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sc Nursing 2nd Sem Fundamental of Nursing-II Bhushan Science

[Link] Nursing 2nd Sem Fundamental of Nursing-II Bhushan Science

UNIT 1
HEALTH ASSESSMENT

INTERVIEW TECHNIQUE

INTRODUCTION
• It is the gateway to building an effective nurse patient relationship that will make patient feel
at ease, supported and empowered.
• The most effective health assessment interview techniques include.

INTERVIEW TECHNIQUE IN NURSING

1. Active Listening:
• Central to understanding patient's health issues and concerns.
• Pay full attention to both what is said and how it's said. Observe body language, facial
expressions, and other non-verbal cues.
• Use verbal and non-verbal prompts to encourage patients to provide more details about their
symptoms and experiences.

2. Adaptive Questioning:
• Helps gather detailed and relevant information without leading or influencing patient's
responses.
• Begin with open-ended questions to get a broad understanding, then use more specific
questions to delve deeper.
• A mix of open and closed-ended questions facilitates a more complete health history. Echoing
patient’s words can also encourage further elaboration.

3. Non-Verbal Communication:
• Enhances understanding of patient’s emotional and psychological state.
• Be conscious of your own body language and that of the patient. Actions like nodding,
maintaining eye contact, and appropriate facial expressions can build rapport.
• Mirroring patient’s posture and using therapeutic touch (when appropriate) can make patients
feel more at ease and understood.

4. Empathy, Validation, and Reassurance:

• Essential for establishing trust and rapport.
• Show genuine concern and understanding of the patient's feelings and experiences.
• Use empathetic statements and non-verbal cues to demonstrate understanding. Reassure
patients that their feelings are valid and taken seriously.

5. Partnering and Summarization:

• Reinforces that the patient is a valued partner in their care.
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• Summarize the information gathered to confirm understanding and identify any missing
elements.
• Regularly summarizing information helps to verify the accuracy of the collected data and
allows patients to add or correct information.

6. Transition and Empowerment:

• Helps manage patient anxiety and promotes active involvement in their health care.
• Clearly communicate what will happen next in the assessment or care process.
• Informing patients about the next steps and encouraging their participation empowers them
and can improve care outcomes.

Phases of Nursing Interviews

1. Introductory Phase
• Purpose: Introduce yourself, explain the interview, and set the patient at ease.
• Key Actions: Ensure comfort, privacy, and ask non-intrusive, patient-centered questions.

2. Working Phase
• Purpose: Collect detailed data.
• Key Actions: Use critical thinking to interpret information, collaborate on identifying
problems and goals.
• Note: Focus more on the patient than on taking notes.

3. Termination Phase
• Purpose: Summarize the interview and plan the next steps.
• Key Actions: Clarify any doubts, share feelings, and discuss follow-up plans.

OBSERVATION TECHNIQUES

INTRODUCTION:
• Observation in nursing involves using senses like sight, smell, hearing, and touch for data
collection.
• It's a systematic method to understand patients' behaviors, emotions, and cultural contexts.

PURPOSE OF OBSERVATION

1. Understanding Patients' Backgrounds: Identifies cultural, social, and personal factors

affecting health.
2. Detecting Non-Verbal Cues: Interprets body language and facial expressions, essential for
non-verbal patients.
3. Assessing Mental and Emotional State: Notes changes in behavior to identify mental health
issues.
4. Monitoring Health Changes: Tracks subtle changes in condition, vital for acute care.
5. Enhancing Personalized Care: Tailors care to individual patient needs for better satisfaction.
6. Improving Safety: Early detection of complications to prevent adverse events.
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7. Facilitating Communication: Builds trust and rapport through responsive care.

CHARACTERISTICS OF OBSERVATION
• Systematic and scientific, focusing on specific, relevant data.
• Involves immediate recording and verification for accuracy.
• Performed by trained professionals.

TYPES OF OBSERVATION
1. Structured vs. Unstructured Observation:
• Structured: Predefined method with specific recording style and data selection.
• Unstructured: Spontaneous, without predetermined guidelines.

