Health assessment SKILLS

• A comprehensive health assessment includes the physical, psychological, social, and spiritual dimensions of human living
• Physical health involves basic functions like breathing, eating, and walking
• Psychological health encompasses the intellect, self-concept, emotions, and behavior
• Social dimensions of health include relationships and interactions among family, friends, and colleagues
• Spiritual health focuses on belief in a higher being, personal interpretations of the meaning of life, and attitudes towards moral decisions and personal conduct
• In a comprehensive health assessment, the nurse considers all dimensions to provide the highest level of quality patient care
• Techniques of Interview:

  • Collection of subjective data through interview and health history
  • Biographic data includes the patient's name, address, birth date, profession, emergency contact, age, marital status, religion, and nationality
  • Reasons for seeking health care help explore past and present problems
  • Chief complaints indicate why the patient is seeking health care
• To ensure nurses do not omit pertinent data, the PQRSTU method is used:

  • P = Provocative or Palliative
  • Q = Quality or Quantity
  • R = Region or Radiation
  • S = Severity
  • T = Timing
  • U = Understanding
• Communication tips for effective interviews:

  1. Choose a quiet private place

  2. Make the patient and family comfortable

  3. Introduce self and explain the purpose of the interview

  4. Assure confidentiality

  5. Avoid touching without consent

  6. Assess for language barriers and cultural differences

  7. Listen attentively and make eye contact

  8. Use reassuring gestures

  9. Be aware of nonverbal clues

  10. Observe the patient closely
• Verbal communication:

  • Open-ended questions allow patients to answer freely
  • Closed-ended questions elicit yes or no responses
  • Trust is the foundation of a positive nurse-client relationship
• Nonverbal communication:

  • More accurate than verbal communication
  • Includes gestures, facial expressions, posture, body language, eye contact, and tone of voice
• Characteristics of communication:

  1. Simplicity

  2. Clarity

  3. Timing and relevance

  4. Adaptability

  5. Credibility
• Objective data collection:

  • Obtained through observation and is verifiable
  • Physical examination techniques include inspection, palpation, and percussion
• Inspection:

  • Using vision, smell, and hearing to observe normal conditions and deviations
  • Begins when the nurse first meets the patient and continues throughout the assessment
• Palpation:

  • Requires touching the patient with varying pressure
  • Types include light, moderate, and deep palpation
  • Evaluate texture, temperature, moisture, motion, consistency, patient response, pulses, size, shape, and tenderness
• Percussion:

  • Involves tapping fingers or hands against the body
  • Helps locate organ borders, identify shapes, and determine if organs are solid or filled with gas/fluid
  • Types include direct and indirect/mediate percussion
• Blunt percussion is used to detect tenderness over organs such as kidneys
• For the abdomen, the order of examination is INSPECTION, AUSCULTATION, PALPATION, and PERCUSSION
• Different sounds produced during percussion are related to the structure of body organs:

  1. Tympany: drum-like sound heard over enclosed air (air in bowel) – liver and diaphragm

  2. Resonance: hollow sound over areas of part and part solid organs (normal lungs)

  3. Hyperresonance: booming sound heard over areas filled with air like in lungs with emphysema

  4. Dull: thud-like sound over solid tissue like liver, spleen, and heart

  5. Flat: flat sound heard over dense tissue like muscle and bones
• Auscultation involves listening for various breaths, heart, and bowel sounds with a stethoscope

  • Hold the diaphragm of the stethoscope firmly against the patient’s skin to listen for high-pitched sounds
  • Hold the bell of the stethoscope lightly against the patient’s skin to listen for low-pitched sounds
  • Do not auscultate over a gown
• Health assessment includes:

  • Orientation of equipment needed for physical examination, such as cotton balls, gloves, thermometer, sphygmomanometer, stethoscope, weighing scale, ophthalmoscope, otoscope, head mirror, percussion hammer, nasal speculum, vaginal speculum, tonometer, tuning fork, flashlight, tongue depressor, waste container, drapes, lubricant, cotton applicator, slides, and goniometer
• Different positions during physical examination:

  1. Fowler’s position

  2. Supine position

  3. Prone position

  4. Lithotomy position

  5. Sims position

  6. Lateral position

  7. Dorsal recumbent

  8. Sitting position

  9. Trendelenburg position

  10. Standing position

  11. Knee-chest position
• Vital signs include:

  • Temperature: oral, axillary, rectal, and tympanic
  • Pulse rate: 60-100 beats/min, with different pulse sites
  • Respiration: 16-20 breaths/min, involving ventilation, diffusion, and perfusion
  • Blood pressure: 120/80 mmHg, with normal systolic and diastolic pressure ranges and measurement techniques
  • Pain as the 5th vital sign, measured on a scale of 0-10