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Steps of Health Assessment

Ms. Cres P. Quinzon RN MAN


OMAN COLLEGE OF HEALTH SCIENCES
STEPS OF HEALTH
ASSESSMENT
 Collection of subjective data
WHAT TO  Collection of objective data
KNOW  Validation of data
 Documentation of data
Assessment is the first and most critical
phase of the nursing process.
Systematic, rational method of planning
and providing individualized nursing
care.
Purpose
WHAT TO
KNOW  To Identify a client’s health status and
Actual or potential health care problems
or needs
 To establish plans to meet the identified
needs
 To deliver specific nursing interventions
I. Collection of
subjective data
Data collection is the
process of gathering
information about a
client's health status.
Types of Data
 Subjective data
 Objective data
Subjective data that can be elicited and verified only
by the client.
SUBJECTIVE DATA ARE
 sensations or symptoms (e.g., pain, hunger),
 feelings (e.g., happiness, sadness),
Collecting  perceptions,
Subjective  desires,
Data  preferences,
 beliefs,
 ideas,
 values, and
 personal information
The major areas of subjective data include
 Biographical information (name, age, religion,
occupation)
 Physical symptoms related to each body part
or system (e.g., eyes and ears, abdomen)

Collecting  Past health history


Subjective Data  Family history
 Health and lifestyle practices (e.g., health
practices that put the client at risk, nutrition,
activity, relationships, cultural beliefs or
practices, family structure and function,
community environment)
The information is obtained
through interviewing.

Collecting Therefore, effective interviewing


Subjective Data skills are vital to accurate and
thorough collection of subjective
data.
A meeting of people face to face,
INTERVIEWING
especially for consultation.
Meeting between nurse and patient.
GOALS
 It collects subjective data –what the
person says about him or her self
 To record a complete health history.
 Establish rapport and trust
Successful  Gather complete and accurate data
interview about the person’s health state
 Teach the person about the health state
 Build rapport for a continuing
therapeutic relationship
 Begin teaching for health promotion
and disease prevention.
 Communication is exchanging
information so that each person
closely understand the others.
 No understanding or no conveyed
The process of meaning…. no communication.
communication  Communication is not just talk or
hear but all behaviour, conscious
or unconscious, verbal or
nonverbal .
 Verbal communication- words you
speaks or vocalization, the tone of voice
 Nonverbal communication –body
language

1. Sending Example: posture, gestures, facial


expression, eye contact, foot tapping,
touch etc
Nonverbal communication more
reflective of your true feelings.
 Words and gestures must be
interpreted in a specific context to
have meaning.
 You have a specific context in mind
when you send your words.
2. RECEVING  The receiver put his or her own
interpretation on them based on his or
her past experience, culture, and self
concept as well as current physical
and emotional state.
2. RECEVING
Needs to bring into the interview
3. Internal a)Empathy
Factors b)The ability to listen
3. Internal Factors

a) Empathy Recognising and accepting the others


person’s feelings without criticism.
Feeling with the person rather than
feeling like the person.
3. Internal Factors

b) Ability to listen Active listening and demanding


Complete attention
No more important than patient
during interview.
1. Introducing interview
2. The working phase
Techniques of 3. Closing the interview
communication
1. Introducing interview
 Keep beginning short if you are
nervous
 Address the patient using his or her
surname and shake hands if that
Techniques of seems comfortable
communication :
 Introduce yourself and state your
Introducing
Interview role in the agency
 Give the reason for this interview
 After this brief introduction , ask an
open ended question (‘tell me how I
can help you?’)
2. The working phase
 Data gathering phase
 Question and Responses to what the patient
has said.
Techniques of
communication : Two type of question
Working Phase I. I. Open ended : Use open ended question
to begin interview and to introduce a new
section of questions, and use it whenever
the person introduce new topic
II. Closed or direct question: ask
for specific information
 Elicit a short, one or two word
answer, Yes or No or forced
choice.
Techniques of Advantage and disadvantage
communication :  Direct question limit his or her
Working Phase
answer
 Need direct questions to speed
up the interview
III.Responses: Assisting the
Narrative
to encourage free expression of the
patient
Techniques of Nine types of verbal responses
communication :  First five responses( facilitation,
Working Phase silence, reflection, empathy,
clarification,) involve nurse
reactions to the facts or feelings the
person communicate.
III.Responses: Assisting the
Narrative –
Last four responses (confrontation,
Techniques of interpretation, explanation,
communication : summary), start to express your own
Working Phase
thoughts and feelings
i. Facilitation : encourage the patient to
say more, to continue with story.
Example: say yes. Hmm, eye contact etc
ii.Silence : time to think, organise what he
Techniques of or she wishes to say without interruption
communication: from you.
Working Phase iii.Reflection: repeating part of what the
person has just said.
 Its focuses further attention and helps
the person continue in his own way.
Example: I have two little ones at home. I am
so worried they are not getting care they
need.

