Health Assessment Lec (Prelims)

OVERVIEW OF NURSING
PROCESS (ADPIE)

• It is the systematic, rational method of ASSESSMENT

planning and providing nursing care.
PURPOSE
• To provide care for clients that is
individualized, holistic, effective and
efficient.
• Systematic and continuous collection,
organization, validation, interpretation
and documentation of data.
• Carried out during all the phases of the
nursing process.

CHARACTERISTICS OF THE NURSING

PROCESS
• Cylic and dynamic in nature
• Client Centered
• Adaption of problem solving
• Involves decision making
• Interpersonal and collaborative
• Universally applicable
• Uses critical thinking
4 TYPES OF ASSESSMENT

PHASES OF THE NURSING PROCESS TYPE TIME PURPOSE

PERFORMED
1.Initial During To establish a
A – Assessment admission database
2.Problem Ongoing To monitor and or
D – Diagnosis focused process identify a specific,
new or overlooked
P – Planning problems
3.Emergency Emergency or To identify life-
crisis situations threatening
I – Implementation problems
4.Time-Lapsed Several months To compare a client
E – Evaluation after initial status over a period
assessment of time
 3. Elimination Pattern
• describes pattern of excretory function (bowel,
ACTIVITIES DURING ASSESSMENT bladder)
1) Data Collection 4. Activity – Exercise Pattern
2) Validation of Data • describes pattern of exercise, activity, leisure,
3) Organization of Data and recreation.
4) Documentation of Data 5. Cognitive – Perceptual Pattern
• describes sensory, perceptual, and cognitive
TYPES OF DATA pattern
Subjective (covert, symptoms) 6. Sleep – Rest Pattern
• describes patterns of sleep, rest, and relaxation.
- Felt and experience by the patient 7. Self-perception – Self-concept
Objective (overt, signs) Pattern
• -describes self-concept and perceptions of self
- Detected by an observer (body comfory, image, feeling state)
8. Role – Relationship Pattern
SOURCES OF DATA • describes pattern of role engagements and
1) Primary – client relationships.
2) Secondary – family members, friends, 9. Sexuality – Reproductive Pattern
health, professionals, records • describes client’s pattern of satisfaction and
dissatisfaction with sexuality pattern, describes
METHODS OF DATA COLLECTION reproductive patterns.
1. Observation 10. Coping – Stress Tolerance Pattern
2. Interview • describes general coping patterns and
3. Physical Examination effectiveness of the pattern in terms of stress
tolerance.
DATA ORGANIZATION 11. Value – Belief Pattern
• Nurse organizes and clusters the • describes pattern of values and beliefs,
information together in order to identify including spiritual and /or goals that guide
areas of strengths and weaknesses. choices or decisions.

GORDON’S FUNCTIONAL HEALTH OREM SELF-CARE DEFICIT THEORY

PATTERN

1. Health Perception – Health

Management Pattern
• describes client’s perceived pattern of health
and well being and how health is managed.
2. Nutritional – Metabolic Pattern
• describes pattern of food and fluid consumption
relative to metabolic need and pattern indicators
of local nutrient supply.
 ROY ADAPTION MODEL COMPONENTS OF A NURSING CARE
PLAN

ASESSMENT NURSING GOALS AND INTER- EVAL-

DIOGNOSIS OBJECTIVES VENTIONS UATION
Subjective Problem + Goal: First Format Met
cues Etiology Desired Independent: Partially Met
Objective Outcomed Dependent: Not Met
cues Collaborative

Second
Format
Observation
Prevention
Intervention
Treatments
Health
Promotion
Interventions

HUMAN BODY SYSTEMS CONCLUSION

• Assessment is the first and most critical
step of nursing process. Accuracy of
assessment data affects all other
phases of the nursing process. A
complete data base of both subjective
and objective data allows the nurse to
formulate nursing diagnosis, develop
client goals, and intervenes to promote
health and prevent disease.

DATA DOCUMENTATION
• Basis for determining quality of care and
should include appropriate data to
support identified problems.
 INTRODUCTION TO HEALTH
ASSESSMENT (PART 2)

FOUR BASIC TYPES OF NURSE’S ROLE IN HEALTH

ASSESSMENT ASSESSMENT

INITIAL COMPREHENSIVE ROLES OF NURSES IN HEALTH

ASSESSMENT ASSESSMENT

• Total health assessment when a client • Gather information

first enters a health system • Nursing Diagnoses and Care Planning
• Collection of subjective data: • Managing Problems
• Evaluation
1. Past health history • Discharge Teaching
2. Family history • Advocate
3. Lifestyle and health practices

