NSG2317

Health Assessment

Patrick O’Byrne RN-EC PhD

Associate Professor
University of Ottawa
School of Nursing
pjobyrne@uottawa.ca
Lecture Outline – Class 1

1. Introduction to course
a. Professor
b. Syllabus
c. Correspondence

2. Lecture Material
Introduction
Patrick O’Byrne – Education
BScN MScN PhD

Post-Doc Post-Doc NP
Patrick O’Byrne – Research
• STI/HIV testing, diagnosis, treatment

• STI/HIV prevention
• PEP
• PrEP

• Sexual behaviour
Patrick O’Byrne – Clinical Practice
• Sexual Health Centre
• STI/HIV testing, treatment, and prevention
• Contraception
• Hormonal
• Long-acting reversible

• Primary Care
• Urgent care walk-in
• Same day access
• Well baby/child checks
• Chronic disease management
• Trans-health
Syllabus
• Take notes

• Ask questions
Correspondence
• Contact
• Send to my uOttawa email: pjobyrne@uottawa.ca
• DO NOT USE COURSE WEBSITE
• Use YOUR uOttawa email

• Contact limitations
• Evenings
• Weekends
• Holidays

• Contact agreement
• 48 hour return time
• If no response, email again
Correspondence
• Ensure emails are professional and courteous
• Title (with course code)
• Salutation
• Text
• Signature (with FULL NAME, student #, graduation year)

• Emails that do not fulfill the above will be:

1. Returned marked “read”
2. Without any further information
Lecture Material
The Patient Trajectory
• Health issue manifestation All signs / Sx

• Data collection Clustering

• History
• Examination
• Investigations

• Diagnosis Dx

• Treatment

• Evaluation

Misiaszek BC. (2008). Geriatric Medicine Survival Handbook, Revised.

https://fhs.mcmaster.ca/medicine/geriatric/docs/Geriatric_Handbook08.pdf
Nursing Process - ADPIE
• Assessment

• Diagnosis

• Planning

• Intervention / Implementation

• Evaluation
Assessment / Dx – Priority Setting
1. Immediately life-threatening

2. Require prompt intervention to prevent deterioration

3. Important, but no threat of imminent or short-term harm

Communicating Assessment Findings
• SOAP

• SBAR
 Assessment – Relevance
CC: -painful red eye (OS)
S:
HPI: -acute onset 2 days ago, no trigger, constant since, sharp sensation, 7/10 severity, photophobia
-nothing alleviates/worsens
RoS: -no fever, feels well otherwise, no one else sick at home / work
-no foreign body sensation, no itch, no burn, no dryness, no discharge, no lid edema, no scalp pain, no
jaw claudication, no headache, no rhinorrhea, no sore throat
-no cough, no dyspnea, no hemoptysis, no chest pain, no palpitations, no abdo pain, no n/v/d
-no myalgias, no arthralgias, no weakness
General: -looks well, NAD, AOx3
O:
HEENT: -head: no masses, no lesions, no pain, face symmetrical
-eyes: no lid edema, no d/c, erythematous bulbar conjunctiva with limbal injection (OS only), pink
palpebral conjunctiva bilat., OS pupil constricted with poor reaction to light, OD reacts to light,
Snellen 20/20 (OU), 20/20 (OD), 10/20 (OS), equal EOM (without pain)
-ears: no external pain, no d/c, no erythema, external canals with scant cerumen, TMs / light reflexes
/ landmarks visible, no bulging, no erythema, no effusion, no suppuration
-nose: mucosa pink/moist, no d/c, no lesions
-mouth: buccal mucosa pink/moist, tongue midline, no lesions, uvula midline, tonsils 2+, no edema,
no erythema, no exudate, no post-nasal drainage, no petechiae
-neck: supple, no lymphadenopathy, no masses, no tenderness
Resp: -vesicular breath sounds in peripheral fields, no adventitious sounds, no cough during exam
Cardiac: -s1s2 present, no s3s4, no murmurs, no peripheral edema
Abdo: -flat contour, no striae, no pulsations, no masses
-normal bowel sounds x 4
-dullness & resonance to percussion, no pain/masses on palpation, no organomegaly
The Health History
Health Hx
• Definition:
• Collection of subjective data

• Can be whole or focused

• Purpose:
• Identifies health issues & strengths
• Guides physical exam
Basis of most nursing / medical care
Bent S, et al. JAMA 2002; 287(20):2701-10.
Health Hx
• Biographical data (Bio)

• Reason for care provision (CC + HPI)

• Review of systems (RoS)

• Past medical history (PMHx)

• Family history (FamHx)

• Social history (SocHx)

Bio
• Name

• Birth date & age

• Sex & gender

• Birthplace

• Address & phone number

CC & HPI
• CC

• HPI
• P

• Q

• R

• S

• T

• U
CC & HPI – Examples
• CC: sore throat
• HPI:
CC & HPI – Examples
• CC: cough
• HPI:
RoS
• Purpose:
1. Evaluate past/present state of each system
2. Double-check in case important data were missed in HPI
3. Evaluate health promotion practices

Sx are not exhaustive

Just most common
RoS
• General

• Derm

• HEENT

• Resp

• Cardiac
RoS
• GI

• GU

• MSK

• Neuro

*add other relevant items as clinically indicated (e.g., breasts)

RoS – Examples
• CC: sore throat
• HPI:
RoS – Examples
• CC: cough
• HPI:
PMHx
• Allergies

• Medication use

• Previous / ongoing:
• Illnesses
• Injuries
• Surgeries / operations / procedures
• Hospitalizations
PMHx
• Last examination date

• Vaccination statuses

• Obs/gyne history (GTPAL)

FamHx
• Age + health (or cause of death) of immediate blood relatives
• Family tree (genogram)
SocHx
• Occupation
• Education
• Family & relationships
• Exercise & nutrition
• Sleep/rest
• Personal habits
• Substance use
SocHx – Importance
• Health is greatly influenced by social determinants
• Income & social status
• Social support networks
• Education + literacy
• Employment + working conditions
• Social environments
• Physical environments
• Personal health practices + coping skills
• Healthy child development
• Biology and genetic endowment
• Gender
• Culture

• The care continuum

• Skills are useless if patients do not / cannot present for / follow-through with care