2. Participant vs. Non-Participant Observation:

• Participant: Observer is part of the group being observed.
• Non-Participant: Observer does not interact with the group.

3. Controlled vs. Uncontrolled Observation:

• Controlled: Conducted under prearranged, experimental conditions.
• Uncontrolled: Occurs in natural settings for spontaneous observation.

TECHNIQUES IN OBSERVATION

1. Note Taking: This involves writing down observations as they happen. It's crucial in nursing
to document patient symptoms, behaviors, and responses to treatments accurately. Good note-
taking helps in tracking patient progress, ensuring consistent care, and communicating
effectively with other healthcare team members.

2. Photography: In some nursing contexts, photographs can be used to document patient

conditions, especially for wounds or skin conditions. This visual record supports accurate
monitoring of changes over time and can be useful for consultations with specialists or for
educational purposes.

3. Mapping: This technique is about understanding the patient's environment, which can include
their home setting or the hospital layout. Knowing the physical context helps in planning
patient care, ensuring safety, and understanding the impact of the environment on health and
recovery.

4. Scheduling: This involves planning and timing observations to ensure comprehensive patient
monitoring. In nursing, it's important to observe patients at different times to get a complete
picture of their condition. Scheduled observations help in managing workload and ensuring
timely interventions.

Advantages of Observation
• Provides firsthand, reliable data in natural settings.
• Enables longitudinal analysis and captures non-verbal behavior.
• Cost-effective compared to other methods.
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Disadvantages of Observation
• Limited control and precision in data measurement.
• Timing might not always align with events.
• Observer bias and inconsistency in tasks can be issues.

PURPOSES OF HEALTH ASSESSMENT

Definition: Health assessment is the process of collecting, analyzing, and using data to understand
a patient's health status.

Purposes of Health Assessment

1. Establishing a Patient Database:
• Goal: The primary aim is to create a comprehensive record of the patient's current health status,
including their normal physical and mental abilities, any risk factors they may have, and
noticeable changes in their functioning.
• Importance: This database is fundamental in nursing care as it provides a baseline against
which future changes in health can be measured. It's crucial for tracking the progression of a
patient’s condition and for identifying early signs of deterioration or improvement.

2. Planning Health Strategies:

• Goal: The objective here is to use the information gathered during the health assessment to
devise personalized health plans. These plans may include strategies for promoting healthy
lifestyles, preventing potential health issues based on identified risk factors, and managing any
existing health conditions effectively.
• Importance: Such planning is vital in both proactive health promotion and reactive disease
management. It allows for early intervention in potential health issues and ensures that existing
conditions are managed efficiently, enhancing the overall quality of patient care.

3. Providing a Holistic View:

• Goal: Health assessments aim to consider the patient's health in its entirety. This involves not
just physical symptoms but also mental health, social circumstances, lifestyle choices, and
emotional well-being.
• Importance: By adopting a holistic approach, nurses can ensure that all aspects of a patient's
health are taken into account. This comprehensive view is essential for addressing all factors
that can affect a patient's health and recovery, leading to more effective and personalized care.

4. Formulating Conclusions or Nursing Diagnosis:

• Goal: The data collected during the health assessment is used to identify and label specific
health issues. This process involves analyzing the information to reach conclusions about the
patient’s health status.
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• Importance: Formulating a nursing diagnosis is a critical step in the care process. It guides
the development of care plans and interventions. Accurate diagnoses are key to effective
treatment and ensuring that patients receive appropriate and targeted care.

5. Foundation for Patient Care:

• Goal: The health assessment provides a foundational basis for all subsequent patient care and
interventions. It informs every aspect of the nursing care plan.
• Importance: This foundational assessment is critical for continuity and consistency in patient
care. It ensures that care is tailored to each patient’s unique needs and conditions, facilitating
better outcomes and patient satisfaction.

