Nursing Health Assessment


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Nursing Health Assessment

  1. 1. Assessment is refers to systematicappraisal of all factors relevant to aclient’s health.Health Assessment components•Nursing Health History•Physical Examination•Records & reports•Review of lab & diagnostic test results
  2. 2. Nursing Health HistoryThrough the health history, the nurse elicits a detailed, accurate, and chronologic health record as seen from the client’s perspective.Data collection techniques Provide privacy and comfort for the patient Greet the client and introduce yourself Establish a verbal contract with the client that delineates the purpose of the history taking session, the client role , and a time limit for the interview Ask open- ended questions  how may I help you
  3. 3. Components of Nursing History1.Biographical Data Date & Time Client’s name, address, telephone #, social ID#. Name , address, telephone#, of person to contact if emergency or other situation. Gender ,race, ethnic origin, religious preference. Age , birth date, birth place, and marital status. Occupation and level of education Health insurance
  4. 4. 2. Chief complaintsIdentify the client reason for seeking health care. A brief statement (client own words) for the current problem. A description of onset and duration of problemPresent Health HistoryThe history of present health concern or illness is the single most important factor in helping the health care team to arrive at a diagnosis or determine the person needs A detailed chronologic statement of the problem, beginning with when the client last felt well and ending with a description of the current condition.
  5. 5. Past Health HistoryA detailed summary of the person’s past health is an important part of the database. Immunization status Known allergies Childhood illness Adult illness Psychiatry illness Injuries – burns, fractures, head injuries Hospitalization Surgical and diagnostic procedures Medication history Use of alcohol and other drugs.
  6. 6. Family History Cancer Hypertension Heart disease Diabetes Epilepsy Mental illness Tuberculosis Kidney disease Arthritis Asthma Alcoholism obesity
  7. 7. Review of systemsSubjective information about what the patient feels or sees with regard to major systems of the bodySkinRash, itching, change in pigmentation, or texture, sweating, hair growth and distribution, condition of nails.SkeletalStiffness of joints, pain, deformity, restriction of motion, swelling, redness, heat.HeadHeadaches , dizziness, syncope, head injuries.EyesVision, pain, diplopia, photophobia, blind spots, itching, burning, discharge, recent changes in appearance of vision, contact lens , glaucoma, cataracts.
  8. 8. EarsHearing acuity, earache, discharge tinnitus, vertigo.NoseSense of smell, frequency of colds, obstruction, epistaxis, sinus pain, use of any nasal spray.TeethPain, bleeding, swollen, extractions, dentures,.Mouth and TongueSoreness of tongue or buccal mucosa, ulcers, swellingThroatSore throat, tonsillitis, hoarseness, dysphagia.NeckPain, stiffness, swelling, enlarged glands or
  9. 9. EndocrineGoiter, thyroid tenderness, tremors, weakness, tolerance to heat and cold, changes in hat or glove size, changes in skin pigmentation, libido, bruisability, muscle cramps, polyuria, polydipsia, polyphagia, hormone therapy.RespiratoryPain in the chest relatioship to respiration, dyspnea, wheezing, cough, sputum, hem optysis, night sweats, last chest X-Ray, exposure to TB.CardiacPresence of pain or distress and location, palpitations, Orthopnea, edema, cyanosis, BP, last ECG.Hematologic
  10. 10. Lymph nodesEnlargement, tenderness,GastrointestinalAppetite and digestion, intolerance to certain classes of food.Pain associated with hunger or eating, eructation, regurgitation, heartburn, na usea, vomiting, hematemesis.Regularity of BM, hemorrhoids, jaundice, h/o of ulcer, gall stones, polyps, tumorsGenitourinaryDysuria, urgency, frequency, hematuria, nocturia , polydipsia, poly uria, oliguria, edema of the face, hesitency , stress incontinence, passage of stones, h/o STD
