Professional Documents
Culture Documents
Introduction To Health Assessment
Introduction To Health Assessment
◦ culture and beliefs - The nurses use structured head to toe examination
to identify changes in the patient’s body system
7 Facets PESCSED
Purpose of Health Assessment:
-The ability to juggle and align the facets in a
harmonious network leads to a healthy state for an ▪ To determine a patient’s health status, risk factors,
individual and need for education as a basis for developing a
nursing care plan.
-Patient’s view and definition of health
- The ability of the nurse to extrapolate the findings,
Physical health - how the body works and adapts.
prioritized them, and formulate and implement the
Emotional health - positive outlook and emotions plan of care is the overall goal (Nursing Process)
channeled in a healthy manner.
- The information obtained should be documented
Social well-being - supportive relationships with in a clear, concise manner (patient’s medical
family and friends records)
Developmental level - how one thinks, solve ▪ Preparing for the Assessment
problems, and make decisions.
Before actually meeting the client:
HEALTH ASSESSMENT
- review the client’s medical record, if available (it
- Includes a complete health history and physical provides background about chronic diseases and
examination
gives clues to how a present illness may impact the and helps to prevent documentation of inaccurate
client’s activities of daily living (ADL) data.
- know the client’s basic biographical data ▪ Prioritizing Data
- keep an open mind and avoid premature Assists you in prioritizing the patient’s
judgments that may alter your ability to collect problems. When prioritizing, consider the acuity of
accurate data the problem, the patient’s perception of the
problems, and the situation at hand.
- take time to educate yourself about the client’s
diagnosis and tests performed Top priority or primary problems – such as airway
problems – are life-threatening.
- obtain and organize materials that you will need
for the assessment Secondary problems – such as pain – require
prompt attention to prevent further progression or
1. Collection of subjective data
deterioration in your patient’s condition.
To elicit accurate subjective data, learn to
Third level problem – such as teaching needs – do
use effective interviewing skills with a variety of
not require immediate attention and can be
clients in different settings.
addressed once your patient’s condition has
Major areas of subjective data include: stabilized.
- history of present health concern It forms the database for the entire nursing
process and provides data for all other members of
- personal health history
the health care team.
- family history
Pieces to Complete Health Assessment:
- health and lifestyle practices
▪The review of system is the basis for the
2. Collection of objective data assessment and how to proceed with the PE
*Assumption:
Avoid Traps when Interviewing Patient
The information will be used for the benefit of
the patient. ◦ Leading the Patient
Reasons for sharing information: People will tell you what you want to hear,
so don’t lead the patient. Them describing what is
- Patient is a danger to self and others. happening is more helpful.
- Teaching institution where team approach is
used. ◦ Blasting Yourself
▪ Biases and Preconceptions If you fail to check your biases, you limit your
objectivity during assessment.
- Personal belief and value systems, attitudes,
biases and preconceptions of the nurse and ◦ Letting family answer for the patient
patient influence the sending and receiving of You will learn a lot by having the patient
messages. describe things in his/her own words.
◦ Asking more than one question at a time made, and clarify if your are still unsure. Recognize
the patient’s feelings and focus on them.
If you do, the patient may not know which
one to answer and get confused. ◦ Giving advice
◦ Not allowing more response time The patient needs to be informed, but can
make his/her own decisions.
Give the patient time to think through
his/her answer.
◦ Using medical jargons
Express questions in lay terms for the patient ◦ Jumping to conclusions
to understand.
Make sure to have all the facts before
◦ Assuming than clarifying and validating drawing conclusions.
Assuming can lead to inaccurate Phases of the Interview
interpretations and incorrect conclusions.
1.) Pre-interview
◦ Taking patient’s response personally
- Take time for self-reflection – is a continual part
Realize that the patient is displacing his/her of professional development in clinical work. It
feelings on you and using you as a sounding board. brings a deepening personal awareness to our
work with patients, which is one of the most
◦ Feeling personally uncomfortable
rewarding aspects of patient care.
Often happens at the beginning, it will get - Review the medical and nursing records.
easier with experience. - Set goals for the interview.
- A nurse must balance these provider-centered
◦ Using cliché
goals with patient-centered goals.
No one expects you to have all the answers. - Review clinical behavior and appearance.
If you do not have an answer, tell the patient that
you will try to find one and get back to him/her. Professionalism requires the nurse maintain
equanimity (calmness under pressure)
◦ Offering false reassurance
-Adjust the environment
Telling the patient that everything will be -Take notes
fine is condescending.
2.) Joining or Introductory Phase
◦ Asking persistent or probing questions
- introduce yourself to your patient, put him or
Makes the patient uncomfortable. The her at ease, and explain the purpose of the
patient has a right to not answer a question. interview and the time frame needed to
complete it.
◦ Changing the Subject
- Reassure your patient that the information
You are attending to the patient’s needs, not collected is confidential.
your own. - Choose a distance that facilitates conversation
and allows good eye contact.
◦ Taking things literally
- Establish the agenda
May lead to misunderstanding. Always Identifying all the concerns at the beginning
consider the context in which the statement is of the interview allows the patient and the nurse
to negotiate which concerns are most pressing
for the visit, and which can be postponed to a - Generating and testing diagnostic hypotheses
follow-up appointment.
- Identify and respond to the patient’s emotional Disease is the explanation that the nurse
cues uses to account for the symptoms. It is the way
◦ respond immediately when you hear an that the nurse organizes what is learned from
emotional cue the patient that leads to a nursing diagnosis
◦ responding to emotional cue: Illness can be defined as how the patient
N – Naming experiences the disease, including its effects on
relationships, function, and sense of well-being
“That sounds like a scary experience”
U – Understanding or legitimization Learning about the patient’s perception of
illness means asking patient-centered questions
“It’s understandable that you feel that “way” in four domain:
R – Respecting - FEELINGS including fears or concerns, about
the problem.
“You’ve done better than most people would - IDEAS about the nature and the cause of the
with this” problem.
- Expand and clarify the patient’s story - The effect of the problem on the patient’s
◦ use patient’s words, making sure you clarify life and FUNCTION.
their meaning - EXPECTATIONS of the disease, of the
◦ do not use medical jargon clinician, or of health care, often based on
◦ establish the sequence and timing of each prior personal or family experiences.
patient symptoms - Negotiate a plan
◦ interview moves back and forth from open-
ended questions to increasingly focused 4.) Termination Phase
questions and then on to another open-ended - The end of the interview.
questions, returning the lead in the interview to - Summarize and restate your findings.
the patient - Allow patient to ask questions.