L2: Modalities of Assessment

• Assessment is considered a critical component of the nursing process since the information that will be collected in this phase will be used in the prioritizing, planning and formulation of patient care. The assessment may include but is not limited to, the following aspects: environmental, physical, cultural, psychological, safety, and psychosocial assessments. The most common methods for collecting data are the patient interview, physical examination, and observation
• Health history is a crucial part of evaluating a patient’s health status. Full history taking together with a physical examination is warranted for a new patient, while a focused history and physical examination may be sufficient for an established or known patient
• A health history is typically done on admission to a hospital or a care agency, or with initial contact with community nursing services, but a health history may be taken whenever additional information may be helpful to inform care
• Health history also:

   Gives information (subjective data) on how a health condition came about

   Normally takes place before the physical assessment.

   Includes collection of data/information about the client’s level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness and other health conditions
• The purpose of obtaining a health history is to gather data from the patient and/or the patient’s family, so the healthcare team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions

  The format may be standardized or adaptable to the unique needs of a client
• Guidelines in Taking Health History

  1. Sources of information may include the client, family or significant others, health team members, and the client’s health record. When the client is not capable of giving information, the family and significant others or previous health histories are necessary sources of information.
  2. Most of the information in the health history is SUBJECTIVE data; this information should not be challenged but rather explored with the client to clarify vagueness
• Subjective data

   Refers to information provided by the patient that focuses on perceptions and feelings.

   May include signs and symptoms described by the patient but not noticeable to others.

   May also include demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history
• Guidelines in Taking Health History

  3. The health history should focus on data/information from all the client’sdimensions so that the nurse can develop a holistic health care plan.

  4. The recording of data or information must be clear and concise with the use of appropriate terminology.
• General Approach in Taking Health History

  1. Present with a professional appearance.
  2. Ensure an appropriate environment (good lighting, comfortable temperaturelack of noise and distractions) and adequate privacy.
  3. Sit facing the patient at eye level, with the patient in a chair or on a bed. Ensure that the patient is as comfortable as possible because obtaining a health history can be lengthy process.
  4. Ask the patient whether there are any questions about the interview before it is started.
  5. Avoid the use of medical jargon. Use terms the patient can understand.
• General Approach in Taking Health History

  6. Reserve asking intimate and personal questions until rapport is established.

  7. Remain flexible in obtaining the health history. This means that you should also be willing to depart from the usual interview structure. You might understand the patient's condition more quickly if you elicit his or her past medical history immediately after the chief complaint, before making a complete evaluation of the present illness. It does not have to be obtained in the exact order.

  8. Remind the patient that all information will be treated confidentially.
• Main Components of Health History

  Demographic or Biographical Data

  • Source of information
  • Living situation
  • Name, age, gender
• Main Components of Health History

  Chief complaint; history of present illness; reason for seeking health care

   Chief complaint

   Onset & duration of present health concern

   What caused the health concern to occur?

   Signs, symptoms, and related problems

   Alleviating and aggravating factors

   How the concern affects life and activities of daily living?

   Previous history and episodes of this condition
• Main Components of Health History

  Past Health History

   Allergies (Including reaction)

   Immunization History (If applicable)

   Chronic disease(s)

   Previous hospitalizations

   Previous Surgical Interventions

   Mental Health History

   Current medications: prescriptions, over-the-counter, herbal remedies

   Alcohol consumption and recreational drug use

   History of Antibiotic Resistant Organisms (ARO)
• Main Components of Health History

  Social

   Language & ability to communicate

   Pertinent health history of family members (heart disease, lungdisease, cancer, hypertension, diabetes, tuberculosis, arthritis,neurological disease, obesity, mental illness, substance use & abuse, genetic disorders)
• Main Components of Health History

  Developmental Variables

   Relationship status

   Significant physical and psychosocial changes or concerns
• Main Components of Health History

  Mental Health Status

   Stressors experienced by the individual: Their perception, how theycope, ability to communicate emotion

   Coping and stress management
• Main Components of Health History

  Patterns of health care

  • What health care resources the client has used in the past and is currently using
• CRITICAL COMPONENT: Phase where information will be collected

  ASPECTS: Environmental, physical, cultural, psychological, safety, and psychosocial assessments

  METHODS: Patient interview, physical examination, and observation
• Assessment

  Health history taking --> Review of System --> Physical Assessment
• Health History

  • typically done on admission to a hospital or a care agency, or with initial contact with community
  • Takes place before the physical assessment.
  • Gives information (subjective data)
  • collection of data/information about the client’s level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness and other health conditions
• Guidelines in Taking Health History

  • Data/information from all the client’s dimensions= HOLISTIC CARE PLAN
  • Information must be clear and concise USE OF APPROPRIATE TERMINOLOGY
• Main Components of Health History

