HA

• Health assessment involves collecting, validating, organizing, and recording patient health data

Nursing vs. Medical Assessment

• Nursing assessment collects holistic data to determine a client's overall functioning for professional judgment
• Nurses collect physiological, psychological, sociocultural, developmental, and spiritual data
• Nursing assessment identifies human responses to health problems and the patient's strengths
• Medical assessment focuses primarily on the client's physiological status
• Medical assessment focuses on the disease process and its treatment

Phases of Nursing Process (ADPIE)

• Assessment involves collecting subjective and objective data
• Diagnosis involves analyzing data to make and prioritize clinical judgements
• Planning involves generating solutions, developing a plan, and determining outcomes
• Implementation involves taking action, prioritizing, and implementing interventions
• Evaluation involves assessing whether outcomes are met and revising plan if needed

Assessment

• The systematic and continuous collection, organization, validation, and documentation of data

Types of Assessment

• Initial comprehensive assessment is done within a specified time after admission to a healthcare agency
• Initial assessment establishes a complete database for problem identification, reference, and comparison
• Ongoing or partial assessment involves data collection after the comprehensive database is established
• Ongoing assessment consists of a mini-overview of the client's systems and health patterns as follow-up
• Problem-focused assessment is performed when a database exists, but the patient has a specific health concern
• Problem-focused assessment thoroughly assesses a particular client problem, not unrelated areas
• Emergency assessment occurs during any physiological or psychological client crisis
• Emergency assessment identifies life-threatening problems and new or overlooked issues

Steps in Health Assessment

• Data collection
• Data validation
• Data documentation

Data Collection

• Primary data source: patient, including subjective and objective data
• Secondary data sources: family, healthcare team, medical records, and nurse's experience

Subjective Data

• Subjective data are sensations, feelings, preferences, beliefs, and personal information from the client
• Examples include biographical information, history of present concerns, family history, lifestyle practices, and review of systems

Objective Data

• Objective data is observable and measurable facts gathered by general observation and physical examination
• Using inspection, palpation, percussion, and auscultation
• Sources of objective data include client's medical records and family observations

Methods of Data Collection

• Subjective data is verified by the client while objective data is directly or indirectly observed through measurement
• Sources for subjective data are the clients
• Sources of objective data includes physical assessment finding made by the client's family
• Client interviews are used to gather subjective data
• Observation and physical examination are used to gather objective data
• Skills needed include therapeutic communication, listening, caring, and empathy
• Examples of subjective data: "I have a headache"
• Examples of objective data: Blood pressure 180/100

Organizing, Validating, and Prioritizing Data

• Use a written or electronic format to organize assessment data, such as a nursing health history form
• Validation confirms the accuracy of data using "double-checking"
• Ensure assessment information is complete and subjective/objective data agree.
• Consider the acuity and patient perception when prioritizing data
• Prioritize life-threatening problems, then those affecting basic needs

Types of Problems

• Top-priority: Airway or life-threatening issues
• Secondary: Requires attention to prevent worsening, such as pain
• Third-level: Resolved once the patient is stable, like teaching needs

Nursing Interview

• Interview: Conversation between nurse and patient
• Purpose: gather, organize complete accurate data

Interview Phases

• Review the client's medical record prior to initial contact
• Introduce self, cite the interview's purpose, explain questions and note-taking, ensure confidentiality, and ensure privacy
• Gather biographic data, chief complaints, and health history
• Listen to the client and observe cues; collaboration of both parties
• Summarizes information, identifies possible plans, and encourages questions

Communication

• Communication: exchanging information between people
• Verbal communication: Spoken or written words
• Non-verbal: Body language, gestures, touch, facial expression, and posture

Types of Questions

• Open-ended: "How can I help you?"
• Closed-ended: Yes/No questions
• Laundry list: Provides specific options
• Example: "Is the pain sharp, dull, or mild?"
• Rephrasing: Restates client's words

Techniques for Encouraging Communication

• Well-placed phrases like "um-hum" to encourage the client to keep talking
• Inferring: Observing behavior and combining it with words
• Providing Information: Answer questions thoroughly

Data Validation

• Confirmation to avoid errors in judgements.
• Requires validation in discrepancies or inconsistencies.
• Validate through rechecking, clarifying, and comparing.

Documentation of Data

• Provides record, facilitates communication, and helps in diagnosis, it is in legal and procedural context.
• Includes subjective nursing interview and objective physical examination data.
• Document when provided, changes occur, after intervention and before shift ends.
• Ensure confidentiality with HIPAA, be legible, and use proper grammar.
• Use conciseness, objectivity with quotes, support observations and describe specific details.
• Identify missing data and use critical thinking to formulate diagnoses.

