Note on Health assessment - 1

Note on Health assessment - 1

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  Health Assessment part -1 By:- Mrs. Babitha K Devu Asstt. Professor SMVDCoN
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  • Define HealthAssessment • Discuss the purpose • Describe the techniques used • Describe proper positioning for the patient • Make environmental preparations • List the articles needed • Perform systemic assessment
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  Introduction While working ina variety of settings, nurses seek information about patient’s health status. Health screenings focus on a specific physical problem. A complete health assessment involves a nursing history and behavioural and physical examination. Continuity in health care improves when you make ongoing, objective, and comprehensive assessment.
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  DEFINITION • Health assessment Healthassessment is an organized systematic assessment of human body which involves the use of one’s senses to determine the general physical and mental conditions of the body by collecting both subjective and objective data.
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  Indication of healthassessment • On admission • On discharge • On follow up • Health camps • Before and after diagnostic and therapeutic procedure.
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  Purpose • Gather baselinedata about the patient’s health status • Supplement, confirm, or refute data obtained in the history • Confirm and identify nursing diagnoses • Make clinical judgement about a patient’s changing health status and management • Evaluate the outcomes of care
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  Principles of HealthAssessment • An accurate and timely health assessment provides foundation for nursing care & intervention. • Go for comprehensive assessment. • The health assessment process should include data collection, documentation and evaluation of the client’s health status. • All documents should be objective, accurate, clear, concise, specific and current. • It should be practiced in all settings whenever there is nurse-client interaction. • Information gathered should be communicated to other health care professional. • Keep the confidentiality.
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  Legal Issues • Intoday’s litigious society, you must be ever vigilant when engaging in nursing practice. Documentation issues have previously been addressed. Equally important is how you execute the nursing assessment. Establishing a trusting and caring relationship is the primary element in avoiding malpractice claims. • While performing each step in the physical assessment process, you need to inform the patient of what to expect, where to expect it, and how it will feel. Protests by the patient need to be addressed prior to continuing the examination. Otherwise, the patient may claim insufficient informed consent, sexual abuse, or physical harassment. • All assessments and procedures, including any injury that was caused during the physical assessment, must be completely documented. The institutional policy regarding patient injury in the workplace must be followed.
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  TYPES OF HEALTHASSESSMENT The type of health assessment dependents on several factors like context of care, the patient’s needs and the nurse’s experience. o Comprehensive assessment: This involves a detailed history or physical examination performed at the onset of care in a primary care setting or an admission to a hospital or long term carte facility. o Problem- based / focused assessment: It involves a history and examination that are limited to a specific problem or complaint. This type of assessment is most commonly used in a walk in clinic or emergency department and out patient departments.
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  Contin.. o Episodic/ Follow-upassessment: This type of assessment is usually done when a patient is following up with a health care provider for previously identified problem. o Shift assessment: When individuals are hospitalized, nurses conduct assessment each shift. The purpose is to identify changes in a patient’s condition from baseline . o Screening assessment: It is a short examination focused on disease detection. It may be performed in a health care provider’s office or at a health fair.
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  TECHNIQUE/ SKILLS OFPHYSICAL ASSESSMENT
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  CONTIN..  Inspection  Palpation Percussion  Auscultation Olfaction Other techniques are: Manipulation  Reflex Testing
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  INSPECTION It is theuse of vision and hearing to distinguish normal from abnormal findings. Inspection is a simple technique, and the quality of an inspection depends upon your willingness to be thorough and systematic. PRINCIPLES: 1. Adequate lighting 2. Position & expose body parts 3. Inspect each areas 4. When possible, compare each area with opposite side of the body 5. Use additional light to inspect cavities 6. Do not hurry, pay attention to detail
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  GENERAL INSPECTION OFA CLIENT FOCUSES ON • Overall appearance of health or illness • Signs of distress • Facial expression and mood • Body size • Grooming and personal hygiene • Colour, texture, symmetry, movement
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  PALPATION Palpation, which isthe act of touching a patient in a therapeutic manner to elicit specific information.
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  PRINCIPLES OF PALPATION •Perform slowly, gently, and deliberately. • Encourage the patient to continue to breathe normally throughout the palpation. • If pain is experienced during the palpation. discontinue the palpation immediately. • Inform the patient where, when, and how the touch will occur, especially when the patient cannot see what you are doing.
