Documente Academic
Documente Profesional
Documente Cultură
HEALTH ASSESSMENT
Health Assessment
n Incorporates
critical thinking
n Includes knowledge of
developmental stages through the
life cycle
n Health assessment includes,
physical & mental along with
assessment for domestic violence
and child abuse
Cultural Assessment
Brief History of the cultural group patient
identifies with
n Communication
n Values
n Cultural Sanctions/Restrictions and Health
related beliefs/practices
n
nIs
Health Assessment
nRequires
proficient
communication skills and
interviewing techniques
nConsiders
n
cultural aspects
Cultural Competency
Cross-Cultural
Communication
n Cultural
perspectives on professional
interactions
n Etiquette
n Space and distance
n Cultural considerations on gender
and sexual orientation
Techniques of
Communication
n
(cont.)
Health Assessment
n Begins
Nonverbal skills
n
Physical appearance
Posture
Gestures
Facial expression
Eye contact
Voice
Touch
History Taking
nComplete
n Well
nInterval
nProblem
focused or chief
complaint
n Review
of
systems
n Reason for
seeking health n Psychological
care
n Functional
Assessment
n Present health/
Illness
n Perception of
n Past health
health
n Family health
sensation
n Sign
n Objective
abnormality
on physical exam or in
laboratory reports
n Detectable
Present Health/Illness
n Onset,
duration, precipitating
factors.
n Frequency, duration
n Associated symptoms i.e. N/V
n Alleviating/ aggravating factors
n ROS re: CC
n Relevant family, occupational or
recreational history.
n Past
Current Health
Family History
n Allergies
n Habits
n Meds
(including OTC/Herbal/
Vitamins)
n Exercise
n Sleep
general health
illnesses
n Accidents/ injuries
n Hospitalizations/surgeries
n Acute and chronic illnesses
n Immunizations
n Allergies, medications, transfusions
n Childhood
n Important
to know to determine
risks
n Spouse/significant other
n Children
n Cultural considerations
Psychological Function
nCognitive
Functional Assessment
memory,
comprehension
nResponse to illness and
health
nPsych history, meds,
anxiety?
nCultural considerations
n ADLs
Perception of Health
nHow
Techniques of PE
n Four
n Sleep/rest
n Nutrition/problems
with diet,
weight
n Alcohol problems /Substance
abuse
n Coping difficulties
n Domestic/child abuse
nGoal
is to identify variations
form normal.
nExplain procedure first
nHead to Toe
nUnaffected areas before
affected
Techniques of PE
n Inspection-
n Palpation-
Palpation Technique
The RN must utilize different parts of the hand
One hand or bimanual (2 hands)
n
n
n
n
Techniques of PE
n Methods
n Direct-
of Percussion
n Indirect-
Techniques of PE
n Auscultation-Usually
last technique
during PE (*exception abdomen,
its the 2nd technique after
inspection)
n Use stethoscope to block sounds not
magnify
n Diaphragm-firmly against skin
n Bell- lightly against skin
Techniques of PE
Percussion- Third techniquestapping
on skin surface which creates a vibration
of underlying structures. The vibration
produces a sound, may aid in diagnosis.
n Resonant- normal lung.
n Hyperresonant- Childs lung or
emphysema.
n Tympany- Air filled organ, e.g., stomach
or intestine.
n Dull- Dense organ, e.g., liver or spleen.
n Flat- No air present, e.g., bone.
n
Techniques of PE
n Uses
Techniques of PE
n Description
of sounds heard
n Pitch- frequency of sound vibrations,
high or low.
n Intensity- loudness of sound: loud or
soft (amplitude)
n Duration- length of sound: short, long
n Quality- subjective terms- harsh,
tinkling, etc
Physical Exam
Summary
nUtilize
nHealth
4 techniques
nProper setting
nEquipment
nClean/ safe environment
nRemember client comfort
SOAP note
Subjective - info given by pt
(health history)
n Objective - PE finding using IPPA
n Assessment - therapeutic ideas,
nsg dx
n Plan - diagnostic, therapeutic or
educational interventions
to work toward problem solving.
n
Objective data
the RN observes
the PE is performed you must
identify the normal and abnormal
findings
n What
n As
Pertinent positives
and
Significant negatives
assessment
includes:
nComplete health history
nROS
nPhysical Exam
Subjective Data
n
n
n
Assessment
After you collect the data then you must
interpret the results
n Written as a NANDA diagnosis
Actual health problem
Risk diagnosis
Wellness diagnosis
n Remember the 2 and 3 part statements
n PES format
n Problem r/t etiology AEB S&S
n
Plan
n