PROCESS OF HEALTH ASSESSMENT

1. History Collection: The first step where you gather a comprehensive history of the patient,
which includes their medical, family, and personal history.
2. Physical Examination: Following the collection of the patient's history, a thorough physical
examination is conducted to obtain objective data about the patient.
3. Interpretation of the Gathered Information About Patient Health: After the physical
examination, the nurse analyzes all the collected information to make sense of the patient's
health status.
4. Find Out the Abnormalities or Recognize the Differential Diagnosis: The nurse then
identifies any abnormalities or potential health issues from the normal findings and considers
various possible diagnoses.
5. Clinical Decision Making: Based on the interpretation of the patient's data and the potential
diagnoses, clinical decisions are made regarding the management and care of the patient.
6. Documentation: Finally, all findings, decisions, and care plans are documented accurately in
the patient's health record for continuity of care and legal purposes.

HEALTH HISTORY

Introduction: It is collecting information about the person, his family, socio-economic

background, nutrition, previous medical and surgical history, accidents and present illness, etc.
History taking is getting the subjective information. It helps to establish rapport with the patient.

Information Needed for a Complete Health History

Category Details
1. Biographical Data Name, Gender, Date of Birth, Place of Birth, Sex, Age,
Religion, Native Language, Nationality, Marital Status,
Bed No., IP No., Address, Phone Number, Contact of
Person Living with Patient (Name, Address, Phone
Number, Relationship), Occupation, Education
2. Health and Illness Patterns
a. Chief Complaints Reason for seeking health care
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b. History of Present Illness - Onset

- Location of Symptoms
- Duration- Precipitating Factors
- Associated Symptoms- Treatments
- Current Medications
c. Past Health History - Childhood Illnesses
- Immunizations- Allergies
d. Obstetric History - Age at Menarche
- Age at Marriage
- Number of Children- Date of Menopause
e. Family Health Status - Type of Family
- Number of Family Members
- Significant Family Illnesses
f. Personal Habits & Patterns of - Work: Type, Hours, Duration, Stresses
Living - Rest and Sleep
- Exercise and Ambulation
g. Activities of Daily Living (ADL) - Ask about the patient’s ability to perform alone or with
help
-Taking medication correctly
-shopping
h. Psychosocial History - Significant Others, Relationships
- Support Systems
- Social Contact Satisfaction
- Employment Satisfaction
i. Significant Stressors - Coping Ability
- Self-Perception
- Interpersonal Trauma History
- Feelings about Current Illness
j. Spiritual Concerns and Needs - Concept of God- Source of Strength
- Religious Practices and Values
- Spiritual Adviser

PHYSICAL EXAMINATION
Definition: Physical examination is the process of evaluating objective anatomic findings through
the use of observation, palpation, percussion, and auscultation.

Goal of Physical Examination

• Main Goal: Identify health strengths and actual or potential health problems.

A. Method of Physical Assessment:

1. Inspection
2. Palpation
3. Percussion
4. Auscultation
5. Olfaction
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1. Inspection: Inspection is the beginning of physical assessment, it is 1st technique and start as
soon as you meet the patient, before the health history interview and continues throughout
examination. Inspection is a systematic visual examination to distinguish the normal from
abnormal findings. It helps to identify the size, shape, color, symmetry, position and any deformity.
Types of Inspection
A. Direct Inspection: Viewing the patient directly without instruments.
B. Indirect Inspection: Using tools like otoscopes or ophthalmoscopes to enhance vision.

2. Palpation: Palpation is the technique in which examiner feels texture, masses (its position, size
or shape), organ size, temperature, tenderness or swelling of body parts with the hands. It is the
2nd technique of physical assessment and usually follows the inspection to confirm the findings
that are seen during inspection. This technique is using sense of touch to collect the data.

