Health Assessment 2024-September PDF

Health Assessment Dr Amira Yahiya , Dr Wdad Alanazy ,Dr Mehru Ahmed  CONTENTS At the End of this presentation the students will be able to : Heath assessment "Understand the definition and components of health assessment." Vital Signs Iden...

Health Assessment Dr Amira Yahiya , Dr Wdad Alanazy ,Dr Mehru Ahmed  CONTENTS At the End of this presentation the students will be able to : Heath assessment "Understand the definition and components of health assessment." Vital Signs Identifying the components of vital signs. “Heath assessment Demonestrate HEALTH ASSESSMENT TECHNIQUES technique.”  Introduction  Nursing health assessment is a fundamental aspect of patient care, involving the systematic collection of comprehensive data to evaluate a patient's health status.  This process includes gathering information about the patient’s health history, conducting a thorough physical examination, and interpreting vital signs. Through health assessment, nurses identify potential health issues, monitor ongoing conditions, and provide a foundation for individualized care plans.  It is a critical skill that ensures holistic care by combining clinical observation with patient-centredd interaction, ultimately promoting better patient outcomes and enhancing the quality of care provided. 01 Definition of Health Assessment  Definition of Health Assessment Health Assessment is the systematic collection of patient data to: 1. Determine the patient’s current health status. 2. Identify potential health problems or risks. 3. Establish a baseline for ongoing care. This process is integral to developing a personalized care plan, tracking patient progress, and guiding clinical decision-making.  Definition of Health Assessment Key Terms: ○ Systematic: Follows a structured and organized approach. ○ Patient data: Includes subjective (what the patient reports) and objective (what you observe) data. EBP(Evidence Base practice) Tip: Health assessment is most effective when aligned with current research and clinical guidelines to ensure comprehensive and accurate data collection. Components of Health Assessment Components of Health Assessment 1-Health History: A narrative of the patient's medical background, including biographical data, family history, and lifestyle choices. ○ It helps understand factors that influence health, such as genetics, past medical issues, and social determinants. Purpose: To gather information that influences a patient's health status. Components: Biographical Data, Chief Complaint, HPI, Medical History, Family History, Social History, Functional Assessment. ○ Tips: Use open-ended questions and active listening. ○ EBP Tip: Incorporate cultural competence (e.g., ask about dietary preferences, and religious beliefs affecting care). Components of Health Assessment 2-Nursing History: Focuses specifically on the patient’s history of nursing interventions, past hospitalizations, and how they manage their health in day-to-day life. ○ Guides nursing interventions and care planning. Purpose: Specific nursing information to guide care. Focus on past and present nursing interventions. ○ Key components: ADLs (Activities of Daily Living), previous hospitalizations, nursing care plans, medication adherence. ○ EBP Tip: Motivational interviewing can improve patient cooperation and adherence to care plans. Components of Health Assessment 3-Vital Signs: Key physiological measurements that provide immediate insight into the patient’s health status. These include: ○ Temperature ○ Pulse ○ Respiration ○ Blood Pressure ○ Pain Assessment (the “fifth vital sign”) Components of Health Assessment 4- Physical Assessment: The hands-on examination of the patient, involves: ○ Inspection ○ Palpation ○ Percussion ○ Auscultation ○ Physical assessments help detect health issues not always apparent through health history or vital signs alone.  Role of Evidence- Based Practice (EBP): EBP refers to the integration of the best available research with clinical expertise and patient values to guide healthcare decisions. ○ Improves Patient Outcomes: EBP ensures that care is based on the most current and reliable evidence, leading to better health outcomes. ○ Standardizes Care: By adhering to evidence-based protocols, nurses can deliver consistent, high-quality care. ○ Reduces Risks and Errors: EBP helps in identifying potential risks, thus allowing for preventive measures that reduce the chances of complications.  