• Objective data FOCUS OF HEALTH ASSESMENT IN

- Step by step physical examination
NURSING
• Collection of subjective and objective
ON GOING OR PARTIAL ASSESSMENT
data to determine a client’s over all level
• Data collection that occurs after of functioning in order to make a
comprehensive data base is professional judgment.
established. • The nurse performs holistic data
• Any problems previously detected were collection
reassessed in less depth to determine
FRAMEWORK FOR HEALTH
any major changes.
ASSESSMENT IN NURSING
• Health of present health concerns
FOCUSED OR PROBLEM ORIENTED • Past health history
ASSESSMENT • Family history
• Lifestyle and health practices
• Performed when an initial data base
• Examination of particular body part or
exist for a client.
system
• Thorough assessment of a particular
client problem

EMERGENCY ASSESMENT
• Very rapid assessment performed in life
threatening situations.
 GUILDELINES OF AN EFFECTIVE
INTERVIEW AND HEALTH HISTORY
SUBJECTIVE DATA
• Can be elicited and verified only by the
client
• Provides clues to possible physiologic,
psychological and sociologic problems
• Obtained through interviewing
• Sensations • Beliefs
• Feelings • Ideas
• Perceptions • Values
• Desires • Personal
• Preferences Information
INTERVIEWING
• Method of obtaining a valid nursing
health history
• Requires professional interpersonal and
interviewing (communication) skills
FOCUS OF NURSING INTERVIEW:
• Establishing rapport and trusting
relationship with the client
• Gathering information on the client’s
developmental, psychological,
physiologic, sociocultural and spiritual
statuses to identify strengths and
weaknesses
PHASES OF THE INTERVIEW
4 Phases of Therapeutic Relationshio
▪ Preinteraction phase
▪ Orientation phase
▪ Working phase
▪ Termination phase
PREINTERACTION PHASE
• The Preinteraction phase starts when
the nurse is given the responsibility to
start therapeutic relationship with a
patient. It also includes the thought
process, planning, and feeling of a nurse
before the first meeting with the patient.
Nurses responsibility in preinteraction
phase
• To become well known about own
feelings, fear, and fantasies.
• Analyze professional strengths and
weaknesses.
• Collect information about the patient like
demographic data, occupational data,
etc.
• Prepare a plan based on the data before
meeting.
ORIENTATION PHASE
• Essential to develop rapport and gain
trust.
• Explain purpose, reason for taking notes
and assure client confidentially of the
information.
• Nurse initiate effective communication.
WORKING PHASE
• Nurse elicits comments on biographical
data.
• Reasons for seeking care
• History of present health concern
• Past health history
• Family history
• Review of body systems for current
health problems
• Lifestyle
• Health practices and developmental
level
 • Nurses uses critical thinking to interpret
and validate information.
/
• Nurse and client collaborate to identify
the client’s problems and goals.

TERMINATION PHASE

• Summary and closing phase.

• Nurse summarizes information.
• Identifies with client possible plans to
resolve the identified problems.

COMMUNICATION DURING THE

CLOSE ENDED QUESTIONS
INTERVIEW
• Used to obtains facts to focus on
POINTERS TO CONSIDER IN NON-VERBAL specific information.
COMMUNICATION • Typically begins with “when” or “did”.
• Can be used to clarify or obtain more
• Appearance accurate information about issues
• Demeanor / Behavior disclosed in response to open ended
• Facial expression questions.
• Attitude
Examples:
• Silence
When was the first time you felt this pain in your
VERBAL COMMUNICATION
abdomen?
• Open ended questions Did you consult?
• Close ended questions
Did you find relief on the medication
“Open questions are used for deeper prescribed?
discussion”
OPEN ENDED QUESTIONS

• Are used to elicit the client’s feelings

and perceptions.
• Typically starts with “how” or “what”.
• Encourage description.
• May reveal data about the client’s health
status.
Examples:
How have you been feeling lately?
What do you feel about going to chemo twice a
week?
 OTHER EFFECTIVE MEANS TO Focus Question
COMMUNICATE
More specific toward the problem

SPECIAL CONSIDERATIONS: • Nurse: So you woke up short of breath;

has this happened before?
• Age
• Culture
• Emotional variations HOW TO DEAL WITH ANXIOUS, ANGRY,
DEPRESSED, & MANIPULATIVE
Laundry List
PATIENTS?
Choice of words to choose from

