Health Assessment

• Purpose of Assessment in health assessment:

  • Establish baseline information on the client
  • Determine the client’s normal function
  • Determine the client’s risk for diagnosis function
  • Provide data for the diagnostic phase
• Types of Assessment:

  1. Initial Assessment:

  • Performed within specified time after admission to a health care agency
  • Establish complete database for problem identification and care planning
  • Example: Nursing Admission Assessment

  2. Problem-Focused Assessment:

  • Ongoing process integrated with nursing care to determine specific problems
  • Identify new or overlooked problems
  • Example: Assessment of client’s ability to perform self-care while assisting client to bathe

  3. Emergency Assessment:

  • Done during psychiatric or physiological crisis to identify life-threatening problems
  • Example: Rapid assessment for airway, breathing, and circulation during cardiac arrest
• Types of Data:

  a. Subjective data:

  • Data from the client’s point of view, including perceptions, feelings, and concerns
  • Collected by interview
  • Also known as symptoms or covert data

  b. Objective Data:

  • Observable and measurable, obtained through physical examination and diagnostic testing
  • Also known as signs or overt data
• Sources of Data:

  • Primary source: The client
  • Secondary sources: Support people, records, other health care professionals, literature
  • Secondary sources should be validated if possible
• Data Collection Methods:

  • Observation
  • Interviewing
  • Physical Assessment
• Interviewing:

  • Interview is a planned communication or conversation with a purpose
  • Used to get or give information, identify problems, evaluate change, teach, provide support, counseling, or therapy
• Directive Approach to Interviewing:

  • Nurse establishes purpose and controls the interview
  • Used when time is limited, e.g., in an emergency
• Nondirective Approach to Interviewing:

  • Rapport-building
  • Client controls the purpose, subject matter, and pacing
  • Combination of directive and nondirective approaches is usually appropriate during information-gathering interviews
• Types of Interview Questions:

  • Closed questions: Yes/no or factual questions
  • Open-ended questions: Specify broad topics to discuss, invite longer answers, get more information from the client
• Purpose of Assessment in health assessment:

  • Establish baseline information on the client
  • Determine the client’s normal function
  • Determine the client’s risk for diagnosis function
  • Provide data for the diagnostic phase
• Types of Assessment:

  1. Initial Assessment – performed within specified time after admission to a health care agency

  • Purpose: establish complete database for problem identification and care planning
  • Example: Nursing Admission Assessment

  2. Problem-Focused Assessment – ongoing process integrated with nursing care to determine specific problem identified in an earlier assessment and to identify new or overlooked problems

  • Example: Assessment of client’s ability to perform self-care while assisting client to bathe

  3. Emergency Assessment – done during psychiatric or physiological crisis of the client to identify life-threatening problems

  • Examples: Rapid assessment or airway, breathing and circulation during cardiac arrest
• Types of Data:

  a. Subjective data:

  • Data from the client’s point of view, include perceptions, feelings, and concerns, collected by interview
  • Also referred to as symptoms or covert data, apparent only to the person affected, can be verified only by that person
  • Examples: itching, pain, feelings of worry, nausea

  b. Objective Data:

  • Observable and measurable, obtained through physical examination and lab and diagnostic testing
  • Also referred to as signs or overt data, can be seen, heard, smelled, or felt by someone other than the patient
  • Examples: Blood pressure, temperature, pulse rate, foul-smelling wound drainage
• Sources of Data:

  • Primary source: The client
  • Secondary sources: All other sources of data (support people, records, other health care professionals, literature), should be validated if possible
• Data Collection Methods:

  • Observation
  • Interviewing
  • Physical Assessment
• Interviewing:

  • Interview is planned communication or a conversation with a purpose
  • Used to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, provide counseling or therapy
• Directive Approach to Interviewing:

  • Nurse establishes purpose
  • Nurse controls the interview
  • Used to gather and give information when time is limited, e.g., in an emergency
• Nondirective Approach to Interviewing:

