PRELIM

• Health Assessment


  The systematic process of collecting and analyzing information to evaluate an individual's health status and make informed clinical decisions
• Nursing Process


  A systematic problem-solving approach used by nurses to provide patient-centered care
• Nursing Process - ADPIE

  1. Assessment: Collecting and analyzing data about the patient's health

  2. Diagnosis: Identifying the patient's health problems

  3. Planning: Setting goals and creating a care plan

  4. Implementation: Carrying out the care plan

  5. Evaluation: Assessing the effectiveness of the care plan
• Health Assessment in Nursing Practice


  The first step in the nursing process, involving the systematic collection, validation, and communication of patient data
• Types of Health Assessment

  • Initial/Comprehensive Assessment
  • On-going or Partial Assessment
  • Focus or Problem-oriented Assessment
  • Emergency Assessment
• Initial/Comprehensive Assessment


  A thorough examination and collection of data at the beginning of the nurse-patient relationship
• On-going or Partial Assessment


  Continuous data collection and monitoring to update the patient's status
• Focus or Problem-oriented Assessment


  Targeted assessment of specific health issues or concerns
• Emergency Assessment


  A rapid and focused assessment conducted in critical situations
• Nurses' Role in Health Assessment

  • Data Collection
  • Physical Examination
  • Analysis and Interpretation
  • Communication
  • Documentation
  • Advocacy
• Data Collection


  The systematic gathering of subjective and objective information about the patient's health
• Physical Examination


  A systematic examination of the patient's body systems to identify abnormalities
• Analysis and Interpretation


  Making sense of the collected data to identify health problems and formulate a care plan
• Communication


  Collaborating with the healthcare team and the patient to ensure effective care
• Documentation


  The accurate and timely recording of assessment findings to facilitate communication among healthcare providers
• Advocacy


  Representing the patient's needs and concerns to ensure they receive appropriate care
• The first assessment began in 1992 by the American medical association
• In 1995, health assessment was considered a basic human right
• Preventive health care


  • Primary prevention
  • Secondary prevention
  • Tertiary prevention
• Periodic health assessment needs to be performed by a physician or a nurse
• Objectives of health assessment

  • Surveillance of health status, identification of occult disease, screening, and follow-up care
  • The periodic assessment, at regular intervals
  • Increasing client participation in health care
  • Accurately define the health and risk care needs for individuals
  • Health assessment is shared with the client in a clearly and understandable manner
  • The client must share in decision making for his own care
• Frequency of assessment


  • Persons under 35 years every 4-5 years
  • Persons from 35-45 every 2-3 years
  • Persons from 45-55 years of age undergo a thorough health assessment every year
  • Persons over 55 years may need assessment every 6 months or less
• Importance of nursing health assessment

  • Systematic and continuous collection of client data
  • It focus on client responses to health problems
  • The nurse carefully examine the client's body parts to determine any abnormalities
  • The nurse relies on data from different sources which can indicate significant clinical problems
  • Health assessment provides a base line used to plan the clients care
  • Health assessment helps the nurse to diagnose client's problem & the intervention
  • Complete health assessment involves a more detailed review of client's condition
  • Health assessment influence the choice of therapies & client's responses
• Purposes of health assessment

  • To Gather data
  • To confirm or refuse data obtained in the health history
  • To identify nursing diagnoses
  • To make clinical judgments about client's changing health status
  • To evaluate bio-psycho-social & spiritual outcomes of care
• Nursing diagnoses


  Depends on the client's problems/response associated with specific disorder. Any problem in nursing diagnosis must notice from a holistic view e.g. bio-psycho-social and spiritual relations
• Medical diagnoses


  Depends on clinical picture and laboratory findings. The specialist doctor has a right to diagnose not else
• Health History


  Systematic collection of subjective data which stated with client, and objective data which observed by the nurse
• NANDA


  The North American Nursing Diagnosis Association (NANDA 1994) defines a nursing diagnosis as "A clinical judgments about individual, family or community response to actual and potential health problems and life responses"
• Phases of taking health history

  • The interview phase
  • The recording phase
• Guidelines for Taking Nursing History


  • Private, comfortable, and quiet environment
  • Allow the client to state problems and expectations for the interview
  • Orient the client the structure, purposes, and expectations of the history
  • Communicate and negotiate priorities with the client
  • Listen more than talk
  • Observe non verbal communications e.g. "body language, voice tone, and appearance"
  • Review information about past health history before starting interview
  • Balance between allowing a client to talk in an unstructured manner and the need to structure requested information
  • Clarify the client's definitions (terms & descriptors)
  • Avoid yes or no question (when detailed information is desired)
  • Write adequate notes for recording?
  • Record nursing health history soon after interview
• Types of Nursing Health History

  • Complete health history: taken on initial visits to health care facilities
  • Interval health history: collect information in visits following the initial data base is collected
  • Problem- focused health history: collect data about a specific problem
• Components of Health History

  • Biographical Data
  • Chief Complaint
  • History of present illness
  • Past Health History
• Biographical Data


  This includes Full name, Address and telephone numbers, Birth date and birth place, Sex, Religion and race, Marital status, Social security number, Occupation (usual and present), Source of referral, Usual source of healthcare, Source and reliability of information, Date of interview
• Chief Complaint


  "Reason For Hospitalization"
• History of present illness

  Gathering information relevant to the chief complaint, and the client's problem, including essential and relevant data, and self medical treatment
• Component of Present Illness

  • Introduction: "client's summary and usual health"
  • Investigation of symptoms: "onset, date, gradual or sudden, duration, frequency, location, quality, and alleviating or aggravating factors"
  • Negative information
  • Relevant family information
  • Disability "affected the client's total life"
• Past Health History


  The purpose: (to identify all major past health problems of the client). This includes Childhood illness, History of accidents and disabling injuries, History of hospitalization, History of operations
• Auscultation


  Listening to air movement within the body using a stethoscope
• Auscultation


  • It is an important component of physical examination and diagnostic assessment across various medical specialties, including cardiology, pulmonology, gastroenterology, and obstetrics
• Auscultation is an essential part of a comprehensive assessment