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  1. 1. Health Assessment Nhelia B. Perez RN MSN Northeastern College College of Nursing Santiago City, Philippines
  2. 2. NEEDS DEFINED <ul><li>Basic human needs are matters such as food, water, safety, and love that are necessary for survival and health. </li></ul>
  3. 3. MASLOW’S HIERARCHY OF BASIC HUMAN NEEDS <ul><li>A theory that nurses can use to understand the relationship among basic human needs when providing care. The hierarchy of human needs arranges the basic needs in five levels of priority: Physiological, Safety & Security, Love & Belonging, Esteem & Self-Esteem, and Self-actualization. </li></ul>
  4. 4. PHYSIOLOGICAL NEEDS <ul><li>Have the highest priority in Maslow’s hierarchy. An individual who has several unmet, needs generally seeks first to fulfill physiological needs. O2, Fluids, Nutrition, Temperature, Elimination, Shelter, Rest and Sex are human physiological needs. </li></ul>
  5. 5. OXYGEN <ul><li>The most essential physiological need. The body depends on oxygen for moment-to-moment survival. </li></ul>
  6. 6. FLUIDS <ul><li>The human body requires a balance between intake and output of fluids. Dehydration and edema indicate unmet fluid needs. </li></ul>
  7. 7. NUTRITION <ul><li>The human body has an essential need for nutrients, although it can survive without food longer than without fluids. </li></ul>
  8. 8. TEMPERATURE <ul><li>The body can function normally within only a narrow temperature range – 37 degrees Centigrade (+/- 1 degree). Also recorded as 98.6 degrees Farenheit. Body temperatures outside this range can result in injuries, permanent effects such as brain damage, or death. </li></ul>
  9. 9. ELIMINATION <ul><li>The elimination of waste materials is one of the body’s metabolic processes. Waste products are eliminated by the lungs, skin, kidneys, and intestines. </li></ul>
  10. 10. SHELTER <ul><li>Although most people have some kind of shelter, sometimes it is substandard and does not offer full protection. Disasters such as floods, tsunamis, fire, hurricanes, tornados, earthquakes, and avalanches can render an entire community homeless. </li></ul>
  11. 11. REST <ul><li>Every person has a basic physiological need for regular rest. The amount of sleep needed varies, depending on the person’s quality of sleep, health status, activity patterns, lifestyle, and age. Patients with chronic disease require more rest than a healthy person of the same age. </li></ul>
  12. 12. SEX <ul><li>Sex is considered by Maslow (1970) to be a basic physiological need that generally takes priority over higher-level needs. Sexual needs and the manner in which they are met are influenced by age, sociocultural background, ethics, value, self-esteem, and level of wellness. </li></ul>
  13. 13. SAFETY & SECURITY NEEDS – MASLOW’S 2 ND TIER <ul><li>Next in priority after the client’s physiological needs are needs for physical and psychological safety and security. </li></ul>
  14. 14. PHYSICAL SAFETY <ul><li>An infant enters the world totally dependent on others for needs and physical safety. As the infant grows and develops, greater independence is gradually achieved. Adults are generally able to provide for their physical safety, but the ill and handicapped may need help. </li></ul>
  15. 15. PSYCHOLOGICAL SAFETY <ul><li>To be safe & secure psychologically, a person must understand what to expect from others, including family members & health care professionals (including procedures & experiences). Everyone feels some threat to psychological safety with new & unfamiliar experiences. </li></ul>
  16. 16. LOVE & BELONGING NEEDS – MASLOW’S 3 RD TIER <ul><li>The next priority after physiological and safety needs is the need for love & belonging. People generally need to feel that they are loved by their family and that they are accepted by peers and the community. Only after individuals feel safe & secure do they have the time & energy to seek love & belonging & to share that love with others. </li></ul>
  17. 17. ESTEEM & SELF-ESTEEM NEEDS – MASLOW’S 4 TH TIER <ul><li>People need a stable sense of self-esteem, as well as the feeling that they are held in regard by others. The need for self-esteem is linked to the desire for strength, achievement, adequacy, competence, confidence, & independence. People also need recognition or appreciation from others. </li></ul>
  18. 18. SELF-ESTEEM (cont’d) <ul><li>When esteem & self-esteem needs are both met, a person feels self-confident and useful. If needs for self-esteem and esteem of others are unfulfilled, a person may feel helpless and inferior. </li></ul>
  19. 19. NEED FOR SELF-ACTUALIZATION – MASLOW’S 5 TH TIER <ul><ul><li>The highest level of human needs. Theoretically, when people have met all of the lower level needs, it is by self-actualization that they achieve their fullest potential. Self-actualized people have a mature, multidimensional personality. They are able to assume & complete multiple tasks, & they achieve fulfillment from the pleasure of a job well done. They do not depend on opinions of others, and handle their doubts realistically. </li></ul></ul>
  20. 20. HOW ILLNESS AFFECT NEEDS <ul><li>In all cases an emergency physiological need takes precedence over a higher level need. With one client the need for self-esteem may be a higher priority than a long-term nutritional need, whereas for another client, this may be reversed. </li></ul>
  21. 21. NURSE’S ROLE (Needs & Illness) <ul><li>To provide the most effective care, the nurse must understand relationships among different needs for the individual. Furthermore, although the hierarchy of needs suggests that one need should be met before another, nursing care often addresses two or more at the same time. The nurse provides care for clients with many needs because illness often disrupts the ability to meet needs on different levels. </li></ul>
  22. 22. FACTORS AFFECTING NEEDS <ul><li>Health </li></ul><ul><li>Illness </li></ul><ul><li>Personality </li></ul><ul><li>Mood </li></ul><ul><li>Socio-economics </li></ul><ul><li>Cultural groups </li></ul><ul><li>Environmental disruptions </li></ul>
  23. 23. PROBLEM VS NEED <ul><li>Needs are matters necessary for survival and health. </li></ul><ul><li>Problems are unmet needs. </li></ul>
  24. 24. ACTUAL VS POTENTIAL PROBLEM <ul><li>Actual Problem: A need is evident and must be met (Example: SOB/Shortness of Breath – give oxygen, raise head of bed, begin CPR) </li></ul><ul><li>Potential Problem: A foreseeable problem that is preventable or must be watched for (Example: Bedridden patient – turn every 2 hours to prevent skin breakdown) </li></ul>
  25. 25. GOOD HEALTH CHARACTERISTICS <ul><li>Enjoy being with other people (trust, respect others, respect diversity, give/receive love) </li></ul><ul><li>Enjoy being alone ( Self-respect/ confidence, Recognizes assets/short comings, Can laugh at self, derives satisfaction from simple pleasures) </li></ul><ul><li>Able to meet demands of life (Sets realistic goals, Makes own decisions, Responsible for self/choices, Welcomes new experiences/adaptable, Realizes everyone meets disappointment and have stress & problems and handles this with honest emotion. </li></ul>
  26. 26. MENTAL HEALTH ASSESSMENT <ul><li>MENTAL AND EMOTIONAL STATUS: A great deal can be learned about mental capacities and emotional state by simply interacting with a patient. To ensure an objective assessment the nurse considers the patient’s cultural & educational background, values, beliefs, & previous experiences. </li></ul>
  27. 27. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>LEVEL OF CONSCIOUSNESS: The level of consciousness exists along a continuum, from full awakening, alertness, and cooperation to unresponsiveness to any form of external stimuli. </li></ul>
  28. 28. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>BEHAVIOR AND APPEARANCE: Behavior, moods, hygiene, grooming, and choice of dress reveal pertinent information about mental status. The nurse must be perceptive of mannerisms & actions during the entire physical assessment. The nurse notes non-verbal as well as verbal behavior. </li></ul>
  29. 29. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>LANGUAGE: The ability of an individual to understand spoken or written words and to express their self through writing, words, or gestures is a function of the cerebral cortex. The nurse assesses the client’s voice inflection, tone, and manner of speech. </li></ul>
  30. 30. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>INTELLECTUAL FUNCTION: Intellectual function includes memory (recent, immediate, and past). Knowledge, abstract thinking, association, and judgment. However, because cultural and educational background influence the ability to respond to test questions, the nurse should not ask questions related to concepts or ideas with which the client is unfamiliar. </li></ul>
  31. 31. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>MEMORY: The nurse assesses immediate recall and recent and remote memory. Often a problem with memory becomes apparent when the nurse takes the nursing history. </li></ul>
  32. 32. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>KNOWLEDGE: The nurse can assess knowledge by asking clients what they know about their illnesses or the reason for seeking health care. By assessing knowledge the nurse determines client’s abilities to learn or understand. </li></ul>
  33. 33. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>ABSTRACT THINKING: Interpreting abstract ideas or concepts reflects the capacity for abstract thinking. A higher level of intellectual functioning is required for an individual to explain complex ideas. The nurse notes whether the client’s explanations are relevant. </li></ul>
  34. 34. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>ASSOCIATION: Another higher level of intellectual function involves finding similarities or associations between concepts. </li></ul>
  35. 35. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>JUDGMENT: Judgment requires a comparison and evaluation of facts and ideas to understand their relationships and to form appropriate conclusions. The nurse attempts to measure the pt’s ability to make logical decisions. By assessing judgment the nurse also measures the pt’s ability to organize thought processes. </li></ul>
  36. 36. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>CRANIAL NERVE FUNCTION: The nurse may assess all 12 cranial nerves or test a single nerve or related group of nerves. </li></ul>
  37. 37. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>SENSORY FUNCTION: The sensory pathways of the central nervous system conduct sensations of pain, temperature, position, vibration, & crude & finely localized touch. Different nerve pathways relay the sensations. For most clients a quick screening of sensory function is sufficient unless there are symptoms of reduced sensation, motor impairment, or paralysis. </li></ul>
  38. 38. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>MOTOR FUNCTION: An assessment of motor function includes the same measurements made during the musculoskeletal examination. The cerebellum coordinates muscular activity to producing smooth, steady, and efficient movements of muscle groups. The maintenance of balance & equilibrium is also a function of the cerebellum. </li></ul>
  39. 39. MENTAL HEALTH ASSESSMENT (cont’d) <ul><li>COORDINATION AND BALANCE: The nurse observes smoothness and balance of movements. </li></ul><ul><li>REFLEXES: Eliciting reflex reactions allows the nurse to assess the integrity of sensory & motor pathways of the reflex arc & specific spinal cord segments. Assessment of reflexes does not determine higher neural center functioning. </li></ul>
  40. 40. PERSONALITY - FREUD <ul><li>Coined the terms PSYCHOANALYSIS and SEXUALITY. </li></ul><ul><li>Freud divided the growth/development of the human into 5 stages from birth to adulthood: (1) Oral – up to1 yr , (2) Anal-Expulsive – 1-3 yrs, (3) Phallic – 4-6 yrs,(4) Latent – 7-12 yrs, and (5) Genital – 12 yrs onward. </li></ul>
  41. 41. PERSONALITY - ERIKSON <ul><li>Erikson compares the evolution of the personality to the evolution of tissues in the early stages of embryonic development. There is a timetable inherent in the development of various specialized tissues, organs, & systems in the physical body. During each stage there is a DEVELOPMENTAL TASK accomplished which lays the groundwork for the next stage. </li></ul>
  42. 42. ERIKSON’S DEVELOPMENTAL STAGES <ul><li>TRUST vs MISTRUST (Infancy: birth to 9 months) </li></ul><ul><li>AUTONOMY vs SHAME & DOUBT (Toddler: 9 months to 36 months) </li></ul><ul><li>INITIATIVE vs GUILT (Early childhood/PreSchooler: 4-5 yrs) </li></ul><ul><li>INDUSTRY vs INFERIORITY (Middle childhood/Early Adolescence: 6-11 yrs) </li></ul>
  43. 43. ERIKSON’S DEVELOPMENTAL STAGES (cont’d) <ul><li>EGO IDENTITY vs ROLE CONFUSION (Puberty & Late Adolescence: 12-20 yrs) </li></ul><ul><li>INTIMACY vs ISOLATION (Early adulthood: 20-40 yrs) </li></ul><ul><li>GENERATIVITY vs STAGNATION (Middle adulthood: 40-60 yrs) </li></ul><ul><li>EGO INTEGRITY vs DESPAIR (Late adulthood: 60 yrs and older) </li></ul>
  44. 44. ANXIETY - DEFINED <ul><li>A critical maturational phenomenon related to change, conflict, & perceived control of the environment. Anxiety is a vague & unpleasant feeling that produces many somatic effects or physical sensations in the body: tenseness, tremors, cardiovascular excitation, GI tightening, restlessness. It causes feelings of apprehension, helplessness & general distress. </li></ul>
  45. 45. ANXIETY – DEFINED (cont’d) <ul><li>When a person is anxious, they may not be able to identify the focus or reason for the emotional distress. Until the cause of anxiety is identified, the feeling will continue as an unspecific and unpleasant physical and mental state. </li></ul>
  46. 46. COPING - DEFINED <ul><li>The way the mind responds to awarenesses that are challenging or threatening. It is important to be aware that an event perceived as threatening by one person may be a challenge to another, and be perceived by a third person as quite normal. Because of the varying subjective experiences of stress, coping responses are also uniquely different. </li></ul>
  47. 47. COPING MECHANISMS <ul><li>DENIAL: Shuts Out – Rejects painful information – The ego senses a severe threat. </li></ul><ul><li>DISPLACEMENT: Transfer of feelings to another, safer, object or person – Anger is the most common cause. </li></ul><ul><li>RATIONALIZATION: Making logical sounding excuses that conceal the real reason for actions, thoughts, or feelings. Very common. </li></ul>
  48. 48. COPING MECHANISMS <ul><li>REGRESSION: Returns to an earlier less stressful stage of development – Behavior is often childlike & uninhibited. </li></ul><ul><li>REPRESSION: Storing painful thoughts, feelings & memories in the unconscious – may be unable to retrieve. </li></ul><ul><li>SUBLIMATION: Channels urges or desires into acceptable alternatives – usually healthy ones. </li></ul>
  49. 49. STRESS - DEFINED <ul><li>Stress is a word in common use today. The word stress is used in 2 ways. The first refers to the subjective feeling of tension experienced in the physiologic, intellectual & emotional realms as a response to environmental events that are perceived as threatening. The second refers to those environmental events that result in internal feelings of stress. </li></ul>
  50. 50. STRESS – DEFINED (cont’d) <ul><li>Stress is any situation in which a non-specific demand requires an individual to respond or take action. It involves physiological & psychological responses. It can threaten emotional well-being, how a person perceives reality, solves problems, thinks and a person’s relationships and sense of belonging. </li></ul>
  51. 51. STRESS – DEFINED (cont’d) <ul><li>Stimuli preceding or precipitating change are called STRESSORS. Stressors represent an unmet need & may be physiological, psychological, social, environmental, developmental, spiritual, or cultural. Stressors can generally be classified as internal or external. </li></ul>
  52. 52. STRESS – DEFINED (cont’d) <ul><li>INTERNAL STRESSORS originate inside a person (fever, pregnancy, cancer, guilt) </li></ul><ul><li>EXTERNAL STRESSORS originate outside a person (environment temperature changes, a change in family or social role, or peer pressure). </li></ul>
  53. 53. COPING WITH STRESS <ul><li>PHYSIOLOGICAL ADAPTATION to stress is the body’s ability to maintain a state of relative balance. It is a dynamic form of equilibrium in the body’s internal environment. The internal environment constantly changes, and the body’s adaptive mechanisms continually function to adjust to these changes and thus to maintain equilibrium or homeostasis. </li></ul>
  54. 54. HOMEOSTASIS DEFINED <ul><li>Maintained by physiological mechanisms that control body functions & monitor body organs. These are mostly controlled by the nervous & endocrine systems & do not involve conscious behavior. The body makes adjustments in heart rate, respiratory rate, blood pressure, temperature, fluid & electrolyte balance, hormone secretions, and level of consciousness – all directed at maintaining adaptation. </li></ul>
  55. 55. MAINTAINING GOOD MENTAL HEALTH – BROAD CATEGORIES <ul><li>(1) Relaxation </li></ul><ul><li>(2) Exercise </li></ul><ul><li>(3) Life style changes </li></ul><ul><li>(4) Laughter </li></ul>
  56. 56. MAINTAINING GOOD MENTAL HEALTH – SPECIFIC IDEAS <ul><li>If you can’t change a situation – ADAPT </li></ul><ul><li>Accept your mistakes – move on & LEARN </li></ul><ul><li>If you must worry – ASSIGN a timeframe </li></ul><ul><li>Don’t act on emotion – WAIT </li></ul><ul><li>Get interested in others – ALTRUISM </li></ul><ul><li>Broaden your interests - GROW </li></ul><ul><li>Live to have “PEACE OF CONSCIENCE” </li></ul>