Health Assessment 2025 .pdf

Health Assessment University of Mosul College of Nursing Munther N. AL-Fattah Lec. BSc.N MSc. MSN 2024/2025 Collect of Nursing University of Mosul Purpose of Assessment The information gathered during an assessment is not merely c...

Health Assessment University of Mosul College of Nursing Munther N. AL-Fattah Lec. BSc.N MSc. MSN 2024/2025 Collect of Nursing University of Mosul Purpose of Assessment The information gathered during an assessment is not merely collected and recorded. It is used to evaluate health status and to make a judgment about 1. Whether a problem or potential problem exists that requires nursing intervention. 2.Status of a previously identified problem or condition in relation to projected outcomes. 3. Strengths present in the situation, be it an individual, family, or community, that can be used to help solve problems. Nursing process in Nursing Health Assessment Nursing process Based on the scientific method, the nursing process is a systematic way of approaching any health problem. To use the nursing process, you'll follow the following five steps: Assess the patient. Formulate nursing diagnoses. Plan your care. Implement your plan. Evaluate the results. 1 Collect of Nursing University of Mosul Assessment The first and most important step of the nursing process, assessment involves Collecting all the relevant information needed to solve a health problem. Interpretation of data. Nursing diagnoses After collecting all the appropriate data about a patient's health problem, you'll use it to formulate your nursing diagnoses. Unlike medical diagnoses, which focus on diseases, nursing diagnoses focus on the patient's response his actual and potential health problems. These responses may be physical, emotional, psychological, cultural, and spiritual. Plan of care Just as the nursing diagnoses grow from the assessment findings, the plan of care grows from your nursing diagnoses. Creating a useful plan takes nursing experience and awareness of the patient's individuality. This individuality, of course, should already be reflected in your nursing diagnoses. Implementation After you've established your plan, you need to put it into action. This may require: Interdependent actions, such as coordinating the contributions of other health care team members Dependent actions, such as carrying out a doctor's orders 2 Collect of Nursing University of Mosul Independent actions, such as applying nursing interventions. Implementation can be the most creatively demanding step of the nursing process Evaluation In this last step of the nursing process, you evaluate the success of your plan by determining whether goals have been met. Thus, this step allows you to maintain a dynamic plan of care over time as the patient moves through the stages of illness and recovery. Data collection. The types of Data can be objective or subjective. 1. Objective data (Signs) are detectable by an observer or can be tested against an accepted standards. They can be seen, heard, felt, smelled, or measured. For example, a discoloration of skin, a blood pressure reading, the act of crying,, swollen joint, or a hand tremor. On the other hand the Objective data can be collected by physical examination, diagnostic and laboratory test results, pertinent nursing and medical literature 2. Subjective data (Symptoms) are apparent only to the person affected and can be described or verified only by that person. Itching, pain, and feeling worried are examples of subjective data. Subjective data can collected from the client, family, significant others, health care team members, and health records. 3 Collect of Nursing University of Mosul Sources of Data 1. Primary (direct source): the patient; is always the best source of data. The client can usually provide subjective data that no one else can offer 2. Secondary (indirect source): Significant others, health personnel, medical records. The Role of the Nurse in Health Assessment 1. Prepare patient, environment, and equipment needed for assessment. 2. Explain the assessment procedure and expected patient's feeling during examination to patient or family. 3. Ensure that all needed format and documentation papers are included in patient's file. 4. Keep privacy for the patient. 5. The nurse obtains the patient's health history and performs a physical assessment, which can be carried out in a variety of settings, including: (the acute care setting, clinic or outpatient office, school, long-term care facility, or the home). 6. A growing list of nursing diagnoses is used by nurses to identify and categorize patient problems that nurses have the knowledge, skills, and responsibility to treat independently. 4 Collect of Nursing University of Mosul 7. Reporting and documenting the procedure with its finding. 8. Orient the patient about the result of assessment including normal and abnormal findings, and the actions that should be carried out to correct the abnormalities. Guidelines In conducting health assessment A. Preparing the patient to ensure an accurate assessment and physical examination. The patient must be properly prepared physically and psychologically. To prepare the patient properly, the nurse will: 1.prepare for patient's physical comfort, by allowing the opportunity to empty the bowel and bladder. 2. keep privacy while the patient changes into a gown and gives patient time to understand, assisting if necessary. 3. Help the patient assume proper positions during examination so that body parts are accessible and the patient stay comfortable. 4. Thoroughly explain what will be done, what the patient should expect to feel, and how the patient can cooperate. 5. Encourage patient to ask questions and mention discomfort felt during examination. 6. Have a witness or third person present in the examination room during examination of genitalia when patient and nurse are of opposite genders. 5 Collect of Nursing University of Mosul 7. Pace or time examination process according to the patient's physical and emotional tolerance. B: preparing the environment To promote patient comfort and ensure an efficient examination, the examination room should have the following features. 1. Privacy for the patient. 2. Curtains or dividers to enclose the patient's bed. 3. Warm room with comfortable temperature. 4. Proper examination clothing for the patient. 5. Adequate lighting. 6. Control of outside noises. 7. Precautions to prevent interruptions by visitors or other health cr personnel. 8. A bed or table set at examiner's waist leve C. preparing equipment. The nurse uses a variety of equipment throughout the assessment process. Equipment and supplies needed for performing a physical examination Equipment Function Incontinent sheet Protect bed linen from getting soiled Drapes Ensure privacy for the client. Paper towel Prevent cross infection Gown for patient For easy access of different body parts. Paper towel Dry hands and arms and to wipe equipment. 6 Collect of Nursing University of Mosul Percussion hammer Test various reflexes of the body. Height/ weight scale For measure body weight and height. Specimen containers Collect specific sample for laboratory evaluation. Sphygmomanometer and cuff Measure blood pressure Stethoscope Auscultator different bogy sounds Tape measure Measure body parts. e.g. abdominal girth. Thermometer Measure body temperature Tongue depressor Facilitate visualizing pharynx and tonsils. Wrist watch with second hands Record time of examination as needed. Cotton applicators Examine superficial sensation of the skin including corneal reflex. Eye chart (Snellen chart Test visual acuity Flashlight Facilitate visualization for Ear, Nose, and Throat and to check corneal reflex. Lubricant Lubricate instrument used in rectal and vaginal examination. Otoscope Examine outer ear and the tympanic membrane Otoscope Examine outer ear and the tympanic membrane Ophthalmoscope Examine fundus of the eye. Sterile safety pin Examine deep sensation of the skin. Tuning fork Test hearing acuity Vaginal speculum Facilitate vaginal examination Proctoscopy Facilitate rectal examination Spirometer Facilitate breathing examination 7 Collect of Nursing University of Mosul Ethical issues Whenever information is elicited from a person through a health history or physical examination, The person has the right to know why the information is sought and how it will be used. For this reason, it is important: to explain what the history and physical examination are, how the information will be obtained, And how it will be used. It is also important that the person be aware that the decision to participate is voluntary. A private setting for the history interview and physical examination promotes trust and encourages open, honest communication. After the history and examination are completed, the nurse selectively records the data pertinent to the patient's health status. This written record of the patient's history and physical examination findings is then maintained in a secure place and made available only to those health professionals directly involved in the care of the patient. This protects confidentiality and promotes professional conduct. ‫غير مسؤول عن أي خطأ بالنقل من الملزمة المستنسخة‬ https://t.me/CollegeOfNursing0 8