Introduction to nursing Health
Assessment
By
Teklu .w
1 02/2/2010
Unit one
Introduction to health assessment
Learning objectives
At the end of this lesson students will be able to:
Define health
Define nursing
Define Nursing process
Describe components of Nursing process.
Carry out Nursing process.
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cont.…
Describe methods of collecting and organizing
nursing assessment data.
List type of assessment
List type of nursing diagnosis
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Health definition
WHO define health “Health is a state
of complete physical, mental and
social well-being and is not merely
the absence of disease or infirmity.”
Holistic model define health
Holistic health is based on the
interdependence of the body, mind
and spirit.
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Cont.…
This interdependence of body, mind and spirit
in dynamic interaction with the environment is
being recognized as fundamental to health
promotion effort.
The term “ holism” also refers to the beliefs
that all parts of a living organism work
together to determine the health of the entire
person.
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Cont.….
Adaptation model
The adaptation model suggests that health
depends on the organism’s ability to adapt
to the internal and external environment.
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Cont…
Health is a global term because it refers to
every aspect of a person's life including:
Physical status
Emotional wellbeing
Social relation ship
Intellectual functioning
Spiritual condition
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Definition of nursing
Nursing – is utilizing the environment of the
patient to assist him in his recovery
(Florence Nightingale 1860.)
Nursing – is assist the sick individual or
well, in the performance of those activity
contributing to health or its recovery or to
peaceful death. (Henderson , 1960)
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Cont..
ANA describe nursing practice as
directed , gol-orented and adaptable
to the needs of individual ,family
and community.
Generally nursing
An arte
science
Client –centered
holistic
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Purpose of nursing health assessment
To identify client health care needs
To make a complete nursing intervention
that meet patient needs.
To make systematic examination that lead
to meaning full diagnosis.
Give you a better picture of the patients
problem.
To establish a data base for intervention.
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Nursing Process
Definition:
Is a systematic problem-solving approach used to
promote health, prevent, identify, and treat health
problems.
A systematic way to assess, identify a problem
,plan, implement and evaluate care for individuals,
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Characteristics of Nursing Process
Dynamic
Client-centered
Planned
Interpersonal and collaborative
Universally applicable
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Characteristics of NP Con…
Focus on problems and strengths
Humanistic and individualized
Cyclical
Outcome focused (results oriented) - is being tied
to what happens at the end of the process.
It is Interrelated
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Benefits of using NP
Continuity of care
Prevention of duplication
Individualized care
Provides standard care for pts
Increased client participation
Collaboration of care
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Components of Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
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I. Assessment
Is the systematic collection, organization, validation
and documentation of client data.
Is a continuous process carried out during all
phases of nursing process.
All phases of the nursing process depend on it.
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Types of Assessment
Comprehensive/initial assessment
Assessment done from head to toe
Performed at the time patient enters the health
care facility.
Usually applied for patients who newly visit health
care facility.
It is vary broad and lead us to a center of our
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diagnosis.
Cont..
Problem focused assessment
An Ongoing process to determine specific
problem identified in an earlier assessment
and to identify new or overlooked problems.
It focused on injured part rather than other
part of body.
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Types of Assessment Con…
Emergency assessment
Done during psychiatric or physiological crisis of the
client to identify life threatening problems
Time lapsed-reassessment
Done several days/months after initial assessment
to compare the clients’ status to baseline data
previously obtained.
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Types of data
1. Subjective data
Also referred to as symptoms or covert data
are apparent only to the person affected and
can be described or verified only by that person.
Information perceived only by the affected person
E.g. pain experience, feeling dizzy, feeling anxious,
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Types of data con…
2. Objective Data
Also referred to as signs or overt data.
Are detectable by an observer or can be measured
or tested against an accepted standard.
They can be seen, heard, felt or smelled
E.g. 37oc, 140/90, Discolorations of the Skin.
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Sources of clinical data
1. Primary Source (Direct Source )
client: Usually best source
2. Secondary Source (Indirect Source)
Family Members
Client’s records such as:
Nursing/Medical Records
Laboratory Records etc.
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Data collection methods
Interviewing
Physical examination
result of diagnostic and Laboratory investigation
Imaging
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a) Interview
Is client –health care provider interaction where
by the clinician asks and the client answers.
Phases of a Nursing interview
Preparatory phase
Introduction
Working phase
Termination 02/2/2010
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I. Preparatory
Is first step to be practiced.
Nurse collects background information from
previous charts if repeat case.