Response: you feel worried and anxious


Techniques of
about your children.
communication:
Working Phase
“You seem a little angry today. Would you like
to talk about it?".
iv.Empathy: recognizes a feeling and put it in
words. The patient feels accepted and can
deal with the feeling openly.
Example :
Techniques of Patient: I direct 20 employee every day, and now
communication: here I am having to call on you for every little
Working Phase things
Empathic response: It must be hard. One day
having so much control, and now feeling
dependent on someone else.
v. Clarification: use when the person's word
choice is confusing.
Example: ‘’tell me what do you mean by ‘tired
blood’ ’’.
vi.Confrontation:
Techniques of
 observed certain action, feelings or
communication :
Working Phase statement and focus the person's attention
on it. Give honest feedback about what see
or feel.
 Focus on a discrepancy
EXAMPLE : you say it does not hurt, but when I
touch you here you grimace.
vii.Interpretation :
 Based on your inference or conclusion
 Its links event, makes associations or
Techniques of implies cause
communication : Example : ‘’it seems that every time you feel
Working Phase the stomach pain, you have had some kind of
stress in your life’’
viii.Explanation
 You share factual and objective
information.
 This may be for orientation to the
Techniques of agency settings.
communication:  Example: “Your dinner comes at 5.30.
Working Phase
You cannot eat because the food may
alter the test results”.
ix.Summary
 Final review of what you understand the
person
 Type of validation in that the person agree
with it or correct it.
Techniques of
 Occurs at the end of the interview.
communication:
Closing the  Example: Is there anything else you would
Interview like to mention?
 Are there any questions you would like to
ask?
 Are there any other areas I should have
asked about?
ix.Summary cont
 "During our discussion today, we have
discussed the roles of diabetic
Techniques of
communication: medications, exercise, diet and other
Closing the factors as they interact with each other
Interview and how these interactions impact on
the successful management of
diabetes."
Traps (messages) are obstacles to obtaining
complete data and to establishing rapport.
1. Providing false assurance or reassurance
Example : A woman says, oh I just know this lump is
going to turn out to be cancer.
False Response : Now u do not worry, I am sure you
Traps of will be all right.
interviewing Closes of communication
True response: you are really worried about the lump,
aren’t you ? It must be hard to wait for the biopsy
results?
“It must be difficult not to know what the surgeon will
find. What can I do to help?”
2.Giving unwanted advice:
Example :
“Dr. Kline just told me that my only
Traps of chance of getting pregnancy is to have
interviewing an operation. I just do not know. What
would you do?”
Correct response: Reflection
Nurse: Have an operation?
Patient: Yes, and I’m afraid of being put
to sleep. What if I don’t wake up?
Traps of Nurse: “What concerns do you have?”
interviewing “What are the pros and cons of this
choice for you?”
“What is holding you back?”
3. Using avoidance language
Use euphemisms (mild or indirect
word) such as
Passed on instead of death to avoid
Traps of reality or to hide their feelings
interviewing Using direct language is the best way
to deal with frightening topics.
4. Engaging in distance
Impersonal speech to put space
between a threat and the self.
Example: “There is a lump in the left
breast.” (using “the” instead of “my” --
Traps of
denying association with her diseased
interviewing breast and protect herself from it).
Health professionals use distancing
too , to soften reality.
Its shows that you also are afraid of
the procedure.
5. Using professional Jargon
Myocardial infarction : heart attack

