HLTENN037: General Health Assessment

General Health Assessment Overview

• HLTENN037 covers performing clinical assessments and contributing to planning nursing care.

Principles of General Health Assessment

• Prioritize assessments based on presenting signs and symptoms.
• Follow a head-to-toe approach (A-I).
• Encourage the client's active participation.
• Record quick notes to aid in accurate documentation.
• Take the client's cultural background into consideration.
• Incorporate health promotion and education into the process.

Steps Before Assessment

• Explain the type of assessment that is to be performed it to the patient.
• Have the patient empty their bladder/bowel before assessment.
• Provide privacy for the patient.
• Ensure proper positioning of the patient.
• Gather all necessary equipment.
• Inform the patient about the expected duration of the assessment.

Steps During Assessment

• Give physical and emotional support to the patient.
• Help the patient with position changes.
• Help with changes in vitals or condition.
• Make sure documentation and reporting is accurate and timely.

Steps After Assessment

• Help the patient into a comfortable position.
• Clean and remove all equipment.
• Send specimens to the lab if necessary.
• Report any concerns to the RN or other healthcare team.

Assessment Techniques

• Inspection: Visual examination of the patient.
• Palpation: Using touch to detect physical characteristics.
• Percussion: Tapping on the body surface to produce vibrations and sounds.
• Auscultation: Listening to body sounds using a stethoscope.
• Olfaction: Using the sense of smell to detect odors.

Inspection

• Assess rest and activity needs.
• Assess nutritional, fluid and electrolyte needs.
• Look at the safety and security of the patient.
• Look at the patient's hygiene and grooming.
• Assess oxygenation and circulation needs.
• Assess psychosocial needs of patient.
• Elimination.

Palpation

• Used to detect resistance, resilience, roughness, texture, temperature, and mobility.
• The back of the hand is sensitive to temperature.
• Fingertips are used to detect texture, shape, size, and pulsation.
• The Palm senses vibration.

Percussion

• A technique where the examiner strikes a body surface to produce vibration and sound.

Auscultation

• Listening with a stethoscope to sounds produced by the body.
• Breath sounds such as wheezes, crackles.
• Heart sounds.
• Bowel sounds that may be hypoactive or hyperactive.

Olfaction

• The using of the sense of smell to detect odors that are characteristic of certain conditions.
• Fishy smelling urine.
• Offensive rotting odor of wound.
• Acetone breath.
• Halitosis.
• Fecal odor of vomitus.
• Smoke and alcohol on the persons breath.

Reasons for General Body Observations

• To asses the patient's condition.
• To Identify issues and needs.
• To Evaluate the effectiveness of care.
• To Recognise the onset of complications or changes in condition.

Assessment Skills

• Interviewing.
• Observing and examining the patient.
• Using equipment.
• Evaluating diagnostic and laboratory test results.

Body assessments involve evaluating:

• Skin condition.
• Weight.
• Height.
• Body Mass Index [BMI].
• Psychological/emotional state.

Physical observation involves:

• What you see.
• What you hear.
• What you feel.
• What you smell.

Assessment using the sense of sight includes observing:

• Appearance and behavior.
• Level of pain versus comfort.
• Condition of eyes, limbs, and any skin abnormalities.
• Color of skin, nails, feet, hands, teeth, mouth, and ears.
• Patient's mood and expression.
• Body posture, gait, height, and weight.
• Ability to perform Activities of Daily Living (ADLs).
• Degree of independence.
• Ability to interact with others.
• Excretions and secretions.

Assessment using the sense of hearing includes identifying:

• Breathing abnormalities, for example, wheezing.
• Heart sound abnormalities, blood pressure, and bowel sounds.
• Manifestations of patient's distress such as coughing.
• Speech and sounds being made.
• Changes in the sound of technical equipment.

Assessment using the sense of touch includes noting:

• Skin textures rough or smooth.
• The moisture and temperature of the skin.
• Rapid, slow, or irregular pulse.
• Rigid or flaccid muscles.
• Swelling.
• Pain assessments.
• Reflexes.

Assessment using the sense of smell can identify:

• Odors that are traits of of certain conditions.
• Mouth odors.
• Fishy smell indicates infected urine.
• Concentrated ammonia indicates an issues.
• Offensive odors indicate infected wound.
• Alcohol on the breath.
• Melaena in stool.
• Assess there Personal hygiene/body odour.

Assessment Using Equipment

• Tools used include a thermometer, sphygmomanometer/stethoscope, scales, urine testing equipment, and a tape measure.

Skin observations involve:

• Color.
• Integrity.
• Turgor.
• Looking at Temperature.
• Evaluating if skin is Dry or wet.

Color observations:

• Jaundice: Yellowish discoloration of skin and sclera due to excess bilirubin in the blood.
• Erythema: Redness of the skin produced by congestion of the capillaries.
• Pallor: Paleness of the skin.
• Cyanosis: Bluish discoloration of the skin and mucous membranes due to low oxygen in the blood.

Lesion observations:

• Ecchymosis: Bleeding into tissue under the skin, leading to small bruises.
• Petechiae: Pinpoint sized red dots under the surface of the skin.
• Purpura: Purple colored spots and patches that occur on the skin.

Oedema

• Oedema is an abnormal accumulation of fluid in the bodies tissues.
• It Can manifest in any part of the body; but is common in the feet and ankles.
• It is Caused by kidney or heart failure or excessive salt intake

Symptoms of Fluid Overload

• weight gain.
• swelling of feet, ankles, hands, fingers, face.
• decreased urine output.
• shortness of breath.
• collection of fluid in abdomen (ascites).

Psychological/emotional observations

• Note the patient's behavior and position to see if they are noncompliant
• Emotional state by noting is the person is emotional state by noting if the person is crying
• Pay attention to Mood or expression.

Recording Height and Weight

• Baseline data on admission is important.
• It helps with determining drug dosages.
• Provides a Measure of loss or gain in body mass.
• Provides a Measure of the Measure of fluid retention or loss.

Measuring Height and Weight

• Height measurements: Feet, Inches, Centimeters.
• Weight measurements: Pounds, Ounces, Kilograms.
• Scales need to remain accurate if moved as little as possible

Weighing Guidelines

• Use same scale each time.
• Have resident void, remove shoes and outer clothing.
• Weigh at same time each day.

Various Weighing scales

• Floor scales.
• Weigh chair.
• Baby scales.
• Weight bed.

Basal Metabolic Index (BMI)

• BMI = weight in kilograms/Height in meters2
• BMI is an indicator of acceptable weight for the height of a person
• It Indicates if a person is within an acceptable weight range for their height.

BMI Numbers Mean

• A BMI range is from 20–25 is healthy.
• <20 means that the person is underweight.
• 25 - 30 Indicates being overweight.

• 30 Indicates obesity.

• 40 Indicates morbid obesity.

Conscious Level Assessment (AVPU)

• A - Alert: Patient is fully awake and aware.
• V - Response to Voice: Patient responds to verbal stimuli.
• P - Response to Pain: Patient responds only to painful stimuli.
• U - Unconscious: Patient does not respond to any stimuli.

Overview of HLTENN037, focusing on health assessment principles. Includes prioritizing assessments, a head-to-toe approach, and client involvement. Covers steps before, during and after assessment, also considering cultural background.