Introduction_to_health_assessment_no_1_MNU_2023_2024_slide_show (1).pps

 Learning objectives 07/27/24 2  Types of assessment 1. Initial Comprehensive assessment Also called an admission assessment it is performed when client enter health care system It Involves collection of subjective data about the c...

 Learning objectives 07/27/24 2  Types of assessment 1. Initial Comprehensive assessment Also called an admission assessment it is performed when client enter health care system It Involves collection of subjective data about the client's perception of health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client's overall function) as well as objective data gathered during a step-by-step physical Ongoing or Partial assessment Consists of data collection that occurs after the comprehensive database is established. This consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on his health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes (deterioration or improvement) from the baseline data. Emergency assessment: It is a very rapid assessment performed in life-threatening situations. In such situations (choking, cardiac arrest, drowning), An immediate diagnosis is needed to provide prompt treatment.  Components of health assessment: Health assessment Health history Physical examination History of present illness, Inspection Past, present Palpation medical history Percussion Family history Auscultation Social history Comparison between subjective and objective data 07/27/24 15  Introduction to Physical Assessment Interviewing and Communication Techniques: Health History Information about the patient's health in his or her own words and based on the patient's own perceptions. Includes biographic data, perceptions about health, past and present history of illness and injury, family history, a 07/27/24 review of systems, and health. 16 Skills needed for taking effective health history 07/27/24 17  The Health History ”Interview” The nurse uses the health history and interview in various healthcare settings to create a comprehensive account of the patient's past and present health. The nurse can use this database, which provides a total picture of the patient's past and present physical, psychological, social, cultural, and spiritual health, to formulate nursing diagnoses and plan the patient's care. 07/27/24 18  Preparing the Client Health examinations are usually painless; however, it is important to determine in advance any positions that are contraindicated for a particular client. The nurse assists the client as needed to undress and put on a gown. Clients should empty their bladders before the examination. Doing so helps them feel more relaxed and facilitates palpation of the abdomen and pubic area. If a urinalysis is required, the urine should be collected in a container for that purpose. 07/27/24 19  Preparing the Environment Providing privacy is important The time for the physical assessment should be convenient to both the client and the nurse. The environment needs to be well lighted, and the equipment should be organized for efficient use. A client who is physically relaxed will usually experience little discomfort. The room should be warm enough to be comfortable for the client. 07/27/24 20  Positioning Several positions are frequently required during the physical assessment. It is important to consider the client’s ability to assume a position. The client’s physical condition, energy level, and age should also be taken into consideration. Draping Drapes should be arranged so that the area to be assessed is exposed and other body areas are covered. Exposure of the body is frequently embarrassing to clients. Drapes provide not only a degree of privacy but also warmth. Drapes are made of paper, cloth, or bed linen. 07/27/24 21  Instrumentation All equipment required for the health assessment should be clean, in good working order, and readily accessible. Equipment is frequently set up on trays, ready for use. 07/27/24 22  Physical Assessment Because When you perform the physical palpation and percussion can assessment, you’ll use four techniques: alter bowel Inspection, palpation, percussion, sounds, the sequence and auscultation. for assessing the Use these techniques in this sequence abdomen is except when you perform an inspection, auscultation, abdominal assessment. percussion, and palpation. 07/27/24 23  Basic Techniques of Physical Assessment 07/27/24 24  Inspection begins with a survey of the patient’s appearance and a comparison of the right and left sides of the patient's body, which should be nearly symmetric. As the nurse assesses each body system or region, he or she inspects for color, size, shape, or region, he or she inspects for color, size, shape, contour, symmetry, movement, or drainage. When inspecting a large body region, the nurse should proceed from general overview to specific detail. For example, when inspecting the leg, the nurse surveys the entire leg first and then focuses on each part, including the thigh, knee, calf, ankle, foot, and toes in succession. 07/27/24 25 Although the nurse will perform most of the inspection without the help of instruments, some special tools for visualizing certain body organs or regions are important. For example, the ophthalmoscope is used to inspect the inner aspect of the eye. 07/27/24 26  Palpation Palpation requires to touch the patient with different parts of hands, using varying degrees of pressure. Because hands are the nurse tools, keep the fingernails short and hands warm. Wear gloves when palpating mucous membranes or areas in contact with body fluids. Palpate tender areas last. 07/27/24 27  Types of palpation Light palpation Deep palpation Use this technique to feel for surface Use this technique to feel internal organs abnormalities. and masses for size, shape, tenderness, Depress the skin 1/2 to 3/4 (1.5 to 2 cm) symmetry, and mobility. with your finger pads, using the lightest Depress the skin 11/2 to 2 (4 to 5 cm) touch possible. with firm, deep pressure. Assess for texture, tenderness, Use one hand on top of the other to temperature, exert firmer pressure, if needed. moisture, elasticity, pulsations, superficial organs, and masses. 07/27/24 28  Percussion Percussion involves tapping fingers or hands quickly and sharply against parts of the patient’s body to locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas. 07/27/24 29  Indirect percussion Indirect percussion Types of percussion This technique elicits sounds that give clues Direct percussion to the makeup of the underlying tissue. This technique reveals tenderness; Press the distal part of the middle finger of it’s commonly used to assess an adult patient’s sinuses. nondominant Here’s how to do it: hand firmly on the body part. Using one or two fingers, tap Keep the rest of the hand off in the body directly on the body part. surface. Ask the patient to tell you which Flex the wrist of the dominant hand. areas are painful and watch his Using the middle finger of the dominant face for signs of discomfort. hand, tap quickly and directly over the point where the other middle finger touches the patient’s skin. Listen to the sounds produced 07/27/24 30  Auscultation 07/27/24 31  How to Auscultate Use the diaphragm to pick up high-pitched sounds, such as first (S1) and second (S2) heart sounds. Hold the diaphragm firmly against the patient’s skin, enough to leave a slight ring on the skin afterward. Use the bell to pick up low-pitched sounds, such as third (S3) and fourth (S4) heart sounds. Hold the bell lightly against the patient’s skin, just enough to form a seal. Holding the bell too firmly causes the skin to act as a diaphragm, obliterating low-pitched sounds. Listen to and try to identify the characteristics of one sound at a time. 07/27/24 32  References KOZIER & ERB’S. (2016). FUNDAMENTALS OF NURSING, Concepts, Process, and Practice.10th Ed. Weber,R.J ,Kelley.H.J (2018): Health Assessment in Nursing, 6th ed. Philadelphia: Lippincott Williams & Wilkins 07/27/24 33 07/27/24 34