Assessment Of Client's Health Status PDF

ASSESSMENT OF CLIENT’S HEALTH STATUS Kevin Michael M. Jasani, RN, MD, MPH Two aspects of assessing client’s health status: Nursing Health History Physical Examination Nursing Health History It paves a way for identifying nursing problems and gives direction to the physical examination....

ASSESSMENT OF CLIENT’S HEALTH STATUS Kevin Michael M. Jasani, RN, MD, MPH Two aspects of assessing client’s health status: Nursing Health History Physical Examination Nursing Health History It paves a way for identifying nursing problems and gives direction to the physical examination. This will also assist the primary care provider or the examiner in identifying the areas of strength and limitation of an individual’s lifestyle and current health status. Physical Assessment / Examination Three types: –(1) a complete assessment –(2) examination of the body system –(3) examination of the body area Nursing Health History Taking health history should begin with an explanation to the client of why the information is being requested. The health history has 8 sections: Nursing Health History 1. Biographic data 2. Reasons for seeking health care 3. history of present health concern 4. Personal health history 5. Family health history 6. Review of body systems for current health problems. 7. Lifestyle and health practices 8. Developmental levels 1. BIOGRAPHIC DATA BIOGRAPHIC DATA This includes information which will identify the client such as name, address, phone number, gender, date of birth and who provided the information. Other information such as medical data record number (if any) or any similar identifying data may be included. BIOGRAPHIC DATA The following will also help the nurse identify special needs and practices that may affect the care plan that will be given to the client: – Culture – Ethnicity and subculture – Date and place of birth – Nationality – Marital status – Religious and spiritual beliefs and practices – Primary and secondary language spoken, written and read BIOGRAPHIC DATA Gathering information about the client’s level of understanding such as educational background and working status aids the nurse and medical practitioner if communicating effectively. Knowing the people or family members and/or significant others living with the client provide information of the availability of possible caregivers and support person for the client. 2. REASONS FOR SEEKING HEALTH CARE REASONS FOR SEEKING HEALTH CARE Two important questions: –1. What is your major health problem or concerns at this time? –2. How do you feel about having to seek health care? REASONS FOR SEEKING HEALTH CARE What is your major health problem or concerns at this time? –Chief Complaint (CC) – the reason why the client is seeking medical help REASONS FOR SEEKING HEALTH CARE How do you feel about having to seek health care? –Encourages the client to discuss fears and /or other feelings about having to see a heath care provider 3. HISTORY OF THE PRESENT HEALTH CONCERN HISTORY OF THE PRESENT HEALTH CONCERN History of Present Illness Encouraging the client to explain the health problem or symptom by giving as much details as possible HISTORY OF THE PRESENT HEALTH CONCERN COLDSPA PQRST of Pain COLDSPA Character Onset Location Duration Severity Pattern Associated Factors CHARACTER Describe the sign or symptom –How does the pain feel like? ONSET When did the (sign/symptom) begin/start? LOCATION Where is it located? Can you point to me the location of the pain? Does the pain radiate? Does the pain/sign/symptom occur anywhere else? DURATION How long does the (sign/symptom) last? Does it come and go, or is it constant? SEVERITY How bad is it? How much does is bother you? How intense is the pain? PATTERN What makes it better or worse? Are there treatments that you’ve tried and did it alleviate the pain? ASSOCIATED FACTORS What other symptoms have occurred with it? PQRST of Pain Provocation / Palliation Quality Region / Radiation Severity Timing PROVOCATION / PALLIATION Aggravating Factors Relieving Factors What triggers the pain? What do you do to alleviate the pain? QUALITY Describe the pain/sign/symptom What does the pain feel like? (Sharp, stabbing, burning, dull aching pain) REGION / RADIATION Where the pain/sign/symptom occurs Where is the pain located? Does it radiate or spread to other parts of the body? SEVERITY How severe is the pain? (from 1 – 10) TIMING When does the pain occur? How long does the pain occur? 4. PERSONAL HEALTH HISTORY PERSONAL HEALTH HISTORY Childhood illnesses and Immunizations up to date Adult illnesses (physical, emotional, psychological) PERSONAL HEALTH HISTORY Past surgeries and accidents Allergies Use of medications (prescribed/OTC) 5. FAMILY HEALTH HISTORY FAMILY HEALTH HISTORY Conditions which are hereditary HEREDOFAMILIAL DISEASES –Hypertension –Diabetes Mellitus –Asthma –Cancer 6. REVIEW OF SYSTEMS FOR CURRENT HEALTH PROBLEM REVIEW OF SYSTEMS General: –Weight (gain/loss) –Weakness –Fatigue –Fever REVIEW OF SYSTEMS Integumentary (Skin, Hair, Nails): –Moles (change in color/pigmentation) –Pruritus (Itching) –Birthmarks –Changes in color of hair and nails REVIEW OF SYSTEMS HEENT Head: –Headache –Dizziness –Vertigo REVIEW OF SYSTEMS HEENT Eyes: –Pain –Blurring of Vision –Photophobia –Color blindness –Diplopia REVIEW OF SYSTEMS HEENT Ears: –Pain –Hearing loss –Tinnitus REVIEW OF SYSTEMS HEENT Nose/Sinuses: –Pain –Epistaxis –Rhinorrhea REVIEW OF SYSTEMS HEENT Throat/Mouth: –Pain –Sores/Ulcers –Tooth decay/loss –Hoarseness of voice REVIEW OF SYSTEMS Neck –Pain –Stiffness REVIEW OF SYSTEMS Breast –Pain –Swelling –Redness REVIEW OF SYSTEMS Respiratory (Thorax and Lungs) –Dyspnea (difficulty breathing) –Shortness of breath –Hemoptysis REVIEW OF SYSTEMS Cardiovascular (Heart) –Chest pain –Palpitations –Dyspnea –Orthopnea (difficulty breathing while lying down) REVIEW OF SYSTEMS Gastrointestinal –Change in appetite Abdominal Pain –Diarrhea Constipation –Melena Hematochezia –Hematemesis Nausea –Vomiting REVIEW OF SYSTEMS Genitourinary –Dysuria –Hematuria –Changes in color of urine –Flank pain –Suprapubic pain REVIEW OF SYSTEMS Endocrine –Hot/Cold Intolerance –Tremors –Sweating –Polydipsia –Polyuria –Polyphagia REVIEW OF SYSTEMS Musculoskeletal –Muscle pain –Joint pain –Swelling –Redness REVIEW OF SYSTEMS Hematologic –Bruising –Bleeding REVIEW OF SYSTEMS Neurologic –Seizures –Dizziness –Syncope –Vertigo –Weakness 7. LIFESTYLE AND HEALTH PRACTICES PROFILE LIFESTYLE AND HEALTH PRACTICES PROFILE Nutritional habits Activity and exercise patterns Sleep and rest patterns Self-concept and self-care activities Social and community activities, Relationship, values and belief system Education and work, stress level, coping style and environment. 8. DEVELOPMENTAL LEVELS DEVELOPMENTAL LEVELS Growth –physical change and can be measured quantitatively Development –increase in the complexity of function and skill progression DEVELOPMENTAL LEVELS Theories on Growth and Development –Sigmund Freud –Erik Erikson SIGMUND FREUD ERIK ERIKSON