Module 1-5 Health Assessment PDF

HEALTH ASSESSMENT Session 1 : INTRODUCTION TO HEALTH ASSESSMENT Learning Targets: At the end of the module, students will be able to: 1. Learn the definition of health and health assessment and how it is practiced in the field of nursing; 2. Identify the five steps of the nursing process and ho...

HEALTH ASSESSMENT Session 1 : INTRODUCTION TO HEALTH ASSESSMENT Learning Targets: At the end of the module, students will be able to: 1. Learn the definition of health and health assessment and how it is practiced in the field of nursing; 2. Identify the five steps of the nursing process and how they are applied in all aspects of nursing; and, 3. Enumerate and describe the types of health assessment and to differentiate them from one another. Definition of Health Health is a relative state in which a person is able to live to his or her potential and includes the “7 facets”: Physical health – how the body works and adapts Emotional health – positive outlook and emotions channeled in a healthy manner Social well-being – supportive relationships with family and friends Cultural influences – favorable connections to promote health Spiritual influences – living peacefully, morally, and ethically Environmental influences – favorable conditions to promote health Developmental level – how one thinks, solves problems, and makes decisions Health is a sum of these facets and is not solely defined as the absence of disease or eating right, but rather by the contribution of all dimensions. Health Assessment The nursing health assessment entails both a comprehensive health history and a complete physical examination, which are used to evaluate the health and status of a person. The nursing health assessment involves a systematic data collection that provides information to facilitate a plan to deliver the best care for the patient. The first part of health assessment is the health history, which also incorporates the “7 facets”. The nurse asks pertinent questions to gather data from the patient and/or family. Past medical records may also be used to collect additional information. Learning about the patient’s physical and psychological issues, social and cultural associations, environment, developmental level, and spiritual beliefs contribute to the history. The second component of the health assessment is the physical examination. The nurse uses a structured head-to-toe examination to identify changes in the patient’s body systems.  Health Assessment An unusual or abnormal finding may support the history data or trigger additional questions. The purpose of the nursing health assessment is to determine the patient’s health status, risk factors, and need for education as a basis for developing a nursing plan of care. The nursing process is the ability of the nurse to extrapolate the findings, prioritize them, and finally formulate and implement the plan of care is the overall goal. The information obtained throughout the health assessment should be documented in a clear, concise manner. This information is collated in the patient’s medical records. NURSING PROCESS The nurse uses the NURSING PROCESS (a problem-solving process) to identify patient problems; set a goal and develop an action plan; implement the plan; and evaluate the outcome. The NURSING PROCESS steps are: Assessment Diagnosis Planning Implementation Evaluation ADPIE Assessment – it is the first step of the nursing process. It is the subjective and objective data gathered during the initial health history and physical examination and collected on each patient encounter. Diagnosis has a nursing focus and is based on real or potential health problems or human responses to health problems. The nurse uses clinical reasoning to formulate diagnoses based on the assessment data and the patient’s problem list. Planning is devising the best course of action to address the patient’s diagnoses. During planning, the nurse and patient select goals for each diagnosis in order to alleviate, decrease, or prevent the problems addressed in the nursing diagnosis. Implementation of the interventions can be completed by the patient, the family, or members of the health care team. The interventions should clearly relate to the nursing diagnosis and the planned goals. Evaluation is a continuing process to determine if the goals have been attained. The nursing care plan is revised based on the patient’s condition and whether the goals are realistic or appropriate for the patient. Types of Health Assessment: Comprehensive health assessment - The admission of a new patient to a clinic, hospital, long-term care facility, or visiting nurse agency Focused or problem-oriented assessment - where the nurse focuses on gathering information about the patient’s problem. A follow-up history is a form of a focused assessment. Emergency history - is the data collection which focused on the patient’s emergent problem with a systematic prioritization of need beginning with the ABCs of airway, breathing, and circulation. Session 2: STEPS OF HEALTH ASSESSMENT Learning Targets: At the end of the module, students will be able to: 1. Learn about the phases of the interview and the description of each phase; 2. Explain the four types of histories and when they are used; 3. Describe the components of a comprehensive health history; and, 4. Obtain a comprehensive health