taking a health history Types of Assessment (Weber & Kelley)
 “ is more than just gathering information about the health 1. Initial Comprehensive  a total health
status of the patient. It is analyzing and synthesizing that Assessment assessment
data, making judgments about the effectiveness of  examines the patient’s
nursing interventions and evaluating client care overall health status
outcomes.’’ (AACN,2011)  collection of client’s
 An accurate and thorough Health Assessment reflects perceptions of his health
status and physical
the KNOWLEDGE & SKILLS of a Professional Nurse.
examination
2. Ongoing or Partial  Mini overview of client’s
Assessment body systems and
holistic health patterns
as a follow –up on
health status
 Reassess to determine
any changes to the
abnormality or problem
detected during initial
assessment.
3. Focused or Problem-  thorough assessment of
Oriented Assessment a particular client
problem
 does not cover systems
EVOLUTION of Nurse’s Role in Health Assessment not related to client’s
1930 Patient is crying, says he is problem
Skilled Observer homesick 4. Emergency Assessment  Rapid assessment
1950 25-year-old female admitted performed during
interviewing skills; assess ambulatory. Past history of life-threatening
past and current health ulcerative colitis and situations
status admitted due to vomiting 4  performed when
times, 8 months pregnant immediate
1970 diagnosis is
observation, interviewing, necessary to
performing procedure revive the patient
(venipuncture) and  concerned only
monitoring with vital
1990 up to present biophysical, psychosocial functions
Holistic Health and cultural factors that
Assessment influence the patient’s health
problem FOUR STEPS OF ASSESSMENT PROCESS

 Nurse Roles in conducting Health Assessment ...the 1. COLLECTING DATA

nurse should accurately and timely... Data collection
 Conduct & document a nursing assessment  is the process of gathering information about a
 Collect subjective & objective data client’s health status.
 Database add to the assessment
 all the information about a client comprehensive
assessment
TYPES OF DATA
1. Subjective Data
 Symptoms or covert data
ORGANIZING DATA
 apparent only to the person affected
 Use of a written or computerized format
 can be described or verified only by that person
experiencing it that organizes the assessment data
systematically.
 E.g. itchiness, pain, dizziness, nervousness
Data are organized according to
Nursing Conceptual Models Nonnursing Models
The client’s daughter says: Secondary Subjective Data
“Dad is very confused
today.” -Gordon’s functional health -Body systems model Maslow’s
patterns hierarchy of needs
The client’s daughter says: Secondary Objective Data -Orem’s self-care model Roy’s -Developmental theories
“Dad said he thought it adaptation model
was the year 1941 today,”

Nursing Models
2. Objective Data Orem’s self-care model Roy’s adaptation model
 Signs or overt data • Describes eight universal • classifies observable
 Data which are detectable by an observer or self-care requisites of humans. behavior into four categories:
can be measured or tested against an • The client’s need for • Physiological needs, self-
accepted standard adequate nutrition, normal concept, role function, and
 Can be seen, heard, felt, smelled elimination, and adequate rest interdependence
to promote normal human
 E.g. discoloration of the skin, BP 100/90
functioning and development
Diagnostic test result

SOURCES OF DATA
1. Primary source – client unless the client is too
ill, young, or confused to communicate clearly.
2. Secondary sources – all sources other than the
client
a. Support people
b. Client records VALIDATING DATA
c. Health care professionals
d. Literatures  The act of double-checking or verifying
data to confirm that it is accurate and
Data Collections Methods factual.
 RULE: Validate data when there are
Interview a planned a. Directive discrepancies between data obtained
purposeful Interview - is during the interview and the physical exam
highly structured
and elicits specific
information
b. Non-directive DOCUMENTING DATA
Interview-Rapport
building interview  Data are recorded in a factual manner and not
Observation gathering data Vision – body interpreted by the nurse.
with the use of size, skin color  Example
senses and lesions Smell
The nurse records a client’s breakfast intake:
– body & breath
odors Hearing – “coffee 240 ml, juice 120 ml, 1 egg, 1 slice of
lung sounds toast” “appetite good”
Touch – skin
temperature &  To increase accuracy, the nurse records
moisture subjective data in the client’s own words.
Physical Inspection

