Health assessment

• Health promotion involves activities that enhance an individual's ability to maintain or improve their own health status.
• • Health is a sum of these facets and not solely defined by the absence of disease or eating right
• Definition of Health:

  • Health is a relative state where a person can live to their potential and includes the "7 facets":
  • Physical health: how the body works and adapts
  • Emotional health: positive outlook and emotions channeled in a healthy manner
  • Social well-being: supportive relationships with family and friends
  • Cultural influences: favorable connections to promote health
  • Spiritual influences: living peacefully, morally, and ethically
  • Environmental influences: favorable conditions to promote health
  • Developmental level: how one thinks, solves problems, and makes decisions
• Nursing Health Assessment:

  • Involves a comprehensive health history and a complete physical examination to evaluate a person's health and status
  • Involves systematic data collection to facilitate a care plan
  • Health history includes the "7 facets" and gathering data from patient and/or family
  • Physical examination is a structured head-to-toe examination to identify changes in body systems
• • Evaluation: ongoing process to determine if goals have been attained
• Nursing Process:

  • Problem-solving process to identify patient problems, set goals, develop an action plan, implement the plan, and evaluate the outcome
  • Steps: Assessment, Diagnosis, Planning, Implementation, Evaluation
  • Assessment: subjective and objective data gathered during health history and physical examination
  • Diagnosis: nursing focus based on real or potential health problems
  • Planning: devising the best course of action to address diagnoses
  • Implementation: interventions related to nursing diagnosis and planned goals
• Types of Health Assessment:

  • Comprehensive health assessment for new patients
  • Focused or problem-oriented assessment focuses on the patient's problem
  • Follow-up history is a form of focused assessment
  • Emergency history focuses on the patient's emergent problem with systematic prioritization of need
• Health History Format:

  • Structured framework for organizing patient information in written, electronic, and verbal form
  • Patient's information is organized into past, present, and family history categories
• • Discuss plan of care
• Phases of Interview:

  • Pre-interview:
  • Self-reflection
  • Review patient record
  • Set interview goals
  • Review own clinical behavior and appearance
  • Introduction:
  • Greet the patient and establish rapport
  • Establish the agenda for the interview
  • Working:
  • Invite the patient's story
  • Identify and respond to emotional clues
  • Expand and clarify the patient's story
  • Generate and test diagnostic hypotheses
  • Negotiate a plan for further evaluation, treatment, education, and self-management support and prevention
  • Termination:
  • Summarize important points
• Types of data:

  • Subjective data: information from the client's point of view obtained through interviews
  • Objective data: observable and measurable data obtained through observation, physical examination, and testing
• History of Present Illness (HPI):

  • Complete, clear, and chronologic account of the problems prompting the patient to seek care
  • Includes onset, setting, manifestations, treatments, patient's responses, and effect on daily living
• Key Elements of the Past History:

  • Allergies
  • Medications
  • Childhood illnesses
  • Adult Illnesses (medical, surgical, accidents, psychiatric)
  • Health Maintenance (immunizations, screening tests, safety measures, risk factors)
  • Family History (age, health, cause of death of immediate relatives)
• Review of Systems:

  • Series of questions going from "head to toe"
  • Pertains to symptoms and sometimes includes diseases like pneumonia or tuberculosis
• Health Patterns:

  • Guide for gathering personal/social history and daily living routines that may influence health and illness
• Mental Health History:

  • Cultural constructs of mental and physical illness vary widely
  • Ask open-ended questions to explore emotional or mental health issues