  11. 11. NeuromuscularMental status – orientation to time , place, person.Memory – recalling past medical historyCognitive levelPatient ‘s description of personalityPreseence of tics, twitching, weakness, paralysis, tremor, In coordination, fatigue, sensory loss, temperature, touch, muscle pain, cramps.General constitutional symptomsFever, chills, malaise, fatigability, recent loss or
  12. 12. PHYSICAL EXAMINATIONGeneral principles: Physical examination is the second component of a complete Nursing health assessment. Examine the client in quiet, warm , well lighted room; consider privacy and comfort. Practice and adhere to standard precaution throughout the entire physical examination.Assessment techniques: Inspection Auscultation Palpation percussion
  13. 13. Assessment techniquesPalpation Temperature  Vibration Texture  Position Moisture  Size Organ size and location  Presence of lumps or Rigidity or spasticity masses  Tenderness, or pain
  14. 14. Percussion Assess underlying structures for location, size, density of underlying organs. Direct – sinus tenderness Indirect- lung percussion Blunt percussion- organ tenderness (CVA tenderness)
  15. 15. Assessment techniquesPercussion sounds Flatness – bone or muscle Dullness – heart, liver, spleen Resonance – air filled lungs (hollow) Hyperresonance – emphysematous lung (hyperinflated) Tympany – air-filled stomach (drumlike)
  16. 16. Assessment techniquesAuscultation Listening to sounds produced by the body: Heart Blood vessels Lungs Abdomen Instrument: stethoscope  Diaphragm – high pitched sounds  Bell – low pitched sounds
  17. 17. Vital signsHeight and weightGeneral appearance:Race, sex, general physical development, nutritional state, mental alertness, evidence of pain, restlessness, body posture, clothes, apparent age, hygiene, grooming.Skin – observe (skin color, pigmentation, lesions, jaundice, c yanosis, scars, superficial vascularity, moisture, edema, color of mucous membrane, hair distribution, nails )Palpation:
  18. 18. HeadObserve ( symmetry of face, configuration of skull, hair colorand distribution, scalp.Palpation: hair texture, masses, swelling or tenderness of scalpEyes and VisionEye brows Normal or AbsentEye lashes Infection , styEye lids Edema, lesions, ectropian, entropian.Eye balls Sunken, protrudedConjunctiva Pale, red, prulentSclera JaundicedCornea and iris Irregularities, abrasionsPupils Dilated , constricted, reaction to lightLens Opaque, or transferentFundus Congestion, haemorrhaig spotsEye muscles Strabimus
  19. 19. EarsDischarges, cerumen obstructing the ear passage, hearing acuityNoseDischarges, septal deviations , polypMouth and pharynxLipsredness , swelling, cracked, cyanosis, angular stomatitis.Odour of the mouthfoul smellingTeethdiscolorations , dental caries.Mucous membrane and gumsUlceration, bleeding, swelling , pus formation.TonguePale, dry, lesions, tongue tie.Throat and pharynxenlarged tonsils, redness, pus
  20. 20. NeckLymph nodes: enlarged , palpable.Thyroid glands: enlargedROM: Flexion, extension, and rotationChestThorax – shape, symmetry of expansion, postureBreath Sounds: sigh , swish, rustle, wheezing, rales, crepitations, pleural rub.Heartsize , location, cardiac murmurBreastEnlarged lymph nodes.
  21. 21. AbdomenObservation : Skin rashes, hernia, scars, ascites, distension, pregnancy.Auscultation: Bowel sounds, fetal Heart Sounds.Palpation: liver margin, palpable spleen, tenderness , inguinal hernias.Percussion: presence of gas, fluid or mass.ExtremitiesMovements of joints, tremors, anke edema, clubbing of fingers, varicose veins, reflexes.Edema RATING ASSESSMENT 1+ 5mm depth , recovers immediately 2+ 8-10 mm depth , duration 10-15 sec 3+ 11-20mm , duration 15-30sec 4+ >20mm , duration >30sec
  22. 22. Back spina bifida , curvesGenitals and Rectum:Inguinal lymph glands – enlarged , palpablePatency of urinary meatus and rectum (infant)Descent of testes ( Infant)Vaginal Discharges, presence of STD, haemorrhoids, enlarged prostate gland, pelvic masses.Neurological:Co-ordination , reflexes, equilibrium, sensation