Types of Palpation in Nursing

A. Light Superficial Palpation:
• Technique: Use finger pads to depress the skin up to 1-2 cm in a circular motion.
• Purpose: Assess surface characteristics like temperature, texture, mobility, shape, size, pulses,
edema, and tenderness.
• Procedure: Start with the dominant hand and move fingers systematically across the area to
cover the entire region.
B. Deep Palpation:
• Technique: Apply firm pressure with fingertips or pads of one or both hands to a depth of 4-5
cm.
• Purpose: Evaluate organ size, detect masses, and identify areas of tenderness or deep-seated
abnormalities.
• Caution: Perform slowly and carefully to avoid causing discomfort or injury to internal organs.
C. Bimanual Palpation:
• Technique: Involves using both hands, one on top of the other, to feel the size, shape, and
consistency of organs or masses.
• Purpose: Especially useful for assessing organs or structures that are larger or deeper in the
body, such as the uterus, ovaries, or kidneys.
• Procedure: The top hand applies pressure while the bottom hand remains stationary to feel the
structures.
3. Percussion
Definition: Percussion is a diagnostic technique used in physical examinations, where the nurse
taps on a patient's body surface to produce sounds. These sounds help determine the condition of
internal organs based on the quality, pitch, duration, and intensity of the sound produced.

Types of Percussion:
1. Direct Percussion:
• Technique: The examiner uses one hand and directly taps the body surface with the pads of
fingers or the pad of the middle finger.
• Usage: Often employed for assessing sinuses.
• Method: Involves sharp, rapid wrist movements, striking the body surface with fingers.
2. Indirect Percussion:
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• Technique: Utilizes two hands, where one hand (the pleximeter) is placed on the body surface,
and the other hand (the plexor) strikes it.
• Usage: Commonly used for assessing the lungs and abdominal organs.
• Method: The plexor's fingers strike the pleximeter's hand to create vibrations and sounds for
interpretation.
3. Blunt Percussion:
• Technique: A form of percussion where a closed fist is used to strike the body surface.
• Usage: Typically used to assess for tenderness over organs like kidneys.
• Method: Involves a gentle, firm tapping with a closed fist on the body area being examined.

4. Auscultation
Listening to the sounds made by the body, such as heart, lung, and stomach sounds, with or without
a stethoscope.

5. Olfaction
Using the sense of smell to detect abnormalities that have a scent, such as infections or chemical
exposures.

PREPARATION FOR EXAMINATION: PATIENT & UNIT

a. Preparation of The Unit for Physical Examination
1. Maintenance of Privacy:
• Examination Room: Ensure a private room is available for the patient's examination.
• Closed Doors: Keep the examination room doors closed to maintain privacy.
• Limiting Visitors: Restrict relatives from entering the room during the examination.
• Use of Drapes: Properly drape the patient, exposing only the necessary area for
examination.

2. Adequate Lighting:
• Natural Light Preference: Utilize natural light when possible to help identify conditions like
jaundice, which may not be as evident under artificial lighting.

3. Comfortable Examination Space:

• Examination Bed/Table: A comfortable examination space should include a well-cushioned
and easily accessible examination bed or table to ensure patient comfort and safety during the
assessment.

4. Physical Examination Tools

• Thermometer
• Stethoscope
• Sphygmomanometer
• Visual acuity charts
• Penlight/pocket light: The penlight is typically used to examine the eyes, nose and throat.
• Ophthalmoscope: The ophthalmoscope has a light, magnifying lens and opening for the
physician to view the eye.
• Otoscope: It allows the physician to view the ear canal and tympanic membrane.
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• Goniometer: It is used to measure a joint's range of motion (ROM).