  • Demographic or Biographical Data
  • Chief complaint; history of present illness/Present Health; reason for seeking health care
  • Past Health History
  • Social
  • Family Health History
  • Life Style
  • Developmental Variables
  • Mental Health Status
  • Patterns of Health Care
• Family Health History

  • Many diseases have a genetic component. It is important to understand the risk and likelihood of a patient developing illnesses based on their family health.
  • Ask about the health status, age, and, if applicable, cause of death of immediate blood relatives (parents, grandparents, and siblings). Questions to ask include the following:
  • Tell me about the health of your blood relatives. Does anyone have diseases like cancer, heart problems, or respiratory problems?
  • Have any of your blood relatives died? If so, do you know the cause of death? What age did they die
• Functional Health Assessment

  • Collects data related to the patient’s functioning and their physical and mental capacity to participate in Activities of Daily Living (ADLs) = are daily basic tasks that are fundamental to everyday functioning (e.g., hygiene, elimination, dressing, eating, ambulating/moving)
  • Lifestyle, Developmental Variables, Mental Health Status, Patterns of Healthcare
• Review of Systems

  • subjective history taking component as well as an objective based structured interview and physical examination of all the body systems
  • Serves as a double-check that vital information is not overlooked
  • covers a broad base of clinical states follows a head-to-toe approach
  • includes two types of questions: sign or symptom-related and disease related
• Physical Assessment: A physical examination involves collecting objective data using the techniques of inspection, palpation, percussion, and auscultation as appropriate
• Physical Assessment provides Objective Data:

  • validate the subjective data obtained
  • detect any findings not reported in the history
  • obtain info about the individual's status of health problem
• Principles/Guidelines of Physical Assessment

  • Make client relaxed and comfortable = Modesty is a common trait among females. They will not readily submit themselves for P.E. if their bodies will be exposed
  • Maintain a well-lighted room = Examining gown and draping sheet should be provided.
  • Provide privacy and avoid unnecessary exposure = Expose the regions to be examined one at a time
  • Completely explore the part to be examined, but drape the rest of the body appropriately = Perform the P.E. in an examining room for proper positioning, ensuring privacy and minimizing interruption
• Principles/Guidelines of Physical Assessment

  • Have an order for an examination so as not to miss observing any body part or system – from general to specific, or from head to toe (cephalocaudal)
  • Follow the plan of order for physical examination which is basically: Inspection, Palpation, Percussion, and Auscultation
• Principles/Guidelines of Physical Assessment

  • The body is bilaterally symmetrical, so, compare findings from one side to another, there is slight deviation. Examine both front and back as well
  • While examining each region, consider the underlying structures, their function and possible abnormalities
  • Use all senses: sight, hearing, touch, smell, and most especially, common sense
• Objective Assessment Techniques: Inspection, Palpation, Percussion, Auscultation
• Inspection

  • VISUAL EXAMINATION OF THE APPEARANCE OF THE CLIENT AND THE CONDITION OF EACH BODY PART
  • MOST DIFFICULT TECHNIQUE
  • GOOD LIGHTING AND EXPOSURE IS ESSENTIAL
  • EACH BODY AREA IS INSPECTED FOR SIZE, SHAPE, COLOR, POSITION, SYMMETRY AND PRESENCE OF ABNORMALITIES
• COMMON AREAS TO BE INSPECTED

  Skin: Cuts, Moles, Lumps
• COMMON AREAS TO BE INSPECTED

  Face and Eyes: Even, Normal, Anisocoria, Strabismus
• COMMON AREAS TO BE INSPECTED

  Necks and Veins: Bulging, Distended (Swollen), Jugular Venous Distention
• COMMON AREAS TO BE INSPECTED

  Chest and abdomen: Masses and Bulges
• COMMON AREAS TO BE INSPECTED

  Legs and Msucles: Swelling and Muscle Tone
• COMMON AREAS TO BE INSPECTED

  Elbows and Joints: Swelling, Inflammation, Deformities
• Palpation

  • THE EXAMINER USES THEIR SENSE OF TOUCH TO ELICIT SPECIFIC INFORMATION. PALPATION IS DONE TO ASSESS FOR ANY MASSES ORLUMPS ANYWHERE IN THE BODY
  • MOST DIFFICULT TECHNIQUE
• TOOLS IN PALPATION: EXAMINER’S HANDS

  • DORSUM – MOST SENSITIVE TO TEMPERATURE CHANGES
  • FINGER PADS ARE USUALLY USED – MOST SENSITIVE TO TACTILE STIMULATION
  • PALMAR SURFACE OF FINGERTIPS AND FINGERPADS – DISCRIMINATORY SENSATION (TEXTURE, PRESENCE OF FLUID, SIZE AND CONSISTENCY OFMASS)