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  • Light palpationDeep palpation
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  Ulnar Surface (Vibration)
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  Caution to betaken • To avoid injuring a patient. • Do not try deep palpation without clinical supervision. • Do not palpate without considering the patient’s condition. • Do not palpate a vital artery with pressure that obstructs blood flow.
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  PERCUSSION
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  Direct percussion isused to assess the sinus or infant thorax. Indirect percussion is used to evaluate abdomen or thorax. Another method of indirect percussion is tapping with the rubber head of the reflex hammer. Fist percussion to evaluate back and kidney for tenderness. Or Plexor
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  TYPE OF PERCUSSION •DIRECT PERCUSSION/ Immediate Percussion
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  INDIRECT PERCUSSION/ MEDIATEPERCUSSION
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  FIST PERCUSSION Technique ofDirect Fist Percussion:Left Kidney Technique of Indirect Fist Percussion:Left Kidney
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  Percussion Sounds SOUND INTENSITYDURATION PITCH QUALITY NORMAL LOCATION ABNORMAL LOCATION Flatness Soft Short High Flat Muscle (thigh) or Bone Lungs (severe pneumonia Dullness Moderate Moderate High Thud Organs (liver) Lungs (atelectasis) Resonance Loud Moderate- long Low Hollow Normal lungs No abnormal location Hyper resonance Very loud Long Very low Boom No normal location in adults;normal lungs in children Lungs (emphysema) Tympany Loud Long High Drum Gastric air bubble Lungs (large pneumothorax)
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  AUSCULTATION
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  FOUR CHARACTERISTICS OFSOUND • 1.Frequency/ Pitch (ranging from high and low):frequency or number of oscillations generated per second by vibrating object. The higher the frequency, the higher the pitch of a sound and vice versa. • 2. Loudness (ranging from soft to loud): amplitude of sound wave. • 3. Quality (gurgling or blowing): sounds of similar frequency and loudness from different sources. • 4. Duration (short, medium or long): length of time that sound vibrations last.
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  What you shouldknow? • Need good hearing acuity • A good stethoscope & knowledge of how to use it • Place stethoscope on patient skin directly • Free from extraneous sound • Requires concentration and practice
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  Normal Body Sounds •Normal breath sounds are classified as tracheal, bronchial, bronchovesicular, and vesicular sounds. • Tracheal breath sounds are heard over the trachea. These sounds are harsh and sound like air is being blown through a pipe. • Bronchial sounds are present over the large airways in the anterior chest near the second and third intercostal spaces; these sounds are more tubular and hollow- sounding than vesicular sounds, but not as harsh as tracheal breath sounds. Bronchial sounds are loud and high in pitch with a short pause between inspiration and expiration; expiratory sounds last longer than inspiratory sounds.
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  Contin.. • Bronchovesicular soundsare heard in the posterior chest between the scapulae and in the center part of the anterior chest. Bronchovesicular sounds are softer than bronchial sounds, but have a tubular quality. Bronchovesicular sounds are about equal during inspiration and expiration; differences in pitch and intensity are often more easily detected during expiration. • Vesicular sounds are soft, blowing, or rustling sounds normally heard throughout most of the lung fields. Vesicular sounds are normally heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration. • In a normal air-filled lung, vesicular sounds are heard over most of the lung fields.
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  Contin.. • Bowel soundconsist of clicks and gurgles and 5-30 per minute. • An occasional borborygmus (loud prolonged gurgle) may be heard. • Heart sound: The first heart sound, or S1, forms the "lub“ The second heart sound, or S2, forms the "dub"
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  OLFACTION
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  Olfaction • Olfaction isthe action or capacity of smelling; the sense of smell. • The nurse’s olfactory sense provides vital information about a patient’s health status. • It helps to detect abnormalities not recognized by other means. • E.g., if a patient cast has a sweet, heavy, thick odour, this indicate an underlying infection.
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  Manipulation • It meansmoving with the body parts. It reveals rigidity, difficulty or discomfort in moving the body parts.
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  Reflex Testing • Meansautomatic response to a given stimulus. It reveals reflex is present or not, strength and movement of hands and legs.
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  Nurse’s Responsibility Has theresponsibility to carry out health assessment on every person. Should perform focused assessments in response to client’s need. Obtain consent in prior. Demonstrate a caring attitude, respect and concern for client. Keep confidential. Draw inferences from collected data to make appropriate clinical judgement.
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  Contin.. Acquire specialized skillsand competencies in collecting accurate data. Document the result of health assessment. Should continuously advance their competence in health assessment. Do all the relevant preparation prior.