Ensure environment is conducive
Arrange seating
Interviewer at 45° angle to patient
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II. Introduction
Nurse introduces self
Identifies purpose of interview
Ensure confidentiality /privacy
III. Working
Nurse gathers information
Excellent communication skills such as Active
listening ,Eye contact ,Open-ended questions
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etc. should be practiced. 02/2/2010
IV. Termination
Inform patient when nearing end of interview
Ensure patient knows what will happen with the
information.
Offers patient chance to add anything
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b) Physical examination
Considers all body systems
Clinician practically determines clinical data
Considers data Observable and measurable to the
clinician.
Methods of physical examination
Inspection
Palpation
Percussion
Auscultation
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Inspection
It is a concentrated watching or
looking
Always comes first
Compare right and left side of the
body
It requires good lightening, adequate
exposure and occasional use of certain
instruments (otoscope,
ophthalmoscope and pen light) to
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enlarge your view 02/2/2010
Palpation
The process of examining part of the body
by careful feeling with hands and finger tip.
In palpation we use sense of touching to
assess texture, temperature, moisture,
organ location and size as well as any
swelling pulsation, rigidity, crepitation,
presence of lumps or masses and presence
of tenderness and pain
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Cont.…
Different parts of the hands are best
suited for assessing different factors:
Finger tips: best for fine tactile
discrimination, such as skin texture,
swelling pulsatility and determining
presence of lumps.
A grasping action of the fingers: to
detect the position, shape and consistency
of an organ or mass.
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Cont…
The dorsa (backs) of hands and
fingers: best for determining
temperature because the skin here is
thinner than on the palms.
Base of the fingers
(metacarpophalangeal joints) or ulnar
surface of hand: to detect vibration, to feel
thrills and fremitus
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Cont…
Palpation may be light, deep, or bimanual.
Light palpation:- is the safest and least
uncomfortable, involving exerting gentle
pressure with the finger tip of your
dominant hand, moving them in a circular
motion and depress the skin surface
approximately 1-2cm
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Cont…
Deep palpation:- which is done after
light palpation is used to detect
abdominal masses.
o The technique is similar to light palpation
except that the fingers are held at a
greater angle to the body surface and the
skin is depressed about 4-5 cm.
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Cont…
Bimanual palpation:- involves using
both hands to trap a structure between
them.
o This technique can be used to evaluate the
spleen, Kidney and uterus.
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Cont..
Techniques of palpation
Should be slow and systematic
Warm your hands by kneading them
Palpate tender areas last
Start with light palpation to detect surface
characteristics and accustom the person to
be touched
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Cont..
Then perform deeper palpation through
deep breathing
Bimanual palpation requires the use of
both hands to capture certain organs such
as kidneys, uterus
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Percussion
The technique of examining part of the
body by tapping it with short, sharp
stroke in order to assess the underlying
structures
The strokes yield a palpable vibration
and a characteristics sound that show the
location, size and density of the
underlying organ
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Cont…
Uses of percussion
Mapping out of the location and size of an
organ
Signaling the density (air, fluid, or solid)
of a structure
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Cont…
Eliciting pain if the underlying structure
is inflamed, as with the sinus areas or
over the kidney
Eliciting a deep tendon reflex using the
percussion hammer
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Cont…
Methods of percussion
Direct percussion: Tapping or
hammering the body part directly by
using striking (dominant) hand.
o The striking hand directly contacts the
body wall as in infant’s thorax or the
adult’s sinus areas.
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Cont …
Indirect percussion
Putting non dominant hand on the body
surface and taping the middle finger of
the non dominant hand with the middle
finger of the dominant hand to elicit
sound.
Used more often and involves both
hands
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Characteristics of normal percussion
notes:
o Dull : relatively dense organ ( e.g. Liver
or spleen, full bladder ,pregnant uterus)
o Resonant : over lung tissue
o Flat: when no air is present (over thigh,
Muscle, bone or over tumor
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Cont…
o Tympanic : over air filled stomach or
intestine
o Hyper resonance: normal over child’s
lung; abnormal in adult’s over lungs
( Emphysema-abnormal amount of air)
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Auscultation
The skill of listening to body sounds
created in the lungs, heart, blood vessel,
and abdominal viscera by the help of a
stethoscope.
It is usually the last technique used
during the examination.
Choose a stethoscope with two-end
pieces: a diaphragm and a bell
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Cont…
Stethoscope: an instrument useful for
auscultation which has two ends:
Bell : best for the soft, low pitched
sounds such as extra heart sounds or
murmurs.
