HEALTH ASSESSMENT

in NURSING

N 295 Spring 2012

Revised january 2012 1

ASSESSMENT *WHAT

HOW

WHY

WHERE

WHEN

Revised january 2012 2

Sources of Data *

Primary Source

Secondary Source

Revised january 2012 3

Data Collection Methods *

OBSERVATION

INTERVIEW

PHYSICAL EXAMINATION

Revised january 2012 4

“Why”Leads to Type of Assessment *

CONTINUOUS ?

? SCREENING

! follow-up ??

¿ INTERMITTENT ?

!!? Emergency!!¿ COMPREHENSIVE

..?Functional ¿

FOCUSED ? ¿Revised january 2012 5

NURSING ASSESSMENT

VS

MEDICAL PHYSICAL EXAMINATION

Revised january 2012 6

Steps to Assessment

1.

2.

3.

4.

Revised january 2012 7

Instead: Talk about PARTS of Assessment *

1. Subjective Data Collection

2. Objective Data Collection

3. Validation of Data

4. Documentation of Data

Revised january 2012 8

Subjective Data Where do you get this?

How do you get this information?

Sending and Receiving

Does It Require Skill to obtain data??

Revised january 2012 9

Subjective Data *

Sign or Symptom?

Recognize that all behavior has meaning

Accept the client but set limits on inappropriate behavior

Revised january 2012 10

What do you think?

Identify and face problems honestly

It is best to maintain a professional distance

Revised january 2012 11

COMMUNICATION in the

INTERVIEW*

Internal Factors

External Factors

Revised january 2012 12

INTERVIEW TECHNIQUES

Verbal Communication

Non-Verbal Communication

Revised january 2012 13

Cultural / Diversity Considerations

Language Barriers

Space, Distance & Intimacy Concepts

Variations in Response to Illness

Variation in Non-Verbal Behaviors

Revised january 2012 14

Other Challenging Situations

Anxious Client

Angry Client

Depressed Client

Manipulative Client

Client with Sensitive Issues

Special Situations Revised january 2012 15

Complete Health History

1. Biographic Data2. Reason for Seeking Health Care3. History of Present Illness IF there is an HPI . . .

. . .then do PQRSTIf pain use PQRST or COLDSPA

Revised january 2012 16

EXPLORING S & S

Revised january 2012 17

Precipitating / Palliative Factors

Quality / Quantity

Region / Radiation / Related Symptoms

Severity

Timing

EXPLORING S & SC CharacterO OnsetL LocationD DurationS SeverityP PatternA Associated symptoms

Revised january 2012 18

Complete Health History *1. Biographic Data2. Reason for seeking Health Care3. History of Present Illness4. Past Health History5. Family History6. Review Of Systems 7. ADL & IADL8. Lifestyle & Health Practice Profile9. Developmental Level

Revised january 2012 19

Revised january 2012 20