• Tuning fork: It is used to test a patient's hearing.
• Nasoscope: Also called Rhinoscope. It is used to examine the inside of the nose.
• Percussion hammer: It is used to assess neurologic reflexes.
• Tongue depressor: It is used to depress the tongue to allow for examination of the mouth and
throat the tongue depressor is ideal for oral examination and patient care.
• Visualize the pharynx
• Stimulate the gag reflex
• Assess the strength of the trigeminal cranial nerve.
5. Additional Supplies
• Cotton Balls:
• Cotton-Tipped Applicators:
Use: For collecting culture swabs, treating wounds, and applying topical
medications.
• Gloves:
Use: To protect against exposure to blood and body fluids during assessments.
• Specimen Containers:
Use: For collecting and storing blood, urine, and other bodily fluids for laboratory
analysis.
• Disposable Needles and Syringes:
Use: For administering injections, anesthetics, or other fluids; also for drawing
blood samples for lab tests.
b. Preparation of Patient for Physical Examination
1. Physical Preparation:
• Cleanliness: Ensure the patient is clean; shave body parts if necessary for the exam.
• Bladder and Bowel Emptying: Have the patient empty their bladder and, if needed, use
an enema for bowel emptying.
• Hospital Attire: Change into hospital dress and loosen any tight garments.
• Draping: Use sheets to cover the patient, exposing only the area needed for examination.
2. Mental Preparation:
• Explanation: Clearly explain the examination process to build confidence and
cooperation.
• Nurse Support: A nurse, especially with female patients, should remain present during the
examination for support and reassurance.
3. Positions and Draping:
• Hospital Gown: Remove personal clothing and have the patient wear a hospital gown.
• Privacy Screen: Place a screen around the examination area for privacy.
• Draping Method: Varies according to the position and area of examination.
• Appropriate Draping: Ensure draping avoids unnecessary exposure while allowing
access to the examination area.
• Non-Interference: Draping should not hinder the examination process.

GENERAL ASSESSMENT
It includes general appearance
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1. Demographic Data:
• Name, age, sex, marital status, race, and religion.
• Purpose: To identify the patient and understand their background.
2. Body Build:
• Observation: Note if the patient is thin, muscular, obese, or excessively thin.
• Relevance: Helps assess the patient's health status in relation to age and lifestyle.
3. Posture and Gait:
• Whether the patient's posture is erect or slouched, and if their gait is steady or unsteady.
• Significance: Can provide clues about the patient's mood and physical well-being.
4. Height and Weight Assessment:
• Measurement: Record the patient's height and weight.
• Comparison: Use standard charts to compare the findings.
• Indicators: Weight is a key indicator of nutrition, fluid balance, and hydration.
• Body Mass Index (BMI):
• Calculation: Weight in kilograms divided by height in meters squared (kg/m²).
• Purpose: An important measure to assess overall health and potential risk factors.

5. Hygiene and Grooming:

• Observation: Check the cleanliness of nails, hair, skin, and overall appearance.
• Method: These can be assessed while examining other body parts.
6. Body and Breath Odors:
• Indicators: Certain odors can indicate health issues like pulmonary infections, uremia,
liver failure, or diabetes.
• Caution: Avoid jumping to conclusions, especially regarding alcohol use and its relation
to neurological or mental status.
7. Attitude:
• Observation: Notice the patient's willingness to participate, appearance, speech, and
behavior.
• Significance: Can reflect their emotional and psychological state.
8. Affect/Mood:
• Affect: Emotional state as observed (e.g., facial expressions).
• Mood: Emotional state as described by the patient.
• Importance: Provides insight into the patient's emotional well-being.
9. Speech:
• Assessment: Evaluate the loudness, clarity, pace, and coherence of speech.
• Observation: Look for poor articulation or language difficulties.
10. Mental Status:
• Assessment: Check if the patient is oriented to time, place, and environment.
• Behavior: Observe response to commands, comprehension, judgment, and insight.
ASSESSMENT OF EACH BODY SYSTEM

Assessment Details
System Components
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Color Check palms, soles, lips, tongue, nailbeds for cyanosis

or jaundice.
Moisture Assess hydration of skin and mucous membranes.

Temperature Use the dorsal surface of hands for assessment.

Inspection Note skin color changes, especially in different skin

Integumentary types.
System Edema Look for swelling in extremities, around eyes, and
sacrum.
Lesions Observe for any skin breaks or erosions.

Palpation Check skin moisture, temperature, turgor, tenderness,

and edema.
Skin Turgor Assess elasticity by folding skin on the forearm.

General Observe size, shape, and symmetry of the head and

Inspection skull.
Head
Hair Check quantity, distribution, pattern of loss, texture,
and color.
Color and Texture Check for clear color and pink vascular bed.

