Faculty of Nursing-IUG

1. Faculty of Nursing-IUG Chapter (2) Health Assessment-Holistic Approach

2. Holistic approach • 1. The interview • 2. Psychosocial assessment • 3. Nutritional assessment • 4. Assessment of sleep-wakefulness patterns • 5. The health history.

3. 1. Interview • Definition: communication process focuses on the client's development of psychological, physiological, sociocultural, and spiritual responses, that can be treated with nursing & collaborative interventions

4. Major purpose: • To obtain health history and to elicit symptoms and the time course of their development. The interview conducted before physical examination is done. Components of nursing interview 1. Introductory phase 2. Working phase 3. Termination phase

5. Introductory phase: • Introduce yourself and explains the purpose of the interview to the client. • Before asking questions, Let client to feel Comfort, Privacy and Confidentiality

6. Working phase: The nurse must listen and observe cues in addition to using critical thinking skills to validate information received from the client. The nurse identify client's problems and goals. Termination phase: 1.The nurse summarizes information obtained during the working phase 2. Validates problems and goals with the client. 3.Making plans to resolve the problems (nursing diagnosis and collaborative problems are identified and discussed with the client)

7. Communications techniques during interview A. Types of questions : • Begin with open ended questions to assess client's feelings e.g. what, how, which“ • Use closed ended question to obtain facts e.g." when, did…etc • Use list to obtain specific answers e.g. "is pain sever, dull sharp • Explore all data that deviate from normal e.g. “increase or decrease the problem

8. B. Types of statements to be use: • Repeat your perception of client's response to clarify information and encourage verbalization C. Accept the client silence to recognize thoughts D. Avoid some communication styles e.g. • Excessive or not enough eye contact. • Doing other things during getting history. • Biased or leading questions e.g. "you don't feel bad" • Relying on memory to recall information

9. E. Specific age variations :- • Pediatric clients: validate information from parents. • Geriatric clients: use simple words and assess hearing acuity F. Emotional variations: • Be calm with angry clients and simply with anxious and express interest with depressed client • Sensitive issues "e.g. sexuality, dying, spirituality" you must be aware of your own thought regarding these things.

10. G. Cultural variations: • Be aware of possible cultural variations in the communication styles of self and clients H. Use culture broker: • Use culture broker as middleman if your client not speak your language. • Use pictures for non reading clients.

11. 2-Psychosocial assessment • Psychological assessment involves person's growth and development throughout his life. • Discuss crises with the clients to assess relationship between health & illness. “It depends on multiple G&D theoriese.g. Erickson, Piaget, and Freud …. etc.

12. Stages of Age • Infancy period: birth to 12 months Neonatal Stage: birth-28 days Infancy Stage: 1-12 months • Early childhood Stage: It’s refers to two integrated stages of development Toddler: 1 - 3years. Preschool: 3 - 6 years. • Middle childhood 6-12 years • Late childhood: Pre pubertal: 10 – 13 years. Adolescence: 13 - 19 years • Young adulthood 20-40 years • Middle adulthood 40-65years • Late adulthood 65 and more

13. 3-Nutritional assessment • Nutrition plays a major role in the way an individual looks, feels,& behaves. • The body ability to fight disease greatly depends on the individual's nutritional status

14. Major goals of nutritional assessment 1. Identification of malnutrition. 2. Identification of over consumption 3. Identification of optimal nutritional status. Components of Nutritional Assessment 1. Anthropometric measurement. 2. Biochemical measurement. 3. Clinical examination. 4. Dietary analysis

15. A. Anthropometric measurement • Measurement of size, weight, and proportions of human body. • Measurement includes: height, weight, skin fold thickness, and circumference of various body parts, including the head, chest, and arm. • Assess body mass index (BMI) to shows adirect and continuous relationship to morbidity and mortality in studies of large populations. High ratios of waist to hip circumference are associated with higher risk for illness & decreased life span. BMI = (Wt. in kilograms) = 60 = 60 = 23.4 (High in meters) 2 (1.6)2 2.56

16. BMI RANGE

17. B. Biochemical Measurement • Useful in indicating malnutrition or the development of diseases as a result of over consumption of nutrients. Serum and urine are commonly used for biochemical assessment. • In assessment of malnutrition, commonly tests include: total lymphocyte count, albumin, serum transferrin, hemoglobin, and hematocrit …etc. These values taken with anthropometric measurements, give a good overall picture of an individual's skeletal and visceral protein status as well as fat reserves and immunologic response.