history from a patient. INTERVIEWING AND COMMUNICATION Health History Interview -A conversation with a purpose within three folds using health history format: 1. Establish a trusting and supportive relationship 2. Gather information 3. Offer information INTERVIEWING AND COMMUNICATION Health History Format - is a structured framework for organizing patient information in written, electronic, and verbal form to communicate effectively with other health care providers. Patient’s information is concisely organized into three categories: ⮚ past ⮚ present ⮚ family history Phases of Interview 1. Pre-interview: set the stage for a smooth interview Self-Reflection - is a continual part of professional development in clinical work. It brings a deepening personal awareness to our work with patients, which is one of the most rewarding aspects of patient care. Review patient record Set interview goals Review own clinical behavior and appearance Phases of Interview 2. Introduction: put the patient at ease and establish trust Greet the patient and establish rapport Establish the agenda for the interview 3. Working: obtain patient information Invite the patient’s story Identify and respond to emotional clues Expand and clarify the patient’s story Generate and test diagnostic hypotheses Negotiate a plan, including further evaluation, treatment, education and self-management support and prevention THE SEVEN ATTRIBUTES OF A SYMPTOM 1. Onset. When did (does) it start? Setting in which it occurs, including environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness. 2. Location. Where is it? Does it radiate? 3. Duration. How long does it last? 4. Characteristic Symptoms. What is it like? How severe is it? (For pain, ask a rating on a scale of 1 to 10.) 5. Associated Manifestations. Have you noticed anything else that accompanies it? 6. Relieving/Exacerbating Factors. Is there anything that makes it better or worse? 7. Treatment. What have you done to treat this? Was it effective? OLD CART, or Onset, Location, Duration, Characteristic Symptoms, Associated Manifestations, Relieving/Exacerbating Factors, and Treatment EXPLORE THE PATIENT ’S PERSPECTIVE (FIFE)  The patient’s Feelings, including fears or concerns, about the problem  The patient’s Ideas about the nature and the cause of the problem  The effect of the problem on the patient’s life and Function  The patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal or family experiences Phases of Interview 4. Termination: Summarize important points Discuss plan of care “So, you will take the medicine as we discussed, check your blood glucose daily, and make a follow-up appointment for 4 weeks. Do you have any questions about this?” Address any related concerns or questions that the patient raises. Types of data: Subjective data are information from the client's point of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews. Objective data are observable and measurable data (“signs”) obtained through observation, physical examination, and laboratory and diagnostic testing. History of Present Illness (HPI) This section of the history is a complete, clear, and chronologic account of the problems prompting the patient to seek care. The narrative should include the onset of the problem, the setting in which it has developed, its manifestations, and any treatments. The HPI should reveal the patient’s responses to the symptoms and the effect the illness has had on daily living. Key Elements of the History of Present Illness: Seven attributes of each principal symptom Self-treatment for the symptom by the patient or family Past occurrences of the symptom(s) Pertinent positives and/or negatives from the review of systems Risk factors or other pertinent information related to the symptom Key Elements of the History of Past History: Allergies Medications Childhood illnesses Adult illnesses Health Maintenance Family history Review of systems Health patterns Mental health history Session 3 : PHYSICAL EXAMINATION Learning Targets: At the end of the module, students will be able to: 1. Describe how to individualize the physical examination approach based on patient’s needs and the environment; 2. Select an environment features necessary to ensure patient safety and comfort during a physical examination; 3. Discuss the environmental features necessary to ensure patient safety and comfort during a physical examination; 4. Identify safety precautions when conducting the physical examination; and, 5. Indicate the correct order and how to use the four cardinal techniques. Physical Examination A process to obtain objective data from the patient Each body system connects to another The purpose of the physical examination is to determine changes in a patient’s health status and how to respond to a problem as well as promote healthy lifestyles and wellbeing. THE COMPREHENSIVE ADULT PHYSICAL EXAMINATION Setting the Stage Preparing for the Physical Examination: Reflect on your approach to the patient. Adjust the lighting and the environment. Make the patient comfortable. Check your equipment. Choose the sequence of examination. Reflect your Approach to the Patient: Identify yourself as a nursing student. Try to appear calm, organized, and competent. Most patients view the physical examination with some anxiety. Avoid interpreting your findings - If you find anything that is unusual or