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
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
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
2. Chief complaintsIdentify 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 HistoryThe 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.
Past Health HistoryA 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.
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.
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
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
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
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
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
Assessment techniquesPalpation Temperature Vibration Texture Position Moisture Size Organ size and location Presence of lumps or Rigidity or spasticity masses Tenderness, or pain
Percussion Assess underlying structures for location, size, density of underlying organs. Direct – sinus tenderness Indirect- lung percussion Blunt percussion- organ tenderness (CVA tenderness)
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)
Assessment techniquesAuscultation Listening to sounds produced by the body: Heart Blood vessels Lungs Abdomen Instrument: stethoscope Diaphragm – high pitched sounds Bell – low pitched sounds
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:
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
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