Considerations in Health Assessment

• Consider the special need relating to, cultural background, and emotional state of the client and his/her family.
• Follow ethical guides such as informed consent, patient bill of rights and data privacy act.
• The Patient's Bill of Rights includes being informed, making decisions, and receiving respectful care. (RA No. 9439)
• Data Privacy Act is designed to protect healthcare data. (RA No. 10173)
• Privacy ensures respect during medical care, including physical and belongings.
• Confidentiality is the obligation to keep information private and shared only when legally.

Guidelines in Health Assessment

• Prepare setting and client appropriately for PE (physical exam).
• Position client appropriately
• Know types and operation of equipment
• Use assessment techniques

Client Positions for Examination

• Standing for musculoskeletal and neurological.
• Supine for heart and abdominal.
• Prone assesses the back.
• Dorsal Recumbent, knees bent, assess the pelvic.
• Sim's (on side with knee drawn up), rectal exam
• Lithotomy: (on back with legs in stirrups) gynecological exams
• Knee-chest (kneeling) rectal exams

Physical Examination Techinques

• Inspection: Using sight to observe.
• Look and expose body part but inspect first
• Palpation: Using touch to feel for texture, palpate gently
• Percussion: Tapping body part to produce sound
• Auscultation: Listening with stethoscope
• Hair: Clean and evenly distributed
• Skin: Intact with tone
• Color: Pink with temperature

History Taking

• Involves both Subjective and Objective Data
• Lays the groundwork for identifying problems.
• Includes Chief Complaint, Present Illness, Past History, Family History and System Review.
• Obtain biographical data through patient interview
• Determine the clients reasoning through an exam.
• Explore using COLDSPA, PQSRT, LIQORAAA

Mnemonic Devices for Symptom Analysis

• Precipitating/Palliative, Quality, Region/Radiation, Severity, Timing.
• Character, Onset, Location, Duration, Severity, Pattern, Associated factors
• Location, Intensity, Quality, Onset, Radiation, Associated Symptom, Alleviating factors and Aggravating factors

Medical and Surgical History

• Consider menarche, pregnancy, family history, and EDC (Estimated Date of confinement)
• Note review of systems for function, cephalocaudal (head-to-toe), and Proximodistal (inner to outter)

Additional Information

• GCS (Glasgow Coma Scale=15 alert), or levels of eye opening, verbal and motor response.
• Pain and Numeric Rating or Verbal Rating, FLACC Scales

Integument (Skin) Assessment

• The skin's structure includes Epidermis, Dermis and Subcutaneouse Tissue and varies with vascular
• Integuments provide, protection, sensation, vitamin D, regulate temperature and also excretion
• Nails are the hard tops of fingers and toes. Look for texture, inflammation, shape and smoothness.
• Check: hair color, texture, thickness and if scalp is moist.
• Skin is tested by checking color, lesions and moisture content.
• Note all findings and ensure for client understanding.
• Use pen lights, glass and gloves but ask client privacy.

Lesions

• Shapes: round, oval, circular, linear
• Configurations: discrete, confluent, or dermatomal such as in the feet/hands.
• Types: macule, papule, vesicles and secondary. e.g. pressure ulcer

Abnormal Findings

• Pallor, erythema, cyanosis, and or jaundice and linear patterns.
• Skin cancer is squamous if ulcerated red, Actinic from sun and Melanoma form aggressive pigment.
• Palpate for: texture, check for tenderness
• Capillary refill: Check for fluid and blood and oxygen flow.
• In documentation: note findings and ensure for understand.

Hair Disorders

• Patchy -hair loss
• Traction -tight strain
• Alopecia -Total hair thinning.

Inspecting head

• Use lighting, note lesions or abnormal findings.
• Cranium of the skull protect, shape face and contain facial ones giving shape.
• Check: neck range with all equipment and note lumps or mass.

Subjective Assessment

• Determine past history and lifestyle
• COLDSPA Approach is helpful here.
• Determine any signs to sinus, cluster, or tension on eye and head and ear.
• Use a glass when palpating head or neck.
• Use gloves and use light and stethoscope for listening and inspection.
• Listen for: patterns within face (note any drooping/lesions) and vertebrae.
• Document location tenderness (always) and size and consistency of the neck.

Inspection

• For Size and shape of: noduels, lymphs, tumor and enlarged skin

Palpation

• Check: Lymph if rubbery, delmination or location (always Document location)
• Neck Check if any alterations to thyroid.

Abnormal Findinds in Neck

• Nodes round and should not be PALPABLE.
• Can become: fibrous/enlarged. Listen for: bruits.

Alterations

• Can Increase/Depression.
• Fatigue/Weakness.

Palpatations

• Heart beat increase /weightloss and sweating patterns.

Inspection

• Check cervical and lymph on nodes.
• Dowager's and thyroid for: size, mass of tissue and fibroid.
• Consider all ADULTS due to bone structure.