Traps of Express your questions in lay


interviewing terms to make sure your patient
understands you.
6. Using leading or biased
questions
Wrong: "You"re not hurting in your
stomach, are you?“
Traps of Either he is forced to answer
interviewing Or he feels guilty when he must
admit the other answer.
Correct: "Are you having any stomach
problems?
7. Talking too much
Good rule for interviewer is to Listen more than talk.
8. Interrupting
 Often when you think you know what the person will
say, you interrupt and cut the person of.
Traps of  This does not show you are clever rather it signals that
interviewing you are impatient or bored with the interview.
 “Let’s not talk about your insurance problems it’s time for
your walk”
 “After your walk let’s talk some more about what’s going
on with your insurance company.”
9. Using ‘’Why’’ Questions cont
Traps of  “Why are you so upset?”
interviewing
 . “You seem upset. What’s on your mind?”
9. Using ‘’Why’’ Questions
 Wrong: Why did you wait so long before to the
emergency department?

Traps of  Correct: I see you started to have chest pains


early in the day. What happened between the
interviewing
time the pains started and the time you came to
the emergency department.
‘’WHY’’ QUESTIONS SOUND WHINING,
ACCUSATORY AND JUDGMENTAL
LEARN TO LISTEN WITH EYES AND EARS
1. Physical appearance
2. Posture
3. Gestures

NON VERBAL 4. Facial expression


SKILLS 5. Eye contact
6. Voice
7. Touch
LEARN TO LISTEN WITH EYES AND EARS
1.Physical appearance
 Inattention to dressing or grooming
suggests the person is sick to maintain self
care or has an emotional dysfunction such
NON VERBAL as depression.
SKILLS  Professional uniform may create a positive
stereotype (comfort, expertise, or ease of
identification) or negative stereotype
(distance authority, or formality).
 Professional Image
2.Posture
 Note the patient position
 Open position: shows relaxation
and physical comfort and
NON VERBAL willingness to share information.
SKILLS  Closed position: looks defensive
and anxious
 You should appear calm and
unhurried.
3.Gestures
 Nodding or an open turning out of
the hand shows acceptance,
agreement , attention and
NON VERBAL understanding.
SKILLS  Pointing a finger occurs with anger
and vehemence.
 Pain may be shown by pointing one
finger to the exact spot.
LEARNS TO LISTEN WITH EYES AND EARS
4.Facial expression
 Variety of relevant emotions and conditions
 Expression may look alert , interested and
NON VERBAL relaxed, look anxious, angry and suspicious.
SKILLS  Nurse own expression should reflect
attentive, sincere and interested in the
patient.
 Expression of boredom, distraction, criticism
and disbelieved may dissolve rapport .
LEARNS TO LISTEN WITH EYES AND EARS
5.Eye contact
 Lack of eye contact suggests that the person
is shy, withdrawn, confused, bored or
depressed.
NON VERBAL
 But do not stare down.
SKILLS
 Don’t have a fixed penetrating look but
rather have an easy gaze towards the
person’s eyes. (see culture)
LEARNS TO LISTEN WITH EYES AND EARS
6. Voice
 Besides the spoken words, meaning comes
through the tone of voice, the intercity and
rate of speech., the pitch and pauses.
NON VERBAL
SKILLS
Example: an anxious person often speaks in a
loud, fast voice, high pitched.
Soft voice indicates shyness and fear
LEARNS TO LISTEN WITH EYES AND EARS
7. Touch
 Meaning of touch is influenced by the
person’s age, gender, cultural background,
past experience and current settings.
NON VERBAL  Meaning of touch is easily misinterpreted
SKILLS  Do not touch during interview unless you
know the person well and are sure how it
will be interpreted.
 Appropriate touch communicates
effectively such as a touch of the hand or
arm to signal empathy.
 Should end gracefully
 Abrupt and awkward closing can destroy rapport an
leave the person in negative impression of the whole
interview.
To ease into closing, ask,

3. Closing the“Is there anything else you would like to mention?”


interview “Are there any questions you would like to ask”
“Our interview is just about over.” “Let me see if I have
this correct: You came to the hospital with chest pain,
which started an hour ago, after eating lunch. “(This is
time to give your summary of what you have learned
during the interview.)
A complete nursing assessment
includes both the collection of
subjective data and the collection of
objective data.

