Health Assessment and Patient Problems

Health Assessment

• Health is a state in which a person can live to their full potential
• Illness is a person's unique response to a disease
• Wellness is an active state, focused on maximizing potential
• Health assessment purpose is to determine a patient's health status, risk factors, and education needs to develop a nursing care plan
• Provide specific cues for health problems
• Nurses collect comprehensive data pertinent to the patient's health situation
• Comprehensive health history includes all aspects of health
• Complete physical examination is part of health assessment

Steps in Identifying Patient Problems

• Holistic care focuses on the whole person, including community/family, sexual, physical, psychological, and social needs
• Assessment involves health and physical assessments
• Observation and measurement is a crucial part of the process
• Procedures and investigations are also necessary steps

7 Facets/Dimensions of Health

• Physical health
• Emotional health
• Social well-being
• Cultural influences
• Spiritual influences
• Environmental influences
• Developmental level
• Note: Ability to adapt without compromising facets is crucial for health maintenance. Health is not constant and cannot be taken for granted.

Role of the Nurse

• Caregiver: Performs health-related activities a sick person cannot do independently
• Educator: Provides health teaching relevant to each client's needs and knowledge base
• Collaborator: Works with others to achieve a common goal
• Delegator: Assigns tasks to others

Assessment (Subjective/Objective Data)

• A systematic approach to gathering information about a patient's physiological, psychological, sociological and spiritual status
• Health Assessment
• Physical Assessment

Components of Health History

• First step in patient assessment: Collection of subjective and objective data
• Identify patient strengths and areas of health care needs
• Provides the basis for identifying nursing problems and focusing physical exam
• A framework for organizing patient information (written/verbal)
• Seven components of a comprehensive health history
  • Identifying data and source of the history
  • Chief complaints
  • History of Present Illness (HPI)
  • Past history
  • Family history
  • Review of the system
  • Health patterns

Identifying Data

• Age
• Date of birth
• Gender
• Occupation
• Marital relationship
• Education level
• Primary language spoken and read
• Source of history
  • Patient (primary)
  • Family member (secondary)
  • Friend (secondary)
  • Letter of referral (secondary)
  • Medical record (secondary)

Reason for Seeking Health Care/Chief Complaint

• Reason for the client's visit
• Focus on the most significant concern and answer the question "Why are you here?"
• Encourage the client to discuss fears and feelings about needing healthcare

Subjective vs. Objective Data

• Subjective data comes from the patient (symptoms)
• Objective data is gathered through observation and examination (signs)
  • Examples of both are provided

History of Present Illness

• Chronological account of the patient's chief complaint and surrounding events
• Includes self-treatment (OTC drugs), past occurrences of symptoms, pertinent positive/negative information, risk factors, or other related information

Past History

• Allergies
• Medications (name, dose/route, frequency)
• Home remedies/nonprescription drugs
• Childhood illnesses
• Adult illnesses (medical, surgical, accidents, psychiatric)
• Health maintenance (immunizations, screening tests, safety measures, risk factors-tobacco, environmental hazards, substance abuse, alcohol)

Family History

• Siblings, parents, grandparents, and children
• Age and health
• Cause of death
• Documents of presence or absence of specific illnesses (e.g., hypertension, CAD)

Review of the System

• Series of questions about all body systems
• May uncover problems not related to the present illness
• Initial questions are general and become more specific

Review of Systems (Sample Questions)

• Covers multiple body systems, asking about symptoms
• General, skin, head, eyes, ears, nose, throat, neck, breasts, respiratory, cardiovascular, gastrointestinal

Physical Examination

• Process to obtain objective data from the patient
• Purpose is to determine changes in a patient's health status and how to respond to a problem, as well as promote healthy lifestyle and wellbeing

Four Basic Types of Assessment

• Comprehensive health assessment: Involves a complete health history and physical exam to provide a full picture of the patient's health status
• Focused or problem-oriented assessment: Addresses a specific problem or current health concern
• Follow-up history: Form of a focused assessment to evaluate a patient problem after treatment or by a second-shift nurse to follow up on earlier shift concerns
• Emergency assessment (rapid, focused): Conducted when addressing a life-threatening or unstable condition, prioritizing systemic issues such as circulation, airway, and breathing

Standard Precautions

• Universal precautions to prevent exposure to blood and body fluids, protecting healthcare professionals and patients

Cardinal Techniques of Examination

• Inspection (detailed visual observation using lighting): Physical appearance, behavior, movement, facial expression, mood, body build, skin conditions, eye movements, and symmetry of thorax.
• Palpation (assessing through touch): Skin elevation, depression, warmth, tenderness, lymph nodes, pulses, contours, sizes of organs, and masses, crepitus in the joints
• Percussion (striking body parts to produce sound waves): Resonance or dullness from underlying tissue/organs
• Auscultation (listening to body sounds using a stethoscope): Heart, lung, and bowel sounds, location, timing, duration, pitch, intensity

Preparing for the Physical Examination

• Reflect on approach and avoid biases. Adjust environment (lighting, environment). Ensuring equipment is available and in good working order, making the patient comfortable & determine sequence.