Nursing Health Assessment

1. Nursing Health Assessment Akram Mohammad AbuSalah BNS, MSN, Ph. D. Islamic University of Gaza Strip

2. Islamic University of Gaza Strip Chapter (1) The Interview

3. The first assessment begin in (1992) by American medical association • In (1995) health assessment considered as basic human right • Preventive health care divided in three categories, primary, secondary and tertiary prevention. Each level of prevention is based on a thorough assessment of the client's health as status. • Periodic health assessment needed to be performed by a physician, or a nurse

4. Objectives of health assessment • Surveillance of health status, identification of occult disease, screening, and follow-up care • The periodic assessment, at regular intervals • Increasing client participation in health care • Accurately define the health and risk care needs for individuals • Health assessment is shared with the client in a clearly and understandable manner • The client must share in decision making for his own care.

5. Types of Assessment • Comprehensive assessment: is usually the initial assessment it very thorough and includes detailed health history and physical examination and examine the client's overall health status • Focused assessment : is problem oriented and may be the initial assessment or an ongoing assessment

6. Frequency of assessment • The persons under (35) years every (4 – 5) years • The persons from (35 – 45) every (2 – 3) years. • Persons from (45-55) years of age undergo a thorough health assessment every year. • Persons over (55) years may needs assessment every 6 months or less

7. Importance of nursing health assessment F 1. Systematic and continuous collection of client data 2. It focus on client responses to health problems 3. The nurse carefully examine the client’s body parts to determine any abnormalities 4. The nurse relies on data from different sources which can indicate significant clinical problems 5. Health assessment provides a base line used to plan the clients care

8. 6. Health assessment helps the nurse to diagnose client’s problem & the intervention 7. Complete health assessment involves a more detailed review of client’s condition 8. Health assessment influence the choice of therapies & client's responses

9. Purposes of health assessment 1. Gather data 2. Confirm or refuse data obtained in the health history 3. To identify nursing diagnoses 4. To make clinical judgments about client's changing health status 5.To evaluate bio-psycho-social and spiritual outcomes of care

10. Nursing and medical diagnosis • There is a big Difference between both because: • Nursing diagnose is independent role of the nurse • Nursing diagnoses depends on the client's problems/response associated with specific disorder • Any problem in nursing diagnosis must notice from a holistic view e.g. bio-psycho-social and spiritual relations

11. Medical diagnoses • Depends on clinical picture and laboratory findings • The specialist doctor has a right to diagnose not else Example: - DM is medical diagnoses (hypo or hyperglycemia) - Nursing diagnoses in this case e.g. Impaired skin integrity R/T poor circulation, Knowledge deficit about the effects of exercise on needs of insulin. The difference between medical diagnosis, a collaborative problem, and nursing diagnosis is explained with the next table:-

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

14. 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

15. 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

16. 1. 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

17. 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)

18. Communications techniques during interview 1. 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

19. 2. Types of statements to be use: • Repeat your perception of client's response to clarify information and encourage verbalization 3. Accept the client silence to recognize thoughts 4. 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

20. 5. Specific age variations :- • Pediatric clients: validate information from parents. • Geriatric clients: use simple words and assess hearing acuity 6. 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.

21. 7. Cultural variations: • Be aware of possible cultural variations in the communication styles of self and clients 8. Use culture broker: • Use culture broker as middleman if your client not speak your language. • Use pictures for non reading clients.

22. Islamic University of Gaza Strip Chapter (2) Psychosocial assessment

23. 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.

24. 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

25. Islamic University of Gaza Strip Chapter (3) Nutritional assessment

26. 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

27. 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

28. 1. 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

29. BMI RANGE

30. 2. 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.

31. 3. 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

32. 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?

33. 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

34. 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

35. 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

37. 4. 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

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

39. Islamic University of Gaza Strip Chapter (4) Sleep-wakefulness patterns

40. 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

41. 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

42. 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

43. 4. Illusions, hallucination (visual & tactile ) 5. Decreased psychomotor ability with decreased incentive to work 6. Mild Nystagmus 7. Tremor of hands 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

44. 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

45. 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

46. Islamic University of Gaza Strip Chapter (5) Nursing Health History

47. Definition of Health History Systematic collection of subjective data which stated by the client, and objective data which observed by the nurse That using to determine a client functional health pattern status.

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

49. 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.

50. 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".