HEALTH ASSESTMENT

THE NURSING PROCESS

- Guide to client care with 5 sequential steps

Steps in nursing process:

1. Assessment (and data collection)

- If data collection is inadequate or inaccurate: Incorrect msg judgmental may be made
1.1 SUBJECTIVE DATA
E.g. Patient’s pain level and what the pain feels like.
1.2 OBJECTIVE DATA
E.g Patient’s vital sign

TYPES OF HEALTH ASSESMENT:

- Initial comprehensive assessment
: Done within specified time after client admission to the hospital
Purpose: To evaluate clients health
- Ongoing or partial assessment
: EX: HOME HEALTH VISIT, Development screenings
: To evaluate any changes in the client functional health
- Focused or problem-oriented assessment
: EX HOURTY FLUID INTAKE ASSESTMENT
- Emergency assessment

GUIDELINES OD AN EFFECTIVE INTERVIEW AND HEALTH HISTORY

Phases interview
1. Introductory phase
: The nurse introduce himself to the patient
2. Working phase
3. Summary and closing phase
- Summarize information

COMMUNICATION DURING THE INTERVIEW

Verbal communication

- OPEN ENDED QUESTIONS :

HOW OR WHAT”
E.g How have you been lately?
How does this make you feel?
- CLOSE ENDED QUESTION
- Begins with “WHEN OR DID”
- E.g when did your headache start?
- WELL PLACED PHRASE
- Encourage client verbalization “ AH-HUH,YES I AGREE
 - INFERRING
The types of questions that involve reading between the lines
- PROVIDING INFORMATION
- Important thing to do throughout the interview is to provide the client with information and
concerns arise
- LAUNDRY LIST
EX: IT is the pain severe, Dull sharp, mild cutting or piercing
- Providing client with list of words to choose from in describing symptoms
- REPRHASING
- Helps to clarify information the client stated.
- Enables you and the client to reflect on what you said

Nonverbal Communication

- APPRERANCE: wear comfortable

- DEMEANOR
- FACIAL EXPRESSION
- ATTITUDE
- SILENCE
- LISTENING: Eye contact, Facial expressions

1.SPECIAL CONSIDERATION DURING INTERVIEW

1. GERONTOLOGIC VARIATIONS IN COMMUNICATION

- when interviewing an elderly client, you must first Asses hearing acuity. Hearing loss occurs
normally with age and undetected hearing loss is often misinterpreted as mental slowness or
confusion
If you detect hearing loss:
- Speak slowly
- Face the client at all time
2. CULTURAL VARIATIONS IN COMMUNICATION
- ETHNIC/CULTURAL VARITATIONS IN COMUNICATION AND SELF DISCLOSURE.
- “A culture broker”
3. EMOTIONAL VARIATIONS IN COMMUNICATION
- Clients emotions vary

WHEN INTERACTING WITH AN

ANXIOUS CLIENT
Do not hurry and decrease any external stimuli
Ask simple questions
Avoid becoming anxious like the client
 ANGRY CLIENT
- Don’t touch them
DEPRESSED CLIENT
- U Need to understand
- Manipulative client
- SEDUCTIVE CLIENT
- SENSITIVE ISSUES
: EX SEXUALITY,DYING,SPRITUALITY

Steps of assestment

STEP 1: Collection of data

1.Gathering info about the client

2. includes physical, physcological, emotional,sociocultural spiritual factors that may affecr clients
health status.

TYPES OF DATA:

1. SUBJECTIVE DATA : Pasyente lang nakakaramdam ,symptoms

2. Objective data : SIGN OR OVERT DATA, NAOBSERVE
- Can be seen, heared, smelt
- Ex. Discoloration of skin

DATA COLLECTION

1. OBSERVING: To observe is to gather data by using senses

2. INTERVIEWING: Planned communication or conversation with purpose.
3. EXAMINING-

ASSESTMENT TECHNIQUES- Cont. inspection

- Close and careful visualization of the person as a whole and of each body system.
- Perform at every encounter with your client.
Cont. palpation
- Temperature, Texture Moisture.
Cont. Percussion
- Asses underlying structures for location, size, density of underlying tissue
- DIRECT: Mismong naka direct
CONT. AUSCULATION