18. C. Clinical examination • Involves, close physical evaluation and may reveal signs suggesting malnutrition or over consumption of nutrients. • Although examination alone doesn't permit definitive diagnosis of nutritional problem, it should not be overlooked in nutritional assessment

19. Nutritional assessment technique for clinical examination a. Types of information needed • Diet: Describe the type: regular or not, special, "e.g. teeth problem, sensitive mouth. • Usual mealtimes: How many meals a day: when? Which are heavy meals? • Appetite: "Good, fair, poor, too good". • Weight: stable? How has it changed?

20. Food preferences: e.g." prefers beef to other meats" • Food dislike: What & Why? Culture related? • Usual eating places: Home, snack shops, restaurants. • Ability to eat: describe inabilities, dental problems: "ill fitting dentures, difficulties with chewing or swallowing • Elimination" urine & stool: nature, frequency problems • Exercise & physical activity: how extensive or deficient

21. Psycho social - cultural factors: Review any thing which can affect on proper nutrition • Taking Medications which affect the eating habits • Laboratory determinations e.g.: “Hemoglobin, protein, albumin, cholesterol, urinalyses" • Height, weight, body type "small, medium, large" After obtaining information, summarize your findings and determine the nutritional diagnosis and nutritional plan of care. Imbalanced nutrition: Less than body requirements, related to lack of knowledge and inadequate food intake Risk for infection, related to protein-calorie malnutrition

22. b. Signs & symptoms of malnutrition • Dry and thin hair • Yellowish lump around eye, white rings around both eyes, and pale conjunctiva • Redness and swelling of lips especially corners of mouth • Teeth caries & abnormal missing of it • Dryness of skin (xerosis): sandpaper feels of skin • Spoon shaped Nails " Koilonychia “ anemia • Tachycardia, elevated blood pressure due to excessive sodium intake and excessive cholesterol, fat, or caloric intake • Muscle weakness and growth retardation

24. D. Dietary analysis • Food represent cultural and ethnic background and socio- economic status and have many emotional and psychological meaning • Assessment includes usual foods consumed & habits of food • The nurse ask the client to recall every thing consumed within the past 24 hour including all foods, fluid, vitamins, minerals or other supplements to identify the optimal meals • Should not bias the client's response to question based on the interviewer's personal habits or knowledge of recommended food consumption

25. Diseases affected by nutritional problems 1- Obesity: excess of body fat. 2- Diabetes mellitus. 3- Hypertension. 4- Coronary heart disease. 5- Cancer.

26. 4-Assessment of sleep-wakefulness patterns • Normal human has “homeostasis” (ability to maintain a relative internal constancy) • Any person may complain of sleep-pattern disturbance as a primary problemor secondarydue to another condition • 1/4 of clients who seek health care complain of a difficulty related to sleep

27. Factors affecting length and quality of sleep 1. Anxiety related to the need for meeting a tasks, such as waking at an early hour for work. 2. The promise of pleasurable activity such as starting a vacation. 3. The conditioned patterns of sleeping. 4. Physiologic wake up. 5. Age differences. 6. Physiologic alteration, such as diseases

28. Good sleep depends on the number of awakenings and the total number of sleeping hours • The nurse can assess sleep pattern by doing interview with the client or using special charts or by EEG Disorders related to sleep 1.Sleep disturbances affects family life, employment, and general social adjustment 2. Feelings of fatigue, irritability and difficulty in concentrating 3. Difficulty in maintaining orientation

29. 4. Illusions, hallucination (visual & tactile). 5. Decreased psychomotor ability with decreased incentive to work. 6. Mild Nystagmus. 7. Tremor of hands. 8. Increase in gluco-corticoid and adrenergic hormone secretion. 9. Increase anxiety with sense of tiredness. 10. Insomnia "short end sleeping periods“. 11. Sleep apnea "periodic cessation of breathing that occurs during sleep.