disturbing, always talk with your clinical instructor. Adjust the Lighting and Environment: “Set the stage” so that both you and the patient are comfortable. Good lighting and a quiet environment make important contributions to what you see and hear but may be hard to arrange. Tangential lighting optimal for inspecting structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart. Make the Patient Comfortable: Showing concern for privacy and patient modesty must be ingrained in your professional behavior. Close nearby doors and draw the curtains in the hospital or examining room before the examination begins Wash your hands Draping the patient - goal is to visualize one area of the body at a time keep the patient informed, especially when you anticipate embarrassment or discomfort checking vital signs, tell the patient the results the examination is completed, tell the patient your general impressions and what to expect next Observe Standard and Universal Precautions Standard and MRSA precautions: Based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. Hand hygiene, use of protective equipment, safe injection practices, safe handling of contaminated equipment. Universal Precautions Set of guidelines designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other blood-borne pathogens when providing first aid or health care. Following fluids are considered potentially infectious: ✔ All blood and other body fluids containing visible blood ✔ Semen and vaginal secretions ✔ Cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids Protective barriers include: gloves, gowns, aprons, masks, and protective eyewear All health care workers should observe the important precautions for safe injections and prevention of injury from needle sticks, scalpels, and other sharp instruments and devices. Make the Patient Comfortable Patient Privacy and Comfort: Close nearby doors, draw the curtains in the hospital or examining room, wash your hands thoroughly During the examination be aware of the patient’s feelings and any discomfort. Draping the Patient: Goal: to visualize one are of the body at a time. When patient is sitting, auscultate the lungs with the gown unties in back. Breast examination, uncover the right breast and keep the left chest Cardinal Techniques of Examination: INSPECTION Close observation of the details of the patient’s appearance, behavior, and movement such as: ✔ facial expression, mood, body build and conditioning, skin conditions such as petechiae or ecchymosis, eye movements, pharyngeal color, symmetry of thorax, height of jugular venous pulsations, abdominal contour, lower extremity edema, and gait. PALPATION Tactile pressure from the palmar fingers or finger pads to assess areas of skin elevation, depression, warmth, or tenderness; lymph nodes; pulses; contours and sizes of organs and masses; and crepitus in the joints. Metacarpal/phalangeal joint or ulnar surface of the hand is used to detect vibration. Cardinal Techniques of Examination: PERCUSSION Use of the striking or plexor finger, usually the third, to deliver a rapid tap or blow against the distal pleximeter finger, usually the distal third finger of the left hand lay against the surface of the chest or abdomen, to evoke a sound wave such as resonance or dullness from the underlying tissue or organs. This sound wave also generates a tactile vibration against the pleximeter finger. AUSCULTATION Use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowel sounds, including location, timing, duration, pitch, and intensity. For the heart this involves sounds from closing of the four valves and flow into the ventricles as well as murmurs. Auscultation also permits detection of bruits, i.e., turbulence over arterial vessels. Session 4 : PHYSICAL EXAMINATION OF A PEDIATRIC PATIENT Learning Targets: At the end of the module, students will be able to: 1. Identify the sources of subjective and objective data from a pediatric client; 2. Learn how to do a complete physical examination of a pediatric patient; and, 3. Know the different normal vital signs of each stage of childhood. Collecting Subjective Data Information spoken by the child or family is called subjective data. Conducting the Client Interview Most subjective data are collected through interviewing the family caregiver and the child. Why interview? The interview helps establish relationships between the nurse, the child, and the family. Listen and communicate. Listening and using appropriate communication techniques help promote a good interview. Introduce and explain your purpose. The nurse should be introduced to the child and caregiver and the purpose of the interview stated. Establish rapport. Calm, reassuring manner is important to establish trust and comfort; the caregiver and the nurse should be comfortably seated, and the child should be included in the interview process. Interviewing Family Caregivers The family caregiver provides most of the information needed in caring for the child, especially the infant or toddler. Ask questions and note them. Rather than simply asking the caregiver to fill out a form, the nurse may ask the questions and write down the answers; this process gives the opportunity to observe the reactions of the child and the caregiver as they interact with each other and answer the questions. Avoid being judgmental. The nurse must be non-judgmental, being careful not to indicate disapproval by verbal or nonverbal responses. Interviewing the Child It is important that the preschool child and the older child be included in the interview. Be age-appropriate. Use age-appropriate toys and questions when talking with the child. Establish rapport. Showing interest in child and in what he or she says helps both the child and caregiver to feel comfortable; by being honest when answering the child’s questions, the nurse establishes trust with child. Listen. The child’s comments should be listened to attentively, and the child should be made to feel important in the interview.  