II. Collecting Objective data include information


Objective Data about the client that the nurse
directly observes during interaction
with him and information elicited
through physical assessment
(examination) techniques.
Objective data are directly observed by
the examiner.
 Physical characteristics (e.g., skin
color, posture)
 Body functions (e.g., heart rate,
respiratory rate)
II. Collecting
Objective Data  Appearance (e.g., dress and hygiene)
 Behavior (e.g., mood, affect)
 Measurements (e.g., blood pressure,
temperature, height, weight)
 Results of laboratory testing (e.g.,
platelet count, x-ray findings)
The nurse must have basic knowledge in three
areas:
1. Types of and operation of equipment
needed for the particular examination (e.g.,
II. Collecting penlight, sphygmomanometer, otoscope,
Objective Data tuning fork, stethoscope)
2. Preparation of the setting, oneself, and the
client for the physical assessment
3. Performance of the four assessment
techniques: inspection, palpation,
percussion, and auscultation
 Each part of the physical examination
requires specific pieces of
equipment.
 Prior to the examination, collect the
necessary equipment and place it in
1. EQUIPMENT the area where the examination will
be performed.
 This promotes organization and
prevents the nurse from leaving the
client to search for a piece of
equipment
Hospital room, outpatient clinic,
physician’s office, school health office,
employee health office, or a client’s home.
The examination setting meets the

2. A. Preparing following conditions:


the Physical • Comfortable, warm room temperature—
Setting Provide a warm blanket if the room
temperature cannot be adjusted.
Prepare the physical settings
• Private area free of interruptions
from others—Close the
Preparing the door or pull the curtains if possible.
Physical Setting • Quiet area free of distractions—
Turn off the radio, television, or other
noisy equipment.
Prepare the physical settings
• Adequate lighting—It is best to use
sunlight (when available). However, good
overhead lighting is sufficient.
A portable lamp is helpful for
Preparing the illuminating the skin and for
Physical Setting viewing shadows or contours.
• Firm examination table or bed at a
height that prevents stooping—A roll-up
stool may be useful when it is necessary
for the examiner to sit for parts of the
assessment.
Prepare the physical settings
 A bedside table/tray to hold the
equipment needed for the
examination
Preparing the  Use some history form or note taking as
Physical Setting nurse can not rely completely on
memory.
 Keep note taking to a minimum, focus
on the person.
Prepare the physical settings
 Arrange equal-status seating. Seated at
eye-level.
 Avoid facing patient across a desk or
Preparing the table that feels like a barrier.
Physical Setting  90 degrees is good, allowing you to
face patient. Avoid standing, making
you an authority figure.
• Assess your own feelings and anxieties before
examining the client.
• Self-confidence in performing a physical
assessment can be achieved by practicing the

2. B. Preparing techniques on a classmate, friend, or relative.


Oneself • Preventing the transmission of infectious agents
• Wash your hands
• Wear gloves
• Wear a mask and protective eye goggles
• Explain to the client that the physical
assessment will follow and describe what the
examination will involve.
• “Mr. Smith, based on the information you have

2. C. Approaching given me, I believe that a complete physical


and Preparing examination should be performed so I can better
the Client
assess your health status. This will require you to
remove your clothing and to put on this gown.You
may leave on your underwear until it is time to
perform the genital examination.”
• Respect the client’s desires and requests
related to the physical examination
• Ask the client to urinate before the
examination to promote an easier and more
2. C. Approaching comfortable examination of the abdomen and
and Preparing genital areas.
the Client
• Ask the client to undress and put on an
examination gown. Allow him or her to
keep on underwear until just before the genital
examination to promote comfort and privacy.
• Begin the examination with the less intrusive
procedures such as measuring the client’s
temperature, pulse, blood pressure, height, and
weight.
2. C. Approaching • Approach the client from the right-hand side of
and Preparing the examination table or bed ( most
the Client
examination techniques are performed with
the examiner’s right hand (even if the
examiner is left-handed).
Thank you for listening…
have a nice day ahead of
you!!