INTRODUCTION TO HEALTH ASSESSMENT

1. INTRODUCTION TO HEALTH ASSESSMENT • TECHNIQUES OF PHYSICAL ASSESSMENT • GENERAL SURVEY NUR123 Spring 2009 K. Burger, MSEd, MSN, RN, CNE PPP by: Victoria Siegel RN, CNS, MSN Sharon Niggemeier RN, MSN Revised by: Kathleen Burger

2. Health Assessment • Is holistic data collection AND analysis • Utilizes the nursing process • Incorporates critical thinking.

3. Health Assessment • Includes knowledge of developmental stages throughout the life cycle • Includes physical,mental,psychosocial assessment along with assessment for domestic violence, elder abuse and child abuse

4. Health Assessment • Requires proficient communication skills and interviewing techniques • Requires the establishment of rapport and trust • Considers cultural aspects

5. Health Assessment:The Health History • Begins with reason for seeking care(chief complaint is previously used term) & health history • Document using the patient’s own words • Elicit a complete description from patient • Document duration of complaint • What aggravates condition, what may alleviate it?

6. Types of Health Histories • Complete • Interval • Problem focused or chief complaint

7. History Taking • Well developed interview skills and careful documentation • Environment conducive to privacy and comfort • Is the client a good historian? • Reasons for seeking health care • Interview- intro, working, termination phases

8. Biographical Reason for seeking health care Present health/Illness Past health Family health Review of systems Psychological Functional Assessment Perception of health Complete Health History

9. Present Health/IllnessReason for seeking care • Onset, duration, precipitating factors. • Frequency, duration… • Associated symptoms i.e. N/V • Alleviating/ aggravating factors • ROS re: CC • Relevant family, occupational or recreational history.

10. Past Health History • Past general health • Childhood illnesses • Accidents/ injuries • Hospitalizations/surgeries • Acute and chronic illnesses • Immunizations • Allergies, medications, transfusions • Obstetric History

11. Current Health • Habits • Meds (including OTC/Herbal/Vitamins) • Exercise • Sleep

12. Family History • Important to know to determine risks • Status of family membersParents, siblings, grandparents • Status of spouse/significant other and Children • Construct Genogram

13. Review of Systems: ROS • Review past and present health status of each body system. • Review health maintenance. • A Head-to- Toe approach • May elicit new information

14. Psychological Function • Cognitive – memory, comprehension • Response to illness and health • Psych history, meds, anxiety? • Cultural considerations

15. Functional Assessment • ADLs • Sleep/rest • Nutrition/problems with diet, weight • Alcohol /Substance abuse • Smoking history (in pack years) • Coping difficulties • Domestic/ child abuse

16. Perception of Health • How one defines health • Views on one’s health status • What are one’s expectations pertaining to health and health care

17. Physical Examination (PE) • Goal is to identify variations from normal. • Explain procedure first • Head to Toe • Unaffected areas before affected

18. Techniques of PE • Four components used in specific order: • Inspection • Palpation • Percussion • Auscultation

19. Techniques of PE • Inspection- First techniques used. What examiner sees, hears and smells. Observe symmetry. • Palpation- Second technique using fingers and hands to touch. Light palpation first then deep palpation

20. Techniques of PE • Percussion- Third technique…tapping on skin surface which creates a vibration of underlying structures. The vibration produces a sound, may aid in diagnosis. • Resonant- normal lung. • Hyperresonant- Child’s lung or emphysema. • Tympany- Air filled organ, e.g., stomach or intestine. • Dull- Dense organ, e.g., liver or spleen. • Flat- No air present, e.g., bone.

21. Techniques of PE • Uses for Percussion: Mapping out location and size of an organ • Determining density (air, fluid, solid) of a structure • Detecting superficial mass (up to 5 cm deep) • Eliciting pain if underlying structure is inflamed • Eliciting a DTR using a percussion hammer

22. Techniques of PE • Auscultation-Usually last technique during PE (*exception – abdomen, it’s the 2nd technique after inspection) • Use stethoscope to block sounds not magnify • Diaphragm-firmly against skin • Bell- lightly against skin

23. Auscultation • Description of sounds heard • Pitch- frequency of sound vibrations, high or low. • Intensity- loudness of sound: loud or soft (amplitude) • Duration- length of sound: short, long • Quality- subjective terms- harsh, tinkling, etc…

24. Physical Exam • Utilize 4 techniques • Proper setting • Equipment • Clean/ safe environment • Remember client comfort

25. Summary • Health assessment includes: • Complete health history • ROS • Physical Exam

26. General Survey • Study of the whole individual • Overall impression • Begins at the first encounter with a person • Introduction to the physical assessment • Composed of 4 parts: physical appearance, body structure, mobility & behavior

27. Physical Appearance Age Sex LOC Skin color Facial features Body Structure Stature Nutrition Symmetry Posture Position Body contour General Survey

28. Mobility Gait Range of Motion (PROM or AROM) Behavior Facial expression Mood Speech Dress/Hygiene General Survey

29. General Survey • Includes Height & Weight • Vital signs: Temperature, Pulse, Respiration & Blood Pressure • Recognize transcultural considerations • Note S/S (signs/symptoms) of distress/pain

30. Assessing Distress/Pain • Assessment includes: • S- Severity • L- Location • I- Influencing factors • D- Duration • A- Associated Symptoms

31. Assessing Distress/Pain • Pain assessment = 5th vital sign • Utilize pain scale • Understand chronic vs acute pain • Recognize gender, transcultural and developmental factors effecting pain