Role of Evidence- Based Practice (EBP): Example of EBP in Health Assessment: ○ Using standardized pain assessment tools (e.g., Visual Analog Scale) based on research shows they improve pain measurement and management accuracy. ○ Updated guidelines on blood pressure management help clinicians identify hypertension earlier and provide better interventions. Introduction to Vital Signs  Vital signs Purpose: Vital signs as indicators of body function and health status. Vital signs include: Temperature, Pulse, Respiration, Blood Pressure, and Pain Assessment. EBP Tip: Use accurate, consistent methods for measurement to avoid variability in patient care. Importance of trend monitoring: Explain that changes over time may signal deterioration or improvement.  Temperature Temperature of the body tissues, is controlled by the hypothalamus (control center in the brain) – maintained within a narrow range. Skin temperature Rises & Falls in response to environmental conditions Depends on Blood flow to skin & atmosphere heat The body’s tissues & cells function best between the range from 36◦C to 37.5◦C Temperature is lowest in the morning, highest during the evening.  Temperature Purpose: Explain the measurement and significance of body temperature. Normal Range: 36.1°C to 37.2°C (97°F to 99°F) Methods of Measurement: Oral: Common for adults. Axillary: Common for infants and young children. Tympanic (Ear): Quick, but can be inaccurate if the technique is poor. Rectal: Most accurate, used for core temperature (typically +0.5°C compared to oral).  Temperature ○ Fever (hyperthermia): Body temperature above 38°C (100.4°F), signals infection or inflammation. ○ Hypothermia: Below 35°C (95°F), signals cold exposure or metabolic disorder. ○ EBP Tip: Use digital thermometers over mercury for faster, safer, and more accurate results.  Temperature 1. Fever (Hyperthermia) - Body Temperature Rise A rise in body temperature (fever) occurs due to pyogens, which are substances produced by the immune system in response to infection, inflammation, or other stimuli like cancer or autoimmune disorders. Pathological Mechanism: Infection or Inflammation. Inflammatory Disorders: Conditions like rheumatoid arthritis or lupus can trigger chronic inflammation, causing ongoing release of pyrogens and a persistent rise in body temperature.  Temperature 1. Fever (Hyperthermia) - Body Temperature Rise Malignancies: Some cancers, such as lymphoma, can cause fever due to the release of inflammatory cytokines by tumor cells or the body's immune response to the cancer. Heat-related Illness: Heatstroke: This is a form of hyperthermia that occurs when the body’s heat-regulation mechanisms are overwhelmed by external heat, leading to a dangerous rise in temperature above 40°C (104°F), which can cause cellular damage, organ failure, or death..  Temperature ○ Type of thermometers ○ Digital ‘stick' thermometers 1. Under the arm (axillary) digital thermometer is the preferred method for babies younger than 3 months of age. 2. Under the tongue (oral) digital thermometer is useful if your child is old enough to understand how to keep the thermometer under their tongue.  Temperature ○ Type of thermometers ○ Ear (tympanic) thermometers ○ Infrared thermometers ○ Strip-type thermometers  Temperature ○ Type of thermometers ○ Mercury thermometers ORAL no hot or cold drinks or Leave in place for posterior sublingual pocket – smoking 30 minutes prior to taking temp. 3 minutes placed under the tongue (close to carotid artery) must be awake & alert. not for small children AXILLARY good for children. Leave in place for place Bulb in center of axilla less accurate (no major blood 5-10 min. Lower arm position across vessels nearby) Measures 0.5 C lower chest sweat or perspiration affects than oral temp. reading RECTAL When unsafe or inaccurate by Leave in place for side lying with upper leg mouth (unconscious, disoriented or irrational) 2-3 minutes. flexed, insert lubricated bulb Measures 0.5 C higher (1-11/2 inch adult) (1/2 inch Not ideal for rectal surgery, than oral infant) diarrhea, GI dis, hemorrhoids EAR (TYMPANIC) Rapid measurement Leave in place for close to hypothalmus – Easy 2-3 seconds sensitive to core temp. Otitis media, cerumen, ear wax changes. Adult and Pedia can distort reading  Pulse Purpose: Measuring heart rate and rhythm. Content: ○ Normal Range: ○ Normal Pulse Rates: Adults: 60-100 bpm. ○ Children: 70-120 bpm (varies by age). ○ Athletes: May have a lower resting pulse rate (40-60 bpm). ○ Common Sites: Radial pulse: Wrist, most commonly used. Apical pulse: Heart, measured with stethoscope for 60 seconds. ○ Tachycardia: Pulse >100 bpm, could indicate fever, stress, dehydration. ○ Bradycardia: Pulse 20 breaths per minute, could indicate fever, anxiety, or lung disease. ○ Bradypnea: Slow breathing,