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25 Cards in this Set
- Front
- Back
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What is a health assessment?
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A deliberate & systematic collection of data to determine a client’s current & past health status & functional status, as well as coping patterns
Nurse collects and analyzes client data through interaction with the client, significant others, and other health care providers. Includes taking a subjective health history and doing an objective physical assessment. From this collected data, the nurse develops a nursing diagnosis and plan of care |
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Health history survey should be done before doing physical exam Why?
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Because you want to focus on areas that might be of more concern
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What are the health history objectives?
(4) |
1. Identify patterns of health and illness
2. Identify deviations from normal 3) Identify risk patterns Physical health Mental health 4) Identify resources for adaptation The goal is to get the patient functioning at optimal level |
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Who should you get health history information from?
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Patient, family & significant others, other HCP, past medical records
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DATA COLLECT - Nurse must determine what to assess, where focus should be depending on client condition
E.g. ER nurse may focus on ABCs Oncology nurse – sx and response to tx Cues are information obtained through use of senses Inferences are your judgment or interpretation of those cues Need to validate How? |
If pt presents with chest pain and sob…nurse will prob focus on ABC
Different practice nurses focus on different things Sense of smell – alcoholism, fruity breath indicates diabetic ketoacidosis Inferences need to be validated by asking pt and spouse and by looking at diagnostic tests (ex pulse ox, pulse, blood sugar…all can be done immediately) |
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DATA COLLECT - What are some other ways to collect data?
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Move from general to specific
Assess all areas systematically and determine patterns or problems. Ask more focused questions about problem areas Another approach is a problem-oriented approach. Start with client’s presenting problem & expand |
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How often is an assessment done?
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Dependent on client condition, agency protocol, and/or physician order
Initial Assessment Every shift Hourly, Weekly, Monthly Ongoing Before & after a procedure or meds If patient has a health complaint In long term care head to toe assessments are not done every day…nurses may have 25 patients to care for In long term care you will have adventicious (crummy) lung sounds regularly Sometimes a pt has to have 24hr monitoring depending on what they are having issues with. |
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How do you prep a patient for assessment?
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Client Preparation – explain purpose, let them know what your doing, get them comfortable, welcoming, establish rapport
Environmental Setting – use standard precautions to protect you and the patient Ensure confidentiality & privacy Comfortable temperature – make sure the temp and lighting is good Patient should be in comfortable position Communication – use understandable language, translator prn – make sure glasses are on and hearing aids are in – speak in lay terms not nursing terms. (ex do you need to void vs do you need to use the restroom) Consider their education level and whether or not it is a child Cultural considerations – eye contact, family presence, health care practices, modesty (Ex eye contact in some cultures is disrespectful) be aware (Ex large group prayer) Language can be a big barrier You may have to have parents leave the room in order to have the child disclose honestly (ex sex and drug use) |
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Admission documentation...what is that?
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Upon admission, the nurse completes the Nursing Initial Assessment Form
May be a complete history form OR May be an urgent/emergent nursing history form depending on status of client |
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Data collection - Interview pases - what are they? (3)
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Orientation/Introductory phase
Explain purpose of interview, ask non-threatening biographical information Establishing nurse-client relationship. (rapport) Working phase Data regarding chief complaint and health hx collected for care plan development Termination phase Give clue that interview is coming to end. Summarize Offer client opportunity to ask questions. |
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Subjective data is what?
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What patient/family tells you
Patient Health History |
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Objective data is what?
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Findings w/physical assessment
Diagnostic test results |
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What are the 4 types of health history and assessment?
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Complete – done in the beginning or when admitted to facility
Episodic – more specific ( sore throat dr appt) Follow up – Ex post op and medication affects (pain meds) Vital signs Urgent/Emergent - ABC issue or pain issue |
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Why is a patient profile important?
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Biographical data that identifies the patient/client.
Includes culture, ethnicity, and subculture data Establish educational level and occupation as well as working status Determine how patient feels about seeking health care Ex: Jehovah Witness and medical care Occupation might clue you in to a possible exposure |
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What is a chief complaint?
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What is the client’s major health problem, concern, or complaint? Why?