Assessment Auscultation
Palpation DOCUMENTATION OF ASSESSMENT DATA
Percussion
Medical Records the nurse reads a an important part  forms the database for the entire nursing
Review medical record of preparing for process
(patient’s chart) to the health
  Provides data for all other members of the
health care team EVALUATION

DIAGNOSING/DIAGNOSIS ➢involves determining the effectiveness of your

plan
 Analyze and synthesize data ➢ Measuring the degree to which goals/outcomes
 to identify client strengths and health problems that have been achieved and identifying factors that
can be prevented or resolved by collaborative and positively or negatively influence goal achievement
independent nursing interventions
 Determine client’s strengths, risks, and problems
 Formulate nursing diagnoses

Nursing Diagnosis
 “a clinical judgment about individuals, family or
community responses to actual and potential health
problems and life processes. “(NANDA 2012-2014)
 “A nursing diagnosis provides the basis for
selection of nursing interventions to achieve
outcomes for which the nurse has accountability ”
(Herdman & Kamitsuru, 2014)

 North American Nursing Diagnosis Association

(NANDA) international - taxonomy of nursing
diagnostic

 The standardized NANDA names for the diagnoses

are called diagnostic labels

Types of Diagnostic statement

Actual Nursing Diagnosis an occurring health problem
High Risk/Potential problem that most likely will
Nursing Diagnosis occur unless preventive
measures are taken
Possible Diagnosis One that needs further data
to support it
Collaborative Problem is a potential medical
complication that warrants
both medical and nursing
interventions
Wellness diagnoses focus on promoting or
enhancing a patient’s level of
wellness

PLANNING

➢Determine how to prevent, reduce, or resolve the

identified priority client problems; ➢Determine how
to implement nursing interventions in an organized,
individualized, and goal- directed manner
➢ establish goals and determine measurable
outcomes. (SMART)

IMPLEMENTATION

➢ Involves carrying out your plan to achieve goals

and outcomes
➢ “doing” phase of the nursing process
 3. STANDING -puts patient and nurse in different
levels.
THE NURSING INTERVIEW
-The nurse may be perceived as
 purposeful conversation between the nurse and the superior
patient
 nurse should be effective communicators
VERBAL COMMUNICATION
GOALS -used to elicit How does this pain
OPEN-ENDED client’s feelings affect your daily
a. establish rapport and a trusting relationship, QUESTIONS and perceptions activities ?
b. b .gather information such as: physiologic,
obtain specific “When did this pain
psychological, sociocultural, and spiritual status. CLOSED-ENDED information start?”
QUESTIONS
Three Basic Phases of Nursing Interview
INTRODUCTORY  Introduce self (nurse) to client
PHASE  Citing the purpose of the interview
 Ensure privacy and confidentiality THERAPEUTIC COMMUNICATION
enables you to hear and
WORKING  Nurse Gathers information about.. 1.Listening analyze everything the patient
PHASE a. biographic data says
b. reasons for seeking care 2. Offering Self “I’ll stay here with you.”
c. present health concern “I’m interested in what you
think.”
3. Broad opening and “What would you like to talk
 Listens and observes cues general statements about?”
4.Clarification Tell me what do you mean by
SUMMARY & tired blood ?
CLOSURE  Summarizes sets of information 5. Focusing “You said your mother and
sister had breast
 Identification of possible plans: cancer?” or “Do you do BSE?

 Clarification is encouraged

COMMUNICATION
NON-VERBAL COMMUNICATION
APPEARANCE NEAT clothes, NEAT hair,
name tag (credentials)
DEMEANOR upon entering the room, aim for
COMPOSURE
focus is towards the client
-do not be overwhelmingly
friendly or “touchy”
shows what you are truly
FACIAL EXPRESSION thinking
non-judgmental attitude –all are
ATTITUDE accepted regardless of beliefs,
ethnicity, lifestyle, & health care
practices
allows you and the client to
SILENCE reflect and organize thoughts
INTERVIEW CONSIDERATIONS
Changes visual and hearing
GERONTOLOGIC acuity
CONSIDERATION simple, straight forward questions
talk slowly
a. willingness to openly express
CULTURAL VARIATIONS emotional distress or pain
b. reluctance to reveal personal
information
d. Variation on disease and
illness perception
EMOTIONAL VARIATION a. anxious
: simple & organized information
b. angry
: calm, reassuring, calm manner
avoid arguing
c. depressed
: express interest and
understanding
d. manipulative
: be firm, set limits
e. client and sensitive issues
: be aware of your own thought
sand feelings