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  PREPARATION FOR ASSESSMENT Properpreparation of the environment, equipment, and patient ensures a smooth examination with few interruptions. A disorganized approach when preparing for a physical examination causes errors and incomplete findings. It is necessary to wear gloves during palpation and percussion when there is possibility of coming in contact with body fluids .
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  PREPARING THE ENVIRONMENT
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  Environment  Requires privacy Well-equipped examination room is preferable  Adequate lighting, sound proof  Make sure the room is warm enough  Special tables to assume positions  Special needs of the client  Surface for placement of equipment Equipment Perform hand hygiene before equipment preparation Set up in a readily available manner and easy to use Check the functioning Maintenance Isolation precautions Adequate number of gloves
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  PHYSICAL PREPERATION OFTHE PATIENT
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  CONTIN.. Patient’s physical comfortis vital It involves being sure the patient is dressed and draped properly Provide privacy Make sure the patient stays warm Routinely ask if the patient is comfortable Positioning: during examination, ask the patient to assume proper positions so body parts are accessible and patient stays comfortable.
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  PREPARING THE PATIENT •PSYCHOLOGICAL PREPERATION A thorough explanation must be provided to the patient regarding each steps of assessment. Keep explanations simple and clear Help patient feel free to ask doubts. Convey an open, professional and relaxed approach. When the patient And examiner are of opposite gender Have a third party of patient gender to assure the patient that you behave ethically and third party is the witness to conduct of examiner and patient.
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  Assessment of Age-Groups Differentinterview styles and approaches are needed to perform a health history and examine patients of different age-groups. When assessing children be sensitive and anticipate the child's reaction to the examination as a strange and unfamiliar experience. A comprehensive health assessment and examination of older adult includes physical data, family relationships etc and also mental status. During the examination, recognize that advancing age the body does not respond vigorously to injury or diseases.
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  EQUIPMENTS • The physicalassessment will proceed in an efficient manner if you have gathered all of the necessary equipment beforehand. The equipment needed to perform a complete physical examination of the adult patient includes: • Pen and paper • Marking pen • Tape measure • Clean gloves • Penlight or flashlight • Scale (You may need to walk the patient to a central location if a scale cannot be brought to the patient’s room.) • Thermometer • Sphygmomanometer • Tongue depressor • Stethoscope • Otoscope • Nasal speculum • Ophthalmoscope • Visual acuity charts
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  Contin.. • Tuning fork• Reflex hammer • Sterile needle • Cotton balls • Lubricant • Cervical brush • Odors for cranial nerve assessment(coffee, lemon, flowers, etc.) • Small objects for neurological assessment (paper clip, key, cotton ball, pen, etc.) • Inch tape • Various sizes of vaginal speculums • Cotton-tip applicator • Cervical spatula • Slide and fixative • Specimen cup • Lubricant • Goniometer • Vital signs tray
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  ARTICLES REQUIRED • Screento provide privacy • Bowl for antiseptic lotion • Kidney tray and paper bag • Weighing machine and height scale • Patient gown
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  ARTICLES REQUIRED • Bathblanket to cover the patient • Pair of leggings • Draw sheet to cover patient’s chest • Square drum containing test tube, gauze piece, cotton swab, specimen bottle, swabsticks
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  EQUIPMENTS • STETHOSCOPE
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  OPHTHALMOSCOPE
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  OTOSCOPE
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  SNELLEN CHART
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  NASAL SPECULUM
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  VAGINAL SPECULUM
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  TUNING FORK
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  PERCUSSION HARMER
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  SPHYGMOMANOMETER
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  Scales For MeasuringWeight & Height
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  Scales For MeasuringWeight & Height
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  Tongue Depressor
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  Thermometer
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  Specimen Container
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  Skinfold Calipers
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  Goniometer
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  Audioscope
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  Sitting Position FowlerPosition
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  STANDING
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  SUPINE AND PRONE
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  DORSAL RECUMBENT
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  Sim’s Position • Inthis position patient is lying on the left side with right knee and thigh drawn up with the left arm placed along the back. Used for rectal examination.
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  LITHOTOMY • In thisposition patient is supine with the feets and legs raised and supported in stirrups. Used for vaginal and rectal examinations.
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  KNEE-CHEST
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  Trendelenburg Position • Inthis position the patien t is lying on the back with the pelvis higherthan the head; the knees are sligh tly bent, and the legs are hangingoff the end of the table. This position is use d for pelvic surgery andfo r some radiographic exam s.