Nails
Firmness and Assess nail bases and blanching response.
Blanching
Vision Use Snellen's chart or ask to read a book/newspaper.
Hearing Assess by whisper test.
Sensory System Smell Test with identifiable scents like powder or soap.
Taste Check with salt/sugar on the tongue.
Touch Use hot and cold water tests.
Inspection Look at symmetry, movement, pupils, iris, sclera, and
Eyes check eyebrows.
Inspection Check pinna for placement, symmetry, and
surrounding tissue.
Ears
Palpation Assess auricle, tragus, and area behind the ear.

Inspection Examine shape, symmetry, color, discharge, nasal

Nose mucosa and septum.
Lips Check color, texture, hydration, lesions.
Mouth &
Oral Mucosa Look for color changes, nodules, ulcers.
Pharynx
Gums and Teeth Examine color, signs of atrophy, edema, ulceration.
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Tongue Assess color, texture, plaques, ulcers in resting and

protruded positions.
Pharynx Inspect color, drainage, signs of inflammation.
Inspection Check for symmetry, swelling, masses, scars.
Neck Palpation Examine parotid/submandibular glands.
ROM Evaluate neck movement.
Inspection Check consciousness, posture, neck veins, skin
changes.
Respiratory Palpation Assess chest elasticity.
System
Percussion Evaluate chest wall and underlying tissues.

Inspection Look for distended neck veins, cyanosis, ulcers.

Cardiovascular Palpation Evaluate pulse characteristics.
System Percussion Check cardiac borders.
Auscultation Listen for abnormal heart sounds.
Inspection Examine abdomen's contour, skin, pulsations.
Gastrointestinal
Auscultation Listen for bowel sounds, vascular noises.
System
Palpation Evaluate muscle guarding, tenderness, masses.
Neurological Consciousness Use Glasgow Coma Scale (GCS) for evaluation.
System Level
General Observe symmetry, gait, posture.
Appearance
Musculoskeletal Spine Check curvature, symmetry.
System
Joints Assess ROM, motor skills, muscle tone.
Muscle Mass Measure circumference of limbs.
Male Inspection and Evaluate pubic hair, penis, scrotum, inguinal area.
Reproductive Palpation
System
External and Inspect hair, labia, clitoris, vaginal and urinary
Female Internal Genitalia orifices. Palpate for tenderness, masses.
Reproductive
System Breast and Inspect and palpate breasts for nodules, symmetry, and
Axillae lymph nodes.
Inspection Check for abdominal masses, urinary meatus
inflammation.
Genitourinary Palpation Examine kidneys and bladder.
System Percussion Detect tenderness in kidney area, assess bladder
fullness.
Auscultation Evaluate for urinary tract issues.
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DOCUMENTING HEALTH ASSESMENT FINDINGS

RECORDING OF HEALTH ASSESSMENT
A. Recording of Health Assessment
• Review and Organize: After the physical assessment, organize and document all findings,
including health history and results from any laboratory and diagnostic tests.
• Formulate Nursing Diagnosis: Use the collected data to identify nursing diagnoses.
• Planning Care: These diagnoses guide the planning, implementation, and evaluation of
nursing care.
B. Genitourinary Assessment
• Patient History: Ask about renal or urologic problems, painful urination, urine color
changes, urination changes, and frequent nocturia.
C. Inspection
• Abdomen: Look for midline or unilateral masses indicating possible tumor or polycystic
kidney.
• Urinary Meatus: Check for inflammation or discharge.
D. Palpation
• Kidneys: Palpate kidneys via the Costovertebral angle (CVA). The right kidney is more
palpable than the left due to anatomical reasons.
• Note: Size and tenderness of the kidney.
E. Percussion
• Flank Area: Check for tenderness to indicate kidney infection.
• Bladder: Assess fullness by percussing above the symphysis pubis.
F. Auscultation
• Abdomen: Listen for signs of ascites related to kidney or liver dysfunction.
G. Specific Assessments
• Older Men: Check for issues like Benign Prostatic Hyperplasia (BPH) and Prostatitis.
• Women: Examine the vulva, urethral meatus, and vagina. Assess for pelvic prolapse and
other conditions.