HEALTH ASSESSMENT

• Nursing Process


  • Specific to the nursing profession
  • A framework for critical thinking
  • Its purpose is to "Diagnose and treat human responses to actual or potential health problems"
  • Organized framework to guide practice
  • Problem solving method - client focused
  • Systematic- sequential steps
  • Goal oriented- outcome criteria
  • Dynamic-always changing, flexible
  • Involves looking at the whole patient at all times
• The Nursing Process provides a "road map" that ensures good nursing care & improves patient outcomes
• Critical Thinking


  • Nurses need to use the Nursing process
  • Always thinking about your thinking, your actions, and your decisions
• Basis in using Critical Thinking: Deal w/ complex problems on a daily basis, Work w/ patient that are unique, Provide holistic care
• Advantages of Nursing Process

  • Provides individualized care - Client is an active participant
  • Promotes continuity of care
  • Provides more effective communication among nurses and healthcare professionals
  • Develops a clear and efficient plan of care
  • Provides personal satisfaction as you see client achieve goals
  • Professional growth as you evaluate effectiveness of your interventions
• Assessment


  • First step of the Nursing Process
  • Systematic, deliberate process by which the nurse collects and analyzes data about the patient
• Process of Systematic Assessment

  1. Collect data

  2. Verify data

  3. Organize data

  4. Identify Patterns

  5. Report & Record data
• Comprehensive data collection: Begins before you actually see the patient, Continues with admission interview and physical assessment once you meet patient, Other information resources include: family, significant others, nursing records, old medical records, diagnostic studies, relevant nursing literature, Consider age, growth & development
• Objective Data


  Signs; those that can be observed and measured
• Subjective Data


  Symptoms; those that described only by the person experiencing it
• Sources of Data


  • Primary - patient/client
  • Secondary - family members, patient's record, health team members, related literature
• Interview


  A purposeful conversation, generally in a face-to-face meeting, involving at least two persons; the interviewer, the one who seeks information, and the interviewee, the person from whom the information is sought
• Categories of Interview


  • Standardized/ Structured
  • Non-Standardized
  • Semi-Standardized
  • Focused
  • Non-Directive
• Interview Instruments


  • Interview Schedule
  • Interview Guide
• Types Of Questions


  • Open-Ended Questions
  • Close-Ended Questions
  • Biased Or Leading Questions
  • Neutral Questions
• Guidelines When Conducting An Interview

  • Initiation
  • Appropriate Use Of Non-Verbal Communication
  • Questioning
  • Focusing
  • Terminating The Interview
• Health History


  Taking a Patient's history is arguably the most important aspect of patient assessment, and is increasingly being undertaken by HCPs including midwives. The procedure allows patients to present their account of the problem and provides essential information for the practitioner.
• Preparing the environment


  The first part of any history-taking process and, indeed, most interactions with patients is preparation of the environment. Respect for the patient as an individual is an important feature of assessment, and this includes consideration of beliefs and values and the ability to remain non-judgemental and professional. Respect also involves maintenance of privacy and dignity; the environment should be private, quiet and ideally, there should be no interruptions.
• Communication


  The HCP should be able to gather information in a systematic, sensitive and professional manner. Good communication skills are essential. Introducing yourself to the patient is the first part of this process. It is important to let patients tell their story in their own words while using active listening skills. It is also important not to appear rushed, as this may interfere with the patient's desire to disclose information. Practitioners should avoid the use of technical terms or jargon and, whenever possible, use the patient's own words.
• Examples of non-verbal and verbal communication skills

  • Non-Verbal: Eye contact, Interested posture, Nodding of head, Hand gestures, Clothing, Facial gestures
  • Verbal: Appropriate language, Avoid jargon and technical terms, Pitch, Rate and intonation, Volume
• Consent


  Before any healthcare intervention, including history taking, informed consent should be gained from the patient. Patients can only provide consent if they are able to act under their own free will, have an understanding of what they have agreed to and have enough information on which to base a decision.
• The History Taking Process

  1. The Presenting Complaint

  2. Past Medical History

  3. Medication History

  4. Family history

  5. Social History
• The Presenting Complaint


  To elicit information about the presenting complaint start by using an open question, for example: 'What is the problem?' or 'Tell me about the problem?' This should provide a breadth of valuable information from the patient, but not necessarily in the order that you would like. The patient should then be asked more specific details about his or her symptoms, starting with the most important first. It is important to concentrate on symptoms and not on diagnosis to ensure that no information is missed.
• When a patient reports symptoms from a specific body system, all of the cardinal symptoms in the system should be explored.
• Direct questioning can be used to ask about the sequence of events, how things are currently and any other symptoms that might be associated with possible differential diagnoses and risk factors. Negative responses are also important, and it is vital to understand how the symptoms affect the patient's day-to-day activities.
• Past Medical History