Helps you understand what the patient sees as the most significant health concern Detailed description of concern: onset, progression, duration, frequency, signs & symptoms What may have caused the problem? What makes it better or worse? |
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What categories should be included in health history? (12)
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Biographical data: Age, address, occupations, marital status, health care insurance.
Client expectations: Find out what clients expect to happen to them while seeking treatments for their health. Present Illness or heath concerns: Determine when the problems began, how severe, intensity, quality, what makes them worse, what makes them better. Health history: Provides you with information regarding the client’s past history. Has there been a hospitalization? Procedure? Medication uses? Prescription, over the counter, herbal, natural? Birth control (note the form), vitamins, etc. Use of alcohol, tobacco, caffeine, recreational drugs? Sleeping patterns? Exercise habits? Nutritional habits? Family history: Blood relative health issues? Recent losses? Religious influences? Relationships? Environmental history: Home environment? Workplace environment? Exposure to pollutants? Psychosocial history: Support system? Spouse? Children? Friends? Family members? Coping mechanisms? Spiritual health: Religion? Religious habits? Nutrtional status Functional status Review of systems: A method for collecting data on body systems. We will learn more abut this in Medication profile |
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A patients past health history should include what?
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Medical history
Surgical history Medication – Rx & OTC including herbal Allergies Communicable diseases Injuries/Accidents Disabilities Blood transfusions Childhood illnesses Immunizations |
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Why do you need to know about family history?
Any genetic testing done? |
May have genetic predisposition to illnesses such as cancer, heart disease, diabetes
Patient may have been “exposed” to certain problems such as second hand smoke, TB or environmental pollution Any genetic testing done? Genetic diseases such as Huntington’s chorea, sickle-cell anemia, cystic fibrosis Will be done more frequently in future May have genetic predisposition to illnesses such as cancer, heart disease, diabetes Patient may have been “exposed” to certain problems such as second hand smoke, TB or environmental pollution Any genetic testing done? Testing confirms dx Genetic diseases such as Huntington’s chorea, sickle-cell anemia, cystic fibrosis Will be done more frequently in future |
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Why is review of systems important?
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Review each system and record health history or current symptoms for each or denial of problems
Include subjective and objective data EENT Neurological Integumentary Cardiopulmonary GI Musculoskeletal Genitourinary Urinary Reproductive |
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What does social history include?
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nutritional habits
sleep/rest use of medications social activities value/belief system education stress level sprituality/religion sexual history cultural/ethnic coping style economic status travel history activity.exercise relationships use of alcohol, tobaccao, rec drugs self concept and self care activities occupation and work history |
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Nutritional Assessment should include?
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appetite, fluid intake, food allergies, intolerance, 24 hr food history recall
height, weight...desired weight |
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Functional status should include?
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Assess client’s ability to perform ADLS
Any functional impairment that limits ability to perform ADLS? & Instrumental ADLS (IADLS) Level of functioning prior to hospitalization? Need to assess rehab needs, level of care required after hospital DC |
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What does ADLS and IADL mean?
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ADLS = activities of daily living, physical self-care such as? Bathing, feeding, grooming, toileting, dressing, oral care
(direct self care) IADLs = instrumental activities of daily living – shopping, meal prep, writing checks, taking meds Things which enable a person to function independently at home |
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What does the mental status assessment include?
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Appearance
Behavior Cognition Orientation Attention span Recent & remote memory New learning Thought Processes – Content & Perceptions Does this person make sense? Can I follow train of thought? Any suicidal tendencies? |
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What are some exam techniques?
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Inspection - “Looking at the client”
Any data collect through “smell” is also considered to be a part of inspection Palpation “Feeling" with the hands during a physical examination - use of hands to determine texture, size, shape consitency and location of certain body parts Percussion – not a Block 1 skill “Tapping” the body with the fingers, hands, or an instrument during physical examination - detects tenderness, or if underlying tissues are air filled, fluid filled, solid - Percussion of a body part produces a sound & subtle vibration (like playing a drum) that indicates characteristics of tissue within the organ Auscultation - “Listen" to the sounds of the body during a physical examination. - listening for frequency, intensity, duration, number, quality of sounds |
