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Health Assessment - Lecture notes Introduction

NCM 101 - Health Assessment Introduction. You'll get to know the impor...
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Health Assessment (NCM 101)

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HEALTH ASSESSMENT

Act of Evaluation The assessment of one's health is an important part of the nursing process. These abilities are critical in assessing and determining the health problems and care needs of patients, as well as in developing nursing care plans and determining nursing treatments. Higher levels of health assessment abilities would allow nurses to better monitor changes in their patients' health and make better assessments and nursing diagnoses. The more precise the assessment, the better the outcomes and the higher the quality of patient care. As a result, training nurses and nursing students in these competencies is critical.

Due to the obvious multiplicity of religions in our world's population, health care practitioners and institutions have obstacles in providing culturally competent medical care. Cultural competency refers to a health care provider's or organization's capacity to provide services that are culturally, socially, and religiously appropriate for patients and their families. Care that is culturally aware can improve patient quality and results. Providing cultural competency training and implementing policies and procedures that reduce barriers to providing culturally competent patient care are two strategies for moving health professionals and systems closer to these aims. A client’s health belief, use of alternative therapies, nutritional habits, relationship with family and comfort with the nurse’s physical closeness during an examination and history taking must be considered.

Purpose of Assessment

 To collect date pertinent to the patient’s health status – Subjective / Objective.  To identify deviations from normal.  To discover the patient’s strengths, limitations and coping resources.  To pinpoint the actual problem.  To build rapport with patient and his/her family.

Purpose of Health Assessment

 To obtain baseline data about the client’s functional abilities.  To supplement, confirm, or refute data obtained in the nursing history.  To obtain data that will help establish nursing diagnoses and plan of care.  To evaluate the physiological outcome of health care and the progress of a client’s health problem.  To make clinical judgement about a client’s health status.  To identify areas for health promotion and disease prevention.

Skills Required for Health Assessment

 Cognitive skills – Assessment is a “thinking” process o Critical thinking ---- Why? How? What? When? o Critical decision making – use knowledge and experience  Problem solving skills - with scientific methods – experience – “intuition” (with experience)  Psychomotor skills  Affective / Interpersonal Skills – assessment is “feeling” trust and mutual respect  Ethical Skills – assessment is “being responsible & accountable) for your practice

FOUR TYPES OF ASSESSMENT

Initial Assessment

The initial assessment, also known as triage, aids in determining the nature of the problem and lays the way for the subsequent stages of evaluation. The initial examination will be far more extensive than other assessments performed by nurses. Obtaining a patient's medical history or performing a physical exam, or preparing a psychosocial assessment for a mental health patient are examples of components.

persons. Interviewing is used mainly while taking the nursing health history. Examining is the major method used in the physical health assessments.

Observation

Nursing observation is the systematic collection of data from persons who are getting care in order to inform clinical decision-making. It entails taking a person-centered approach to actively connect with patients, their families, and nurses. Nursing observation aims to build rapport while also assisting with assessment and rehabilitation. An example for this is the data observed with 4 senses –vision, hearing, smell and touch.

Interview

The interview, also known as the history, serves as the starting point for all other aspects of the nursing process. The physical examination verifies the information gathered during the interview. The interview should be structured in such a way that the nurse gains an understanding of the patient's adaptive processes. It is a planned communication or a conversation with a purpose; with two approaches, directive and non- directive.

 Affected by numerous factors:  Physical setting  Nurse’s behavior  Type of questions asked  How questions are asked  Personality and behavior of patients  How patient is feeling at the time of interview  Nature of information being discussed or problem being confronted

Health history taking is an example of nurse’s interview. It is the collection of subjective data that includes information on both the patient’s past and present health status. It allows positive aspects of health problems, health teaching needs, and health concerns to be identified.

 Personal Profile  Chief Complaint of present illness  Past Health History  Current Medication  Personal Habits and Patterns of living  Psychosocial History – Mental Status Children and Adolescent

Examination

A health care provider examines your body during a physical examination to evaluate whether or not you have a physical ailment. Inspection, palpation, percussion, and auscultation are the four procedures used in a physical examination. Unless you're doing an abdominal exam, use them in that order. Because bowel sounds can be altered by palpation and percussion, you should investigate, auscultate, percuss, and then palpate an abdomen. The examination sequencing starts from head-to-toe assessment, then lead to the body system assessment which will lead to having clues for the client’s signs and symptoms.

Signs – effect of a health problem that can be observe by someone else. Any changes that can be physically observe.  Signs refer to the objective data (overt) and are based on what the nurse sees. Objective data are:  Observable and measurable data.  Collection of data through observation, physical examination, laboratory and diagnostic testing.