  Listing of illness unrelated to the present illness, experienced in the past, Including childhood diseases, Serious injuries and surgery not requiring hospitalization, Mention of each disease with an approximate date, severity, duration, complications and sequel (consequences) is essential
• Medication History


  This is crucially important and should consider not only what medication the patient is currently taking but also what he or she might have been taking until recently. Because of the availability of so many medications without prescription, known as over-the-counter drugs, remember to ask specifically about any medications that have been bought at the pharmacy or supermarket, including homeopathic and herbal remedies. For each medication ask about: the generic name, if possible; dose; route of administration; and any recent changes, such as increase or decrease in dose or change in the amount of times the patient takes the medication. Finally, ask about any allergies and sensitivities, especially drug allergies, such as allergy or sensitivity to penicillin. It is important to find out what the patient experienced, how it presented in terms of symptoms, when it occurred and whether it was diagnosed.
• Family history


  Some disorders are considered familial; a family history can reveal a strong history of, for example, cerebrovascular disease or a history of dementia,that might help to guide the management of the patient. Open questioning followed by closed questioning can be used to gather information about any significance in the patient's family history.
• Social History


  A patient's ability to cope with a change in health depends on his or her social wellbeing. A level of daily function should be established throughout the history taking. The HCP should be mindful of this level of function and any transient or permanent change in function as a result of past or current illness. Questions about function should include the ability to work or engage in leisure activities if retired; perform house hold chores, such as housework and shopping; perform personal requirements, such as dressing, bathing and cooking. In particular, with deteriorating health a patient may have needed to give up club or society memberships, which may lead to a sense of isolation or loss. HCPs should consider the whole of the family when exploring a social history. Relationships to the patient should be explored, for example, is the patient married, is his or her spouse healthy, do they have children and, if so, what age are they? The health and residence to the patient should be known to understand actual and potential support networks. Other support structures include asking about friends and social networks, including any involvement of social services or support from charities. The social history should also include enquiry into the type of housing in which the patient lives. This should include if the accommodation is owned, rented or leased, what condition it is in and whether there have been any adaptations.
• In relation to the social history ask specifically about alcohol intake. The HCP should ask about past and present patterns of drinking alcohol.
• It is documented that smoking causes early death in the population and no safe maximum or minimum limit, unlike alcohol, has been identified. HCPs should ask questions about smoking.
• Relationships to the patient to be explored

  • Marital status
  • Spouse's health
  • Children and their ages
  • Residence and support networks
• Other support structures to be explored

  • Friends and social networks
  • Involvement of social services
  • Support from charities
• Housing


  Type (owned, rented, leased), condition, and any adaptations
• Alcohol intake


  Past and present patterns of drinking
• Smoking


  History of smoking, including age started, type of cigarettes, quantity, use of roll-ups or filtered, and tar content
• Gordon's 11 Functional Health Patterns


  • A nursing assessment theory proposed by Marjorie Gordon in 1987 to guide the nursing process and establish a comprehensive nursing data base
• Gordon's 11 Functional Health Patterns


  • Health Perception and Health Management
  • Nutrition and Metabolism
  • Elimination
  • Activity and Exercise
  • Cognition and Perception
  • Sleep and Rest
  • Self-Perception and Self-Concept
  • Roles and Relationships
  • Sexuality and Reproduction
  • Coping and Stress Tolerance
  • Values and Belief

  
• Health Perception and Health Management Pattern

  Data collection focused on the person's perceived level of health and well-being, and on practices for maintaining health. Habits that may be detrimental to health are also evaluated, including smoking and alcohol or drug use. Actual or potential problems related to safety and health management may be identified as well as needs for modifications in the home or needs for continued care in the home.
• Health Perception and Health Management FHP Assessment Questions

  • What is your opinion about health?
  • Are you immunized about seven target diseases?
  • Last immunization?
  • Do you have any allergy? If yes then type of allergy.
  • Any surgery in past? What type of surgery?
  • Last physical examination & for what purpose.
  • Are you using any medicine recently?
  • Do you know about these medicines?