30. 12. Hypersomnia: "sleeping for excessive periods” the sleep period may be extended to 16-18 hours a day 13. Peri-hypersomnia. "Condition that is described as an increased used for sleep "18-20 hours a day" lasts for only few days 14. Narcolepsy "excessive day time drowsiness or uncontrolled onset of sleep. 15. Cataplexy: abrupt weakness or paralysis of voluntary muscles e.g. arms, legs & face last from half second to 10 minutes, one or twice a year 16. Hypnagogic hallucinations: " Disturbing or frightening dream that occur as client is a falling a sleep

31. Assessment of sleep habits • Let the client record the times of going to sleep and awakening periods, including naps. • Allow client to described their sleep habits in their own words You can ask the following questions: How have you been sleeping?‖ Can you tell me about your sleeping habits?" Are you getting enough rest?" Tell me about your sleep problem" Good History includes: a general sleep history, psychological history, and a drug history

32. 5-Health History Systematic collection of subjective data which stated by the client, and objective data which observed by the nurse. Used to determine a client functional health pattern status.

33. Phases of taking health history Two phases: • The interview phase which elicits the information (primary sources) • The recording phase (secondary sources).

34. Guidelines for Taking Nursing History • Private, comfortable, and quiet environment. • Allow the client to state problems and expectations for the interview. • Orient the client the structure, purposes, and expectations of the history.

35. Guidelines for Taking Nursing History cont.. • Communicate and negotiate priorities with the client. • Listen more than talk. • Observe non-verbal communications e.g. "body language, voice tone, and appearance".

36. Guidelines for Taking Nursing History cont.. • Review information about past health history before starting interview. • Balance between allowing a client to talk in an unstructured manner and the need to structure requested information. • Clarify the client's definitions (terms & descriptions).

37. Guidelines for Taking Nursing History cont.. • Avoid yes or no question (when detailed information is desired). • Write adequate notes for recording? • Record nursing health history soon after interview.

38. Types of Nursing Health History • Complete health history: taken on initial visits to health care facilities. • Interval health history: collect information in visits following the initial data base is collected. • Problem-focused health history: collect data about a specific problem.

39. Components of Health History 1-Biographical Data: This includes • Full name • Address and telephone numbers (client's permanent contact of client) • Birth date and birth place • Sex • Religion and race • Marital status • Social security number • Occupation (usual and present) • Source of referral • Usual source of healthcare • Source and reliability of information • Date of interview

40. 2-Chief Complaint: “Reason For Hospitalization Examples of chief complaints: • Chest pain for 3 days. • Swollen ankles for 2 weeks. • Fever and headache for 24 hours. • Pap smear needed.

41. SYMPTOM ANALYSIS P Q R S T a. Provocative or Palliative • First occurrence : • What were you doing when you first experienced or noticed the symptom? • What to trigger it ? stress?, position?, activity? • What seems to cause it or make it worse? For a psychological symptom. • What relieves the symptom: change diet? change position ? take medication? being active? • Aggravation: what makes the symptom worse?

42. SYMPTOM ANALYSIS P Q R S T b. Quality Or Quantity • QUALITY: • How would you describe the symptom- how it feels, looks, or sounds? • QUANTITY: • How much are you experiencing now? • Is it so much that it prevents you from performing any activity?

43. SYMPTOM ANALYSISP Q RS T c. Region Or Radiation • Region: • Where does the symptom occur? • Radiation : • Does it travel down your back or arm, up your neck or down your legs?

44. SYMPTOM ANALYSISP Q R ST d. Severity scale • Severity • How bad is symptom at its worst? • Course • Does the symptom seem to be getting better, getting worse?

45. SYMPTOM ANALYSISP Q R S T e. Timing • Onset : • On what date did the symptom first occur? Type of onset : • How did the symptom start; suddenly? gradually? • Frequency : • How often do you experience the symptom; hourly? daily? weekly? Monthly? • Duration : • How long does an episode of the symptom last?

46. 3-History of present illness Gathering information relevant to the chief complaint, and the client's problem, including essential and relevant data, and self medical treatment.

47. Components of present illness • Introduction: "client's summary and usual health". • Investigation of symptoms: "onset, date, gradual or sudden, duration, frequency, location, quality, and alleviating or aggravating factors". • Negative information. • Relevant family information. • Disability "affected the client's total life".

48. 4- Past Health History: The purpose: (to identify all major past health problems of the client). This includes: • Childhood illness e.g. history of rheumatic fever. • History of accidents and disabling injuries.

49. Past Health History. Cont… • History of hospitalization (time of admission, date, admitting complaint, discharge diagnosis and follow up care). • History of operations "how and why this done“. • History of immunizations and allergies. • Physical examinations and diagnostic tests.

50. 5-Family History The purpose: to learn about the general health of the client's blood relatives, spouse, and children and to identify any illness of environmental, genetic, or familiar nature that might have implications for the client's health problems.