Interviewing the Adolescent Adolescents can provide information about themselves. Interview in private. Interviewing them in private often encourages them to share information that they might not contribute in front of their caregivers. Obtaining a Client History When a child is brought to any health care setting, it is important to gather information regarding the child’s current condition, as well as medical history. Biographical data. Chief Complaint. History of present health concern. Health history. Family health history. Review of systems for current health problem. Allergies, medications, and substance abuse. Lifestyle. Developmental level. Collecting Objective Data The collection of objective data includes the nurse doing a baseline measurement of the child’s height, weight, blood pressure, temperature, pulse, and respiration. General Status Observing general appearance. Noting psychological status and behavior. Measuring Height and Weight When to measure. How to measure weight. How to measure height. Measuring Head Circumference The head circumference is measured routinely in children to age 2 or 3 years or in any child with a neurologic concern. How to measure. Record and plot. Vital Signs Temperature Pulse Respirations Blood pressure Physical Examination Data are also collected by examining the body systems of the child. Head and Neck Assess the range of motion. Assess the fontanels. Assess the eyes. Assess the ears. Asses the nose, mouth, and throat.  Chest and Lungs How to measure the chest. Assess respiratory characteristics. How to assess breath sounds. Heart Assessing heart rate and rhythm. Assessing for heart abnormalities. Assess the heart function’s effectiveness.  Abdomen The abdomen may protrude slightly in infants and small children. Dividing the abdomen. Assess bowel sounds. Genitalia and Rectum When inspecting the genitalia and rectum, it is important to respect the child’s privacy and take into account the child’s age and stage of growth and development. Inspect the genitalia and rectum. Assess the testes.  Back and Extremities The back and extremities should also be assessed for abnormalities. Assess the back. Assess gait and posture. Assess the extremities. Neurologic Assessing the neurologic status of the infant and child is the most complex aspect of the physical exam. Neurologic exam. Neurologic assessment tools. Session 5: CULTURAL AND SPIRITUAL ASSESSMENT CULTURAL ASSESSMENT −Refers to a systematic, comprehensive examination of individuals, families, groups and communities regarding their health-related cultural beliefs, values and practices. Global Migration – increased the challenges of providing health care to patients with health care beliefs, practices and needs different from health care provider Cultural Humility The process that requires humility as individuals continually engages in self-reflection and self-critique as lifelong learners and reflective practitioners. The process that includes the difficult work of examining cultural beliefs and cultural systems of both patients and nurses to locate the points of cultural dissonance or synergy that contribute to patients’ health outcomes. Begin Self-Reflection by answering the following: 1. Am I aware of my biases? Prejudices? Stereotypes? 2. Am I comfortable interacting with people with different cultures? 3. Do I seek out experiences with other cultures? 4. Do I seek out opportunities to learn about other cultures? 5. Do I respect the beliefs of individuals from other cultures? 6. Do I know how to access language interpreter services for patients? 3 Dimensions of Cultural Humility: Self-awareness. Learn about your own biases--we all have them. Respectful communication. Work to eliminate assumptions about what is “normal.” Learn directly from your patients—they are the experts on their culture and illness. Collaborative partnerships. Build your patient relationships on respect and mutually acceptable plans. SPIRITUAL ASSESSMENT “A pattern of experiencing and integrating meaning and purpose in life through connectedness with self, others, art, music, literature, nature and/ or a power greater than oneself.” Religion System of beliefs or practice of worship. Spiritual Distress When an individual’s sense of purpose or meaning of life is threatened, spiritual distress may result state of suffering related to the impaired ability to experience meaning in life through connections with self, others, the world, or a superior being. Let the patient do the talking Nurse should NOT offer solutions Nurse should help patient identify the problem and resources utilized in the past to cope with problems o “What helps you cope?” o “What is your source of strength? Source of hope?” o “Who are your support persons?”