• “Is the pain sever, dull, sharp, mild, ANXIOUS

cutting or piercing?”
• Structure info
Rephrasing • Explain who you are, your role, and
purpose of visit
Clarify the information the client is providing. • Questions = simple/concise
• Client: I’m really tired and nauseated for • Nurse needs to stay Relax
two months and I feel that I have some • Do not hurry, decrease external stimuli
horrible disease Angry
• Nurse: You are thinking you have a
serious illness • Calm, in-control mannerisms and tone
- Let patient vent
Well Placed Phrases
- If excessive, do not touch or argue back
Encouragement skill • Obtain info from other health
professionals as much as needed
• “um-hum” • Do not argue back; provide personal
• “yes” space
• “I agree”
Depressed
Inferring
• Show interest and understanding to
Do not lead rather get more information client and situation
• Mrs.J: I have bad pain in my stomach • Do not be upbeat or encouraging
• Nurse: (Notices has her hand on the Manipulative
right side of her abdomen) “It seems you
have more difficulty with the right side of • Provide structure and limitations
your stomach” • Fine line b / w reasonable request

Providing Information

• Make sure to answer every question as

well as you can
• Be honest if do not know the answer
STEPS OF HEALTH ASSESSMENT (Part 1) HISTORY OF PRESENT ILLNESS

• Use of mnemonics (COLDSPA)

A.Collection of Subjective Data Mnemonic Questions
Through interview and health history Character Describe the sign or symptoms
(feeling, appearance, sound, small
or taste if applicable)
BIOGRAPHIC DATA Onset When did it begin?
Location Where is it? Does it radiate? Does
• Name it occur anywhere else?
Duration How long does it last? Does it
• Address recur?
• Phone Severity How bad is it? How much does it
• Gender bother you?
Pattern What makes it better or worse?
• Provider of history Associated factors / What other symptoms occur with
• Birth date how it Affects the pt it? How does it affect you?
• Support persons
• Place of birth
Other Sample Questions
• Race or ethnic
• Background • When did you first feel the pain?
• Educational level • How long have you been experiencing
• Occupation it?
• Where does it hurt more?
REASON/S FOR SEEKING HEALTH CARE
• Rate the pain from a scale 1 to 10?
• What is your major health problem or
concern at this time?
PAST HEALTH HISTORY
• How do you feel about having to seek
health care? • Childhood illness (chickenpox, mumps,
measles, rubella and other significant
HISTORY OF PRESENT HEALTH
illnesses)
CONCERNS
• Childhood immunizations
• When the symptoms started (state in • Allergies (type of reactions, how reaction
how many days/weeks/months prior to is treated)
admission) • Accidents and injuries (how, when,
• Characteristics of symptoms e.g. onset, where, type of injury, treatment
location, intensity etc. received, complications)
• Aggravating or alleviating factors? • Hospitalizations (reason, dates,
• Associated symptoms treatment, surgery, performed, course of
• Management done? Effective? recovery, complications)
• What prompted admission or consult? • Medications (all currently used,
previously used)
FAMILY HEALTH HISTORY
• Family genogram reflecting the age and
current state of health of siblings,
parents and grandparents
• Causes of death in the family
• Occurrence of hereditary diseases such
as heart disease, cancer, diabetes,
hypertension, obesity, mental disorders.
Example of GENOGRAM
Developmental Data
• Children mostly pick up the eating habits
of their parents
• Adolescents whose parents or siblings
smoke are more likely to pick up the
habit
• Values, religious affiliation
• Past, current and future plans for
Education
• Type of work, level of job satisfaction
• Finances
• Stressors in life and coping strategies
used
• Residency, type of environment

LIFESTYLE AND HEALTH PRACTICES

• Description of a typical day

• Nutrition/Weight Management
• 24 hour dietary intake
• Who purchases and prepares meals
• Exercise habits and patterns
• Sleep and rest habits and patterns
Lifestyle and Health Practices

• Use of medications/current medications

and other substances
• Self-concepts
• Self -responsibilities
• Social activities for fun and relaxation
• Social activities contributing to society
Lifestyle and Health Practices

• Relationships with family and pets

• Family members influence the health
habits of each other
 SUMMARY OF FREUD’S AND ERICKSONS Lawtons Scale for instrumental activities of
THEORIES OF PERSONALITY daily living (IADL)
DEVELOPMENT
• Score it from 8-28
• The lower the score, the more
independence

KATZ ACTIVITIES OF DAILY LIVING

• Generativity VS. Stagnation

• Have self confidence, able to juggle their
various lives
OLDER ADULTS

• Feels good about the life choices he or

she has made

FUNCTIONAL ASSESSMENT
Gordon’s Functional Health Pattern
 ASSESSMENT IN PREGNANCY PSYCHOSOCIAL HISTORY

Last mentruel perios • Evaluation of an individual’s mental

(LMP) health and social well-being
First day of the last mentrual cycle • Used to determine if the patient is in
a state of mental health or mental
Expected date of birth illness.
(EDB)
Data needed to compute
1. Stress
2. Hostility
NAEGEL’S RULE
3. Depression
4. Hopelessness

NEWBORN AND CHILDREN FUNCTIONAL

ASSESSMENT
Material needed

• Gloves
• Stethoscope
• Tape measure
APGAR SCORE