Health Assessment
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  • 1.  
  • 2. BY: SATHISH R. M. SC (N), LECTURER, BKIN, DAUDHAR
    • HEALTH ASSESSMENT
  • 3. INTRODUCTION
    • Health is a state of wellbeing. (WHO)
    • Assessment is defined as a systematic , dynamic process by which the nurse through interaction with client, significant others and health care providers, collects and analyze data about the client. (ANA).
  • 4. COMPONENTS
  • 5. PURPOSES
    • To establish a data base of client’s normal abilities, risk factors that can contribute to dysfunction and any current alteration in function.
    • To get a clear picture of a client’s health status and health related problems.
    • To identify cause and extent of disease.
    • To identify the problems at early stage.
  • 6. Cont…
    • To determine the nature of treatment required for the client.
    • To get a holistic view of the client.
    • To contribute in medical research.
    • To identify client’s strength, weakness, knowledge, attitude, motivation, support systems and coping skills.
    • To compare clients health status with a ideal status.
  • 7. TERMINOLOGY
    • Diagnosis – It is the determination of the nature and extent of a disease.
    • Prognosis – It is the forecast of the course and duration of a disease.
    • Etiology – It is the science of the cause of a disease.
    • Signs – The presence of a disease that can been seen or elicited E.g. Fever.
    • Symptoms – Any evidence as to the nature and location of a diseases noted by the client.
  • 8. Cont…
    • Subjective Symptoms – When the symptoms are note by the client himself. E.g. Pain.
    • Objective Symptoms – When the symptoms are noted by the observer as well as by the client. E.g. Jaundice .
  • 9. HEALTH HISTORY
    • It is a collection of subjective data in detail regarding client’s health in a chronological order .
  • 10. Factors Affecting The Collection of Subjective Data
    • Physical setting
    • Client’s Personality and Behavior
    • Nurses Personality and Behavior
    • Communication Skill
    • Patient’s Problem
  • 11.
    • Biographic Data
    • Chief Complaints
    • History of present illness
    • Past health History
    • Family History
    • Occupational and Environmental History
    • Psychosocial History
    • Review of Systems
    FORMAT OF HEALTH HISTORY
  • 12.
    • Name, Address, Gender, Age, Marital Status, Occupation, Religion, Family Income (Monthly), Educational Qualification etc.
    BIOGRAPHIC DATA
  • 13. CHIEF COMPLAINTS
    • It is a brief assessment of client’s problem for which clients seeks medical care.
    • It should be written in clients statement.
  • 14. H/O Present Illness
    • Onset
    • Signs and Symptoms S&S
    • Duration
    • Treatment taken (If any)
    • Other complaints such as loss of appetite, insomnia, disorders of stomach etc.
    • Client’s Health Habits – Eating , Sleeping etc.
  • 15. PAST MEDICAL HISTORY
    • Childhood Illness – Mumps, Measles and so on.
    • Allergies
    • Medical disease – HT, DM, Anemia etc.
    • Surgery – Any H/O Surgery
    • Hospitalization – Any hospitalization in the past
    • Obstetric History – No of live births, abortions, mode of delivery
  • 16. FAMILY HISTORY
  • 17. Cont..
    • Family Tree (Pedigree Chart)
    • Information about family members
    • Family history of any illness (Diabetic Mellitus, Hypertension etc.)
  • 18. Occupational History
    • Collecting data regarding clients job, nature of job, environment in job, exposure to any hazardous substances if any?
  • 19. Psycho Social History
    • Smoking – Alcoholism
    • Food habits and Food fads
    • Likes and dislikes
    • Pattern of sleep
    • Exercises
  • 20. Review of Systems
    • Information is gathered system wise
  • 21. Thank you