Health Assessment Course Notes PDF

Health Assessment Course Code BSN201  Week 1/Lecture 1 “Health Assessment” Dr Deema Mahasneh Learning Objectives On completing this lecture, you will be able to: ❑ Define the health assessment ❑ Understand the purposes of health assessment ❑ Identify the steps of health assessment ❑ Different...

Health Assessment Course Code BSN201  Week 1/Lecture 1 “Health Assessment” Dr Deema Mahasneh Learning Objectives On completing this lecture, you will be able to: ❑ Define the health assessment ❑ Understand the purposes of health assessment ❑ Identify the steps of health assessment ❑ Differentiate among the two type of data: subjective and objective ❑ Compare the four types of health assessment  Health Assessment A systematic process of Definition: collecting, organizing, analyzing and validating of data about the client’s health status  Purpose of Health Assessment ❑ This assessment is conducted to: 1) Collect physiologic, psychological, sociocultural, developmental & spiritual data about the client 2) Identify actual and potential health problems 3) Establish whether there are any underlying health conditions that could be prevented or managed 4) Help the health care team and patient develop a plan of care  Systematic Health Assessment General Appearance Physiological Anthropometric Measurements Measurements (Head-to-Toes) (Vital Signs) Physical assessment 1)Temperature 1) Weight techniques 2) Heart rate 2) Height 3) Respiratory rate 3) Head circumference 4) Blood pressure 4) Chest circumference 1) Inspection 5) Skin fold thickness 2) Palpation 6) Mid-arm circumference 3) Percussion 4) Auscultation  Steps of Health Assessment ❑The health assessment process has four major steps: 1. Collection of subjective data 2. Collection of objective data 3. Validation of data 4. Documentation of data  Steps of Health Assessment(Cont….) 1. Collection of subjective data Sensations or symptoms (e.g., pain), feelings (e.g., happiness, sadness), perceptions, beliefs, values, and personal information that can be elicited and verified only by the client Subjective data- what the person says about him/herself during history taking o Example Client states “I have had a rash on my ankle and leg for the last two weeks” A symptom is any subjective evidence of disease  Steps of Health Assessment(Cont….) 1. Collection of subjective data (Cont….) ❑The major areas of subjective data include: I. Biographical information (name, age, religion, ethnicity, occupation) II. History of present health concern III. Personal health history IV. Family history V. Health and lifestyle practices (e.g., nutrition, activity, cultural beliefs, family structure and function, community environment)  Steps of Health Assessment(Cont….) 2. Collection of objective data Obtained by general observation, using four physical examination techniques(inspection, palpation, percussion &auscultation) and client’s medical record Objective data- what you observe by inspecting, percussing, palpation & auscultating during the physical examination o Example You observe that a client has a bright red rash on the dorsal side of the foot A sign is any objective evidence of disease  Steps of Health Assessment(Cont….) 2. Collection of objective data (Cont….) ❑The major areas of objective data include: I. Physical characteristics ( e.g. skin color, posture) II. Body functions (e.g. heart rate, respiratory rate) III. Appearance (e.g. dress & hygiene) IV. Behavior (e.g. mood) V. Measurements (e.g. blood pressure, temperature, height) VI. Results of lab testing (e.g. platelet count, x-ray finding) Subjective data VS Objective data Table1 Comparing subjective and objective data Subjective data Objective data Description ▪ Data elicited and verified by ▪ Data directly or indirectly the client observed through measurement Sources ▪ Client ▪ Observations and physical assessment findings ▪ Documentation of assessments made in client record Table1 (Cont…) Comparing subjective and objective data Subjective data Objective data Methods used ▪ Client interview ▪ Observation and physical to obtain data examination Skills needed to ▪ Interview and therapeutic– ▪ Inspection obtain data communication skills ▪ Palpation ▪ Listening skills ▪ Percussion ▪ Auscultation Examples ▪ I have a headache ▪ BP 180/100, apical pulse 80 and irregular ▪ I am not hungry ▪ X-ray film reveals fractured pelvis Mrs. G is a 54-year-old hairdresser who reports pressure over her left chest “like an elephant sitting there,” which goes into her left neck and arm. Mrs. G is an white female, pleasant and cooperative. Blood pressure 160/80, heart rate 96 and regular, respiratory rate 24, afebrile. I. What are the symptoms (subjective data)? II. What are the signs (objective data)?  Steps of Health Assessment (Cont….) 3.Validating of data ❑ Is a crucial part of assessment that often occurs along with collection of subjective and objective data ❑ Purpose of validation: Confirming or verifying that the subjective and objective data are reliable & accurate; to prevent documentation of inaccurate data  Steps of Health Assessment (Cont….) 3.Validating of data (Cont….) ❑ Methods of validation: I. Recheck your own data through a repeat assessment II. Clarify data by asking additional questions III. Verifying the data with another health care professional IV. Compare your objective findings with your subjective findings to uncover discrepancies  Steps of Health Assessment(Cont….) 4. Documentation of data ❑ Thorough and accurate documentation is vital to ensure valid conclusions are made when the data are analyzed ❑Purposes of documentation i. Promote effective communication among health team members ii. Provide health care team with a database that becomes foundation for care of client iii. Identify health problems, formulate nursing diagnoses, plan immediate and ongoing interventions  Steps of Health Assessment(Cont….) 4. Documentation of data (Cont….) ❑ Methods of documentation I. Electronic health records (EHRs) II. Paper based  Types of Health Assessment The four basic types of assessment (depending on the clinical situation) are:  Types of Health Assessment (Cont….) 1) Complete assessment (total health) Include a complete health history & a full physical examination Describe past and present health status You collect additional information on patient's perception of illness, activities of daily living, coping patterns & spiritual needs It yields the first diagnoses Gathered upon admission to hospital or during initial visit to a health care facility such as pediatric or family clinic, women health care & community health agency  Types of Health Assessment (Cont….) 2) Focused assessment (problem centered) For limited or short-term problems (seeking health care) Collect “mini” database, smaller scope and more focused than complete database Concerns mainly one problem or one body system It is used in all settings—hospital, primary care, or long-term care  Types of Health Assessment (Cont….) 2) Focused assessment (problem centered) (Cont….) ❑ Examples: 2 days after surgery a hospitalized person suddenly has a congested cough, shortness of breath & fatigue; history and examination focus on respiratory & cardiovascular systems In an outpatient clinic a person presents with a rash; history follows the direction of this presenting (acute or chronic onset; associated with a fever, new food, pet, or medicine; localized or generalized)  Types of Health Assessment (Cont….) 3) Follow-up assessment Status of all identified problems should be evaluated at regular and appropriate intervals Note changes that have occurred Evaluate whether problem is getting better or worse Identify coping strategies being used Used in all settings to follow up  Types of Health Assessment (Cont….) 3) Follow-up assessment (Cont….) ❑ Examples: A patient with heart failure may follow up with his or her primary care practitioner at regular intervals to reevaluate medications, identify changes in symptoms, and discuss coping strategies A patient admitted to the hospital with lung cancer requires frequent assessment of lung sounds  Types of Health Assessment (Cont….) 4) Emergency assessment Urgent-rapid collection of crucial data that is compiled with lifesaving measures Diagnosis must be swift & sure Once the person has been stabilized, a complete database can be compiled If the patient is unresponsive, health care providers may need to rely on family & friends  Types of Health Assessment (Cont….) 4) Emergency assessment (Cont….) ❑ Example: A person is brought into an emergency department with suspected substance overdose. The first history questions are “What did you take?” “How much did you take?” and “When?”. The person is questioned simultaneously while his or her airway, breathing, circulation, level of consciousness are being assessed