Infection characterized by delayed onset and slow progression. Persistent pain is pain that carries on for longer than 12 weeks despite medication or treatment. Headaches, for example, might be classified as chronic pain if they last for months or years, even though the discomfort isn't always present.

PHYSICAL ASSESSMENT TECHNIQUES

Inspection

Examine each body system for normal and abnormal conditions using vision, smell, and hearing. As you analyze each body system, look for color, size, position, movement, texture, symmetry, scents, and sounds.

Palpation

Utilize different portions of your hands to touch the patient with varying degrees of pressure. Keep your fingernails short and your hands warm because they are your tools. When palpating mucosal membranes or places in contact with bodily fluids, wear gloves. Last, palpate painful locations.

Light Palpation  Use this technique to feel for surface abnormalities.  Depress the skin ½ to ¾ inch (about 1 to 2 cm) with your finger pads, using the lightest touch possible.  Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.  Deep Palpation  Use this technique to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility.  Depress the skin 1½ to 2 inches (about 4 to 5 cm) with firm, deep pressure.  Use one hand on top of the other to exert firmer pressure, if needed.

Percussion

Tap your fingers or hands against sections of the patient's body fast and sharply to assist you discover organ borders, identify organ shape and position, and decide if an organ is solid, fluid-filled, or gas-filled.

Direct Percussion  Use this technique to reveal tenderness; it's commonly used to assess an adult's sinuses.  Using one or two fingers, tap directly on the body part.  Ask the patient to tell you which areas are painful, and watch his face for signs of discomfort.  Indirect Percussion  Use this technique to elicit sounds that give clues to the makeup of the underlying tissue.  Press the distal part of the middle finger of your non-dominant hand firmly on the body part.  Keep the rest of your hands off the body surface.  Flex the wrist of your non-dominant hand.  Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger touches the patient's skin.  Listen to the sounds produced.

Auscultation

It involves listening for various lung, heart, and bowel sounds with a stethoscope. Provide a quiet environment. Make sure the area to be auscultated is exposed (a gown or bed linens can interfere with sounds. Warm the stethoscope head in your hand.

When you communicate to collect data. These are the factors to be considered:

Genuineness : be open, honest and sincere with patient.

Respect : do not be judgmental, let him feel accepted as a unique individual.

Empathy : acknowledge and understand what the client feels.

Organizing Data

The nurse uses a written or computerized format that organizes the assessment data systematically. He/she must cluster the data into groups of information. The format may be modified according to the client's physical status.

Validating Data

Validation is the act of double checking or verifying data to confirm that they are accurate and factual. Validating data ensures that assessment information is complete. The objective and subjective data agree. You may also obtain additional information that may have been overlooked. This is where nursing diagnosis and intervention based on

Documenting Data

Accurate documentation is essential which include all data collected about patient’s health status. Record in a factual manner, and do not write an interpretation. For example, you are recording the breakfast intakes as “Ate 2 pieces of bread toast, 1 egg and a cup of coffee.”, instead of “good appetite.”

The importance of nursing documentation in clinical communication cannot be overstated. Appropriate documentation allows the multidisciplinary team to give excellent care by accurately reflecting nursing evaluations, changes in clinical status, treatment provided, and pertinent patient information. Documentation is an important professional and medico legal requirement of nursing practice since it offers documentation of care.

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Health Assessment - Lecture notes Introduction

Course: Health Assessment (NCM 101)

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University: University of Rizal System

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HEALTH ASSESSMENT
Act of Evaluation
The assessment of one's health is an important part of the nursing process. These
abilities are critical in assessing and determining the health problems and care needs of
patients, as well as in developing nursing care plans and determining nursing treatments.
Higher levels of health assessment abilities would allow nurses to better monitor changes
in their patients' health and make better assessments and nursing diagnoses. The more
precise the assessment, the better the outcomes and the higher the quality of patient
care. As a result, training nurses and nursing students in these competencies is critical.
Due to the obvious multiplicity of religions in our world's population, health care
practitioners and institutions have obstacles in providing culturally competent medical
care. Cultural competency refers to a health care provider's or organization's capacity to
provide services that are culturally, socially, and religiously appropriate for patients and
their families. Care that is culturally aware can improve patient quality and results.
Providing cultural competency training and implementing policies and procedures that
reduce barriers to providing culturally competent patient care are two strategies for
moving health professionals and systems closer to these aims. A client’s health belief,
use of alternative therapies, nutritional habits, relationship with family and comfort with
the nurse’s physical closeness during an examination and history taking must be
considered.
Purpose of Assessment
To collect date pertinent to the patient’s health status – Subjective / Objective.
To identify deviations from normal.
To discover the patient’s strengths, limitations and coping resources.
To pinpoint the actual problem.
To build rapport with patient and his/her family.

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