  • Rapport-building
  • Client controls the purpose, subject matter, and pacing
  • Combination of directive and nondirective approaches is usually appropriate during information-gathering interview
• Types of Interview Questions:

  • Closed questions: restrictive, yes/no, factual, less effort and information from client
  • Open-ended questions: specify broad topic to discuss, invite longer answers, get more information from client
• Factors in Interview Setting:

  • Time: client free of pain, limited interruptions
  • Place: private, comfortable environment, limited distractions
  • Seating arrangement: informal when a client is in bed, in group interviews circular or horseshoe arrangement is best
  • Distance: personal distance most frequently used for interviews
• Factors in Interview Setting (cont'd):

  • Language: use easily understood terms, interpreter or translator if needed
• Productive Communication Patterns:

  1. Opening questions: “Tell me about…”

  2. Reflection: Repeating the patient’s key statements

  3. Clarification: “What do you mean by…”

  4. Empathetic responses: Show understanding and acceptance

  5. Confrontation: Make observations “You appear to…”

  6. Interpretation: “Do I understand you to be saying…”

  7. Silence

  8. Direct questions

  9. Summary
• Interview Stages:

  • Opening: establish rapport, orient client
  • Body: client communicates, nurse asks questions
  • Closing: nurse ends interview when necessary information is collected
  • Phases: pre-interaction, initial interview, focused interview
• Procedure and Notations:

  • Always review chart before seeing the patient, the interview guides the focus of the physical assessment process
  • Dress appropriately, how you look communicates either respect or disrespect for and toward the interviewee
• Environment for Interview:

  • Sit down in clear view of the patient, preferably at eye level
  • Distance of 1 ½ to 4 feet (personal distance most frequently used for interview)
  • Have the patient sit next to the desk rather than peer over the desk
  • Put the chart to the side if possible
  • If you need to take notes, explain this to the patient
• Comprehensive Health History:

  • Health history provides a comprehensive portrait of the patient’s past and present health
  • Components include biographic/demographic data, reason for seeking care (chief complaint), present health or history of present illness, current medications, family history, review of systems
• Demographic Data:

  • Name, address, phone number, age, birth date, birthplace, gender, marital status, race, ethnic origin, occupation
• Reasons for Seeking Care (Chief Complaint):

  • A brief spontaneous statement in the patient’s own words that describes the reason for the visit
  • States one or two signs or symptoms and their duration
  • Not a diagnostic statement, incorporates wellness needs
• Attachment is a strong reciprocal emotional bond between an infant and a primary caregiver
• Schaffer and Emerson's 1964 study on attachment aimed to identify stages of attachment and find a pattern in the development of attachment between infants and parents
• Participants in the study were 60 babies from Glasgow, and the procedure involved analyzing interactions between infants and carers
• Findings from the study showed that babies of parents or carers who displayed 'sensitive responsiveness' were more likely to have formed an attachment
• Subjective data is information based on the patient's feelings or opinions, while objective data is information that can be measured or observed

  
• Subjective data is enclosed in quotation marks to indicate the person's exact words
• History of Present Illness includes a chronological record of the reason for seeking care, from when the symptom first started until the present
• COLDSPA is a memory-mnemonic used for assessing signs and symptoms:

  • C: Character
  • O: Onset
  • L: Location
  • D: Duration
  • S: Severity
  • P: Pattern
  • A: Associated factors
• PQRST is another memory-mnemonic used for assessing signs and symptoms:

  • P: Provocative factors
  • Q: Quality
  • R: Radiation/Region
  • S: Severity
  • T: Timing
• OLDCART is a memory-mnemonic for assessing signs and symptoms:

  • O: Onset
  • L: Location
  • D: Duration
  • C: Character
  • A: Associated manifestations
  • R: Relieving/aggravating factors
  • T: Treatment
• Past Health History includes previous health events that may have residual effects on the current state of health
• Past Health History may include information on childhood illnesses, serious or chronic illnesses, hospitalizations, surgical history, injuries/accidents, and medications taken regularly
• Family Health History involves asking about the age, health, or cause of death of blood relatives and close family members to identify health problems that may run in families