HINDRANCE TO COMMUNICATION
1. EXCESSIVE / -avoid extremes in eye contact
INSUFFCIENT EYE HEALTH HISTORY
CONTACT -use moderate amount of eye
contact  consists of what the patient tells you, what the patient
2. DISTRACTION AND -being occupied with something perceives, and what the patient thinks is important
DISTANCE else while you are asking
questions PURPOSE OF THE HEATH HISTORY
 Provide the subjective database. Precipitating/Palliative Factors

Identify patient strengths. Quality/Quantity

Region/Radiation/Related Symptoms
Identify patient health problems (actual and potential)
Severity
Identify supports.
Timing
Identify teaching needs. 4. PAST HEALTH HISTORY

HEALTH HISTORY & ITS COMPONENTS Related to clients past, from earliest beginning to the
present
1. BIOGRAPHICAL DATA
Problems at birth
Personal information: Childhood illnesses
Name Immunizations to date
Address, & phone number Adult illnesses (physical, emotional, mental)
Age and Birth date Hospitalizations
Gender Surgeries
Birthplace Accidents
Race & ethnic origin Allergies
Marital status, Laboratory test or examinations
Educational level
Occupation 5. FAMILY HEALTH HISTORY

Genetically linked or familial diseases

2. CHIEF COMPLAINT
6. PSYCHOSOCIAL/LIFESTYLES & HEALTH PRACTICES
“What is your major health problem or concerns at this time?”
1. Activity & exercise patterns
”REASONS FOR SEEKING HEALTH CARE” 2. Sleep & rest
3. Use of medications & substances?
3. PRESENT HEALTH HISTORY
4. Self-concept & self-care activities
well person –short statement about health status 5. Social & community activities relationships
6. Values & Belief systems
ill person –chronological record (reason for seeking health) 7. Education & Work
8. Stress level
“Pls tell me all about your headache, from the time it started 9. Coping style
until the time you came to the hospital” 10. Environment
7. REVIEW OF SYSTEMS
A. sign & symptom
is a litany of questions specific to each body system
B. treatments most frequently occurring symptoms related to a specific
system
C. precipitating factor descriptions of client’s health status for each body system

PRESENT HEALTH HISTORY 8. FUNCTIONAL ASSESSMENT

EXPLORING THE SIGNS AND SYMPTOMS  is a systematic method of evaluating a person ability to
function within the environment.
C haracter describe the signs and symptoms
 standardized instruments on functional assessment
Onset when did it begin?  APGAR SCORE
 KATZ ADL
L ocation Where is it? Does it radiate?
APGAR SCORE
Duration How long does it last? Does it occur
-standardized evaluation of the newborn’s health condition
Severity How bad is it?
Ballard Maturational Assessment, Ballard Score, or
P attern what makes it better/worse? Ballard Scale

A ssociated factors -gestational age assessment

SYMPTOM ANALYSIS -Assesses 6 physical and 6 neuromuscular sign of maturity

 MMDST Metro Manila Development Screening Test

Evaluates and measures developmental advancement or

delay in 4 aspects:

Personal -Social Skills

Child’s ability to get along with other people

Fine Motor Skills

Uses his hands to pick up objects and to draw

Language

Child’s ability to hear follow directions and to speak

Gross Motor Skills

Child’s ability to sit, walk and jump

KATZ INDEX OF ACTIVITIES OF DAILY LIVING ( KATZ
ADL)

Measurement of patient’s ability to perform ADL

independently

Assess based on actual status and not ability.

BARTHEL ACTIVITIES OF DAILY LIVING INDEX

 measures a person’s daily functioning specifically the

activities of daily living
 scores is based on whether they have received
 help while doing task (use of aid to be independent is
allowed)

INSTRUMENTAL ACTIVITIES OFDAILY LIVING

 this tool evaluates the ability to perform

 More complex personal care activities.
 -addresses the activities needed to support independent
living such as: