Health Assessment.pptx

HEALTH ASSESSMENT
KALUPA VINCENT

INTRODUCTION TO HEALTH
ASSESSMENT
Health assessment is a plan that aims to identify
the specific health needs of a person
It aims at addressing the health care needs of
individuals in the health care settings
Health assessment is a comprehensive technique
which aims at detecting health problems early
even before signs and symptoms appear

INTRODUCTION TO HEALTH
ASSESSMENT
It is done to detect illnesses even in persons who
may look and feel well
It evaluates health status of an individual along
the health continuum
It establishes where on the health continuum the
individual is and helps to address health
problems

MAIN OBJECTIVE
At the end of the session, student nurses should
be able to demonstrate an understanding on the
techniques of health assessment in relation to
nursing practice

SPECIFIC OBJECTIVES
At the end of the session, student nurses should
be able;
Explain the process of conducting health
assessment in relation to nursing

HEALTH ASSESSMENT
Health assessment
This refers to a systematic process of obtaining
correct and complete data or information from
the patient.
It is a plan of care that identifies the specific
needs of an individual and aims at formulating
ways of solving them

HISTORY TAKING
During history taking, the following are the
information collected;
Demographic data e.g. age and sex; address;
marital status
Family history
Social and occupational history

HEALTH ASSESSMENT
Health assessment employs two techniques;
1. History taking
2. Physical examinations

HISTORY TAKING
History Taking
This is also referred to as ‘clinical interview’.
It is a planned discussion that is aimed at
establishing the health needs and health problems
of the client.
It is usually conducted before physical
assessment.

HISTORY TAKING
Demographic data
Name of client.
Age
Sex.
Address. (residential)
Marital status
Next of kin.
Religion.
Denomination
Nationality
Tribe.
Occupation

HISTORY TAKING
Presenting complaints
History of presenting illness; history of previous
illnesses
Treatment history

HISTORY TAKING
Presenting complaints
The presenting complaint is simply the
problem, which made the patient seek medical
help.
A nurse kindly ask the patient;
What has brought you to the clinic today?

HISTORY TAKING
The History of the Present Illness
Ask the patient to tell you the story of the illness
from the beginning.
Allow the patient to continue without
interruption.
If the patient is anxious or nervous, you will need
to use tactful encouragement.

HISTORY TAKING
For talkative patients, try to direct their account
of events.
Some patients use medical terminologies without
knowing their meaning; encourage such patients
to tell you what they actually feel to be wrong
Friends/relatives may accompany the patient;
always talk to the patient first

HISTORY TAKING
Symptom analysis
In symptom analysis, it is important to consider
the course or shape of illness, reason for
presentation and finally review of systems
Components of symptom analysis, you may use
this mnemonic OLDCART

HISTORY TAKING
O – Onset of illness
L – Location
D – Duration
C – Characteristics
A – Aggravating factors
R – Relieving factor
T – Treatment

HISTORY TAKING
O.L.D.C.A.R.T
Onset: When did the pain start?
Location: Where is the pain?
Duration: For how long have you been feeling
that pain? When did it start?

HISTORY TAKING
Characteristics: How is the pain? Is it stabbing?
Burning? Pricking? Is it localized or it originates
from a certain body part and moves to other
parts?
Aggravating factor: What worsens the pain? Is
it coughing? Breathing?
Relieving factor: What lessens/reduces the pain?
Treatment: What drugs or treatment are you
receiving?

HISTORY TAKING
The History of Previous Illness
Evaluation of the previous history will help you
to get an insight about the health status of the
patient up until now.
The previous illness history should include;
Operations,
Treatment for the previous illnesses

HISTORY TAKING
The Family History
It is important to evaluate the family history of
your client.
Evaluation of family history will help you to
determine the health of the immediate family
members.
It will also help you to know whether your client
is at risk of developing certain conditions which
run in families.

HISTORY TAKING
Inquire about hereditary disorders in the family.
Ask if there is any family member with similar
symptoms

HISTORY TAKING
The Social History
The patient’s physical and emotional
environment is a greater determinant of health
and illness
One's lifestyle as a huge bearing on their health
and wellness

HISTORY TAKING
Ask your patient questions such as;
What do you do during your spare time?
Type of housing
Do you take alcohol?
Smoke?
Exercise?
Sanitation (water and refuse disposal)

HISTORY TAKING
Occupational History
Certain occupations may predispose to
conditions such as prolonged exposure to
radiation may lead to cancers.
Ask your client whether they have been exposed
to noxious substances at work, number of work
hours, nature of work e.g. director, underground
mine worker

HISTORY TAKING
Menstrual History
Women should be asked about menstruation i.e.
last normal menstrual period, regularity duration,
amount of flow, dysmenorrhea, menstrual
tension, history of taking oral contraception as
some conditions like ectopic pregnancy, uterine
mass are associated with some family planning
methods

HISTORY TAKING
Obstetric History
Data on a woman’s experience of childbirth,
including abortions number of pregnancies,
deliveries whether normal or had complications,
health during pregnancy and whether those
children are alive or they are dead.

What are the Phases of the Nursing
Process???

PHASES OF NURSING PROCESS
The Nursing Process has five (5) distinct
phases;
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

ASSESSMENT
It is an art of collection of
comprehensive data pertinent to the
patient’s health or situation.

PHASE 1: ASSESSMENT
This is the first phase of the Nursing Process
and it involves;
1. Collection of data
2. Documentation of data
3. Data organisation
4. Validation of data
5. Analysis of data

PHASE 1: ASSESSMENT
Assessment employs two (2) vital tequiniques,
namely
History taking -collection of subjective data
Physical examination -collection of objective
data

PHASE 1: ASSESSMENT
Objective data
Dyspnea
Pallor
Jaundice
Wheezing
Oedema
Wasting

PHASE 1: ASSESSMENT
Subjective data
For how long have you experienced the
symptoms?
What is the nature of the pain?
What are the exacerbating factors of pain?
What are the relieving factors?

SOURCES OF DATA
The sources of data can be classified into two
(2) broad categories;
Primary data: usually, the patient is the
primary source and usually the best source of
information.
Secondary data: Family and significant others
may provide information about the illness of
their relatives

SOURCES OF DATA
Health Care Team Members
• Physicians and other members of the health
care team can provide information about the
patient illness.
• During nurses’ handover, nurses exchange
information about a client

SOURCES OF DATA
Patient’s medical records
Patient’s health records are kept confidential
however, they can be retrieved as reference in
management of patient’s illness.
Client’s medical records may contain
laboratory and diagnostic test results and
primary treatment plan.

What are the types of Health
Assessments???

TYPES OF HEALTH ASSESSMENT
Basically, they are four (4) types of Health
Assessments, namely;
1. Comprehensive assessment
2. Focused/problem-based assessment
3. Episodic/follow up assessment
4. Screening assessment

COMPREHENSIVE ASSESSMENT
This is usually done on the first contact
and usually is not linked with management
of emergencies.
It involves getting a detailed history and
physical examination as basis of initial
care, like on Antenatal booking and patient
admission in hospital.

PROBLEM BASED ASSESSMENT
This assessment is usually done on emergency
conditions.
Focused assessment aims at quick reveal of
health problems in emergency conditions.
Involves getting history and examination that
is limited or specific problems or complaint,
like a mother who develops PPH after birth

PROBLEM BASED ASSESSMENT
The history and physical examination will
mainly focus on the precise cause of the
complication.
History taking will include reveal of ANC card
for history of PPH.

FOLLOW-UPASSESSMENT
This assessment is done on a subsequent visit
The assessment is done on follow up visit a
previously identified health problem.
This assessment is usually done in
management of chronically ill.
It aims at maintenance and rehabilitation of
health.

SCREENING ASSESSMENT
This is usually a short and inexpensive
examination
It focuses on disease detection, like blood
pressure, blood group checking.
It may be a routine examination but can detect
health problems before they manifests or
develop into complications.

DIAGNOSIS
Diagnosis is the recognition of a
particular ailment from symptoms,
physical signs and any test which may
have been performed

PHASE 2: NURSING DIAGNOSIS
This is the second phase of the Nursing
Process
Nursing diagnosis entails that the nurse should
be autonomous in the way they make decisions
about patients health and is entitled to
scrutinise questionable Doctor’s orders

It uses the data collected from history taking
and physical examination to identify actual and
potential health problems of the client.
In making a diagnosis, data collected is
analysed assessment data to determine the
diagnosis

For example: A patient with a medical
diagnosis of diarrhea and projectile vomiting;
the nursing diagnosis may be; Risk for fluid
volume deficit.
The nursing diagnosis provides a basis for
selection of nursing interventions.

Nursing diagnosis can be; Actual or Potential
health problems
An Actual nursing diagnosis must have three
parameters;
1. The problem
2. The possible cause
3. The evidence

Example of an actual problem
Fluid volume deficit related to passage of
loose watery stool and projectile vomiting
evidenced by loss of skin tugor and dry
mucous membranes.

A potential nursing diagnosis must have two
parameters;
1.The potential problem
2.The possible cause

Example of a potential problem
Risk for fluid volume deficit related to
passage of loose watery stool and projectile
vomiting.

PHYSICAL EXAMINATION
Physical examination
This is a thorough and systematic process
aimed at evaluating objective anatomic
findings through the use of;
Inspection
Palpation
Percussion
Auscultation

A good physical examination requires a
cooperative patient and a quiet, warm and well-
lit room.
Day light is better than artificial light, which
may mask changes in skin colour, for example
Jaundice

Legal implications
A chaperone should be present when a male
nurse is examining a female patient and during
rectal and vaginal examinations, both to
reassure the patient and to protect the nurse
from subsequent accusations of improper
conduct.

Four major techniques are used in performing
the physical examination;
1. Inspection,
2. Palpation,
3. Percussion, and
4. Auscultation

INSPECTION
Inspection
Inspection is the visual examination of a part or
region of the body to assess normal conditions or
deviations from normal.
Inspection is more than just looking.

INSPECTION
This technique is deliberate, systematic, and
focused.
You are required to compare what you can see
with what are the known, generally visible
characteristics of the body parts being inspected.

INSPECTION
This technique is deliberate, systematic, and
focused.
Some features which can be inspected are;
Skin colour
Asymmetric of body parts
Skin bruises
Eye colour

PALPATION
Palpation
Palpation is the examination of the body with
touch.
During palpation, a nurse can obtain information
related to masses, pulsations, organ enlargement,
tenderness, swelling, muscular spasm or rigidity,
elasticity, vibration of voice sounds, crepitus,
moisture, and differences in texture.

PALPATION
The tips of the fingers are used to palpate lymph
nodes, the dorsa of hands and fingers are used to
assess temperatures, and the palmar surface is
best suited for feeling vibrations.

PALPATION
There are two (2) types of palpation;
1. Light palpation
2. Deep palpation

PALPATION
Light Palpation
This type of palpation is employed to assess
superficial structure like;
The skull bones
Skin for swelling and tenderness
Dislocation of superficial bones
Palpation of superficial structures like lymph
nodes

PALPATION
Deep Palpation
This type of palpation is used to assess deep
structures and organs;
The spleen
The stomach
The liver
The uterus
The kidneys

PERCUSSION
Percussion is an assessment technique involving
the production of sound to obtain information
about the underlying area.
The percussion sound may be produced directly
or indirectly.
Percussion may be direct or indirect

PERCUSSION
Direct percussion is performed by directly
tapping the body with one or two fingers to
elicit a sound.
 Indirect or mediated percussion is the more
common technique.

PERCUSSION
The middle finger (pleximeter) of the non-
dominant hand is placed firmly against the
body surface.
The tip of the middle finger of the dominant
hand (plexor) strikes the distal phalanx or the
distal interphalangeal joint of the pleximeter
finger.

PERCUSSION
A relaxed wrist and rapid strike produce the
best sounds.
The sounds and the vibrations produced are
evaluated relative to the underlying structures.
Deviation from an expected sound may
indicate a problem.

PERCUSSION
Deviation from an expected sound may indicate
a problem.
For example, the usual percussion sound in the
right lower quadrant of the abdomen is
tympanic.
Dullness in this area may indicate a problem that
should be investigated.

AUSCULTATION
Auscultation
Auscultation is listening to sounds produced
by the body to assess normal conditions and
deviations from normal.
Auscultation is usually indirect, using a
stethoscope to clarify sounds by blocking out
extraneous sounds.

AUSCULTATION
The bell of the stethoscope is more sensitive to
low-pitched sounds.
The diaphragm of the stethoscope is more
sensitive to high-pitched sounds.
Auscultation is particularly useful in
evaluating sounds from the heart, lungs,
abdomen, and vascular system.

Physical assessment techniques are usually
performed in the following sequence:
inspection, palpation, percussion, and
auscultation.
The only exception to this sequence is for the
abdominal examination. In this situation, the
sequence is inspection, auscultation,
percussion, and palpation.

INDIVIDUALASSIGNMENT
Read and make notes on Head-to-Toe
examination of a patient

REFERENCE
1. Berkow R. and Beers M.H. (1997), The
Merck Manual of Medical Information,
Home edition, Merck Research Laboratories,
New Jersey.
2. Kumar V., Abul K. and Fauston N. (2007),
Robbins Basic Pathology, 8th edition,
Saunders Elsevier.

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