healh assessment nursing foundation

FUNDAMENTAL OF NURSING

Unit 8

Objectives * Describe and purpose and processes of health assessment

•Describe the health assessment of each body system• Perform health assessment of each body system

HEALTH ASSESSMENT

• Purposes • Process of Health assessment a) Health history b) Physical examination (Methods – Inspection, Palpation, Percussion, Auscultation, Olfaction) c) Preparation for examination : Patient and Unit

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d) General assessment e) Assessment of each body system f) Recording of health assessment

Introduction

• Health assessment is an essential nursing function which provides foundation for quality nursing care and interventions.

• It helps to identify the strength of the clients in promoting health.

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• Health assessment helps to identify clients needs, clinical problems.

• To evaluate response of the person to health

Definition

• Health assessment is refers to systematic appraisal of all factors relevant to client’s health. OR

• Health assessment includes collecting subjective data through interviewing the client and obtaining objective data by physically examining the client

Purposes of health assessment

• Establish a data base for the clients normal abilities risk factors, and any current alterations in function.

•Plan strategies to to encourage continuation of healthy patterns, prevent potential health problems and alleviate or manage existing health problems.

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• To gather information regarding client’s health• To determine client’s normal function• To organize the collected information• To identify the health problems• To identify client’s strengths• To idientify need for health teaching

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• Provide the holistic view of the clients • Formulating conclusion or a problem statement such as a nursing diagnosis.

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• To collect data pertinent to the patient’s health status e.g subjective and objective data • To identify deviations from normal •To pointout actual problems •To build Rapport with patient and family.

TYPES OF ASSESSMENT

• Initial assessment

• Focused assessment

• Emergency assessment

• Time lapsed -assessment

INTIAL ASSESSMENT

It is performed within specified time after admission to a hospital.

The establish a complete data base for problem identification , reference and future comparison.

e.g. Nursing admission assessment

FOCUS or ONGOING ASSESSMENT

• on going or focused assessment is ongoing process integrated with nursing care.• Purpose The main purpose of ongoing or focused assessment to determine the status of a specific and to identify new or overlooked problem• e.g. Hourly assessment of client’s fluid intake and output chart

EMERGENCY ASSESSMENT

• Emergency assessment is life saving assessment the major purpose of emergency assessment is save the patient or client’s life.• Purpose . To identify life- threatining problems• E.g a rapid asessment of person’s airway b breathing ,and cirulation during cardiac arrest

TIME-LAPSED ASSESSMENT

• Time lapsed assessment involves assessment several days after first initial assessment.

• Purpose. To compare the client’s current status to baseline data previously obtained.

e.g Reassessment of a client’s functional health patterns in a home.

METHODS OF ASSESSMENT

• The primary methods used to assess client’s are .

OBSERVING

INERVIEWING

EXAMINING

OBSERVING

• Observation is a conscious,deleberate skill that is developed only through and with an organized approach.• E.g. Client data observed through four senses that is through vision, smell,hearing, and touch.

INTERVIEWING

An interview is a planned communication or a conversation with a purpose.

e.g. History taking

EXAMINING

• The physical examination is a systematic data or information collection method that uses observational skills to detect health problems .

• The conducting the examination , the nurse uses techniques of inspection ,auscultation, palpation and percussion.