Faculty of Nursing-IUG

Chapter (2)Health Assessment- Holistic

Approach

Holistic approach

1. The interview

2. Psychosocial assessment

3. Nutritional assessment

4. Assessment of sleep-wakefulness

patterns

5. The health history.2

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

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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 phase4

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

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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)6

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

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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 8

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.

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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.

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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 theories e.g.

Erickson, Piaget, and Freud …. etc.11

Stages of AgeInfancy period: birth to 12 months Neonatal Stage: birth-28 days Infancy Stage: 1-12 monthsEarly childhood Stage: It’s refers to two integrated

stages of development Toddler: 1 - 3years. Preschool: 3 - 6 years. Middle childhood 6-12 yearsMiddle childhood 6-12 yearsLate childhood: Pre pubertal: 10 – 13 years. Adolescence: 13 - 19 yearsYoung adulthood 20-40 yearsYoung adulthood 20-40 yearsMiddle adulthood 40-65yearsMiddle adulthood 40-65yearsLate adulthood 65 and moreLate adulthood 65 and more

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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

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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

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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 a direct 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 2.5615

BMI RANGEBMI RANGE

Rang kg/m2 Condition

less than 16.0 Very thin

16.0 - 18.4 Thin

18.5- 24.9 Average

25–29.9 Overweight

30-34.9 Obese

≥ 35 Highly obese

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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.17

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 assessment18

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? 19

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 20

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 malnutrition21

b. Signs & symptoms of malnutritionDry 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

skinSpoon shaped Nails " Koilonychia “ anemiaTachycardia, elevated blood pressure due to

excessive sodium intake and excessive cholesterol, fat, or caloric intake

Muscle weakness and growth retardation 22

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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 foodThe 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

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Diseases affected by nutritional problems

1- Obesity: excess of body fat.

2- Diabetes mellitus.

3- Hypertension.

4- Coronary heart disease.

5- Cancer.

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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 problem or

secondary due to another condition

1/4 of clients who seek health care

complain of a difficulty related to sleep

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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

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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 28

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.29

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

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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 history31

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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.

Phases of taking health history

Two phases:

The interview phase which elicits the

information (primary sources)

The recording phase (secondary sources).

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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.

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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".

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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). 36

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.

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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.

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Components of Health History

1-Biographical Data: This includesFull nameAddress and telephone numbers (client's permanent contact of client) Birth date and birth placeSex Religion and raceMarital statusSocial security numberOccupation (usual and present)Source of referralUsual source of healthcareSource and reliability of informationDate of interview

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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.

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SYMPTOM ANALYSIS

P Q R S Ta. Provocative or Palliativea. Provocative or Palliative

First occurrence :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:Aggravation: what makes the symptom worse?

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SYMPTOM ANALYSIS

P Q R S Tb. Quality Or Quantity 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? 42

SYMPTOM ANALYSIS P Q R S T

c. Region Or Radiationc. Region Or Radiation

RegionRegion: : Where does the symptom occur?Where does the symptom occur?

Radiation : Radiation : Does it travel down your back or arm, up Does it travel down your back or arm, up

your neck or down your legs?your neck or down your legs?

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SYMPTOM ANALYSIS

P Q R S T

d. Severity scale

Severity

How bad is symptom at its worst?

CourseDoes the symptom seem to be getting

better, getting worse?44

SYMPTOM ANALYSIS P Q R S Te. Timinge. Timing Onset :Onset : On what date did the symptom first occur?

Type of onset :Type of onset : How did the symptom start; suddenly? gradually?Frequency :Frequency : How often do you experience the symptom;

hourly? daily? weekly? Monthly? Duration :Duration : How long does an episode of the symptom last?

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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.46

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".

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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.

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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.

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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.

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Family History. Cont…

Family history of communicable diseases.

Heredity factors associated with causes of some diseases.

Strong family history of certain problems.

Health of family members "maternal, parents, siblings,

aunts, uncles…etc.".

Cause of death of the family members "immediate and

extended family".

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6-Environmental History:

Purpose

“To gather information about surroundings

of the client", including physical,

psychological, social environment, and

presence of hazards, pollutants and safety

measures."

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7- Current Health Information

Purpose: to record major current health-related

information.

Allergies: environmental, ingestion, drug, others.

Habits "alcohol, tobacco, drug, caffeine"

Medications taken regularly by doctor or self prescription.

Exercise patterns.

Sleep patterns (daily routine).

The pattern life (sedentary or active).53

8- Psychosocial History:

Includes:How client and his family cope with disease or stress, and how they respond to illness and health.You can assess if there is psychological or social problem and if it affects general health of the client.

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9- Review of Systems (ROS)

Collection of data about the past and the

present of each of the client systems.

(Review of the client’s physical, sociologic,

and psychological health status may identify

hidden problems and provides an opportunity

to indicate client strength and disabilities).

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Physical Systems

Which includes assessment of:

General review of skin, hair, head, face, eyes, ears, nose, sinuses, mouth, throat, neck nodes and breasts.Assessment of respiratory and cardiovascular system.Assessment of gastrointestinal system.Assessment of urinary system.Assessment of genital system.Assessment of extremities and musculoskeletal system.Assessment of endocrine system.Assessment of heamatoboitic system.

Assessment of social system.

Assessment of psychological system.56

10- Nutritional Health History

“Discussed Before”

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11- Assessment of Interpersonal Factors

This includes:

Ethnic and cultural background, spoken language, values,

health habits, and family relationship.

Life style e.g. rest and sleep pattern.

Self concept perception of strength, desired changes.

Sexuality developmental level and concerns.

Stress response coping pattern, support system,

perceptions of current anticipated stressors.58