Diaphragm : is used mostly, because its
flat edge is best for high pitched sounds:
breath, bowel and normal heart sounds.
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Consideration during data collection
Time management
Needs of patient
Developmental stage
Physical surroundings
Data Completeness, Accuracy and Relevance.
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Problems in data collection
Inappropriate organization of the database
Omission of pertinent data
Inclusion of irrelevant or duplicate , or
misinterpreted data
Failure to establish rapport and partnership
Recording an interpretation of data rather than
observed behavior.
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2. Nursing Diagnosis
• “A Clinical judgment about individual ,family
and community response to the actual or potential
health problem” ( NANDA).
• It is the second phase of nursing process.
• To analyze collected information and drive
meaning.
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Difference between nursing and medical
diagnosis
Nursing diagnosis :
describes the patient response to disease process.
e.g. ineffective airway clearance R/t
tracheobronchial secretion.
Focused on an healthy response to health or
illness
Describe problem treated by nurse with the scope
of independency nursing practice
May change from day to day as the patient
response change.
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Medical diagnosis
Describe pathological process of the
disease.
e.g. pneumonia
Identify disease
Describe problem for which the physician
direct the primary treatment.
Remain the same for as long as the disease
is present.
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Diagnostic statement in nursing
Each diagnostic statement has two or three parts
depending on the type of the problem.
The three-part statement consists of the following
components:
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Cont..
1. Problem
The problem portion of a statement
describes- problem a client is having.
It derived from the NANDA list (list were
update every two years, it is not considered
to be complete unless it taken from
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NANDA). 02/2/2010
2. Etiology
Is the cause of the problem.
may be physiologic, psychological, spiritual etc.
3. Sign and symptoms
Include several signs and symptoms.
For instance, the client with pneumonia may have
cough with abnormal breath sounds and difficulty
breathing.
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Writing the Diagnostic Statement
The first two parts of the statement are linked by”
related to.
The last two parts are linked by “as evidenced
( manifested by ).E.g. Ineffective Airway Clearance
related to physiologic effects of pneumonia as
evidenced by coughing, abnormal breath sounds,
and dyspnea.
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Cont..
E .g. fluid volume deficit R/T excessive vomiting
manifested by dray mucosal membrane, poor skin
turgor and weak pulse.
Types of nursing diagnosis:
1. Actual nursing diagnosis is a clinical
judgment about individual, family and
community response to a health problem that is
currently being manifested.
It has three diagnostics statement
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Cont..
2. Risk nursing diagnosis
Is a clinical judgment about individual, family
and community more vulnerable to risk
factors.
There is no actual problem and defining
characteristics .
Written as two part statements.
example
1. Risk for fluid volume deficit related to
inadequate fluid in take.
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Cont..
3. Possible nursing diagnosis
Health problem is un cleared and causative
factor is unknown.
Is made when not enough evidence support
the presence of the problem but the nurse
thinks that is highly probable and wants to
collect more information.
It is two part statement includes diagnostic
label, related factors ( unknown).
example
Possible self –esteem disturbance related to unknown etiology.
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Cont.
4. Wellness nursing diagnosis.
Is a clinical judgment about individual, family or
community in transition from a specific level of
wellness to higher level of wellness.
NANDA suggested the term “potential for enhanced”
as quantifier .
Wellness diagnosis stated as one part statement
Example. Potential for enhanced parenting
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3. Planning
Is setting priorities, establishing expected outcomes,
and selecting nursing interventions.
Components:
I. Setting priorities
II. Goal setting for selected problem
III. Formulating intervention.
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Cont.
Setting priorities
The establishment of priorities is the first
element of planning. It performed using various
guidelines .
Guidelines used in the establishment
priorities.
The client need, safety , and desires ,as well as
anticipation of the future diagnosis must be
considered .
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Cont.…
Based on Maslow's hierarchy of need which
requires that a life threating diagnosis be given
more urgent than non life threating diagnosis.
Based on ABC methods
Based on the actuality of the nursing diagnosis
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II. Goal setting for selected problem
Is a measurable client behavior
Indicates whether the person has achieved the
expected benefit of nursing care. c
Is also be called expected outcome or objective.
Should be SMART .
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III. Selecting nursing intervention
Is also called nursing orders or nursing actions.
examples:
Offering fluids frequently
Teaching deep breathing exercise
Monitoring vital signs
Medication administration
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IV. Implementation
Application of interventions planned in the previous phase.
V. Evaluation
Determination of the patient’s responses to the Nursing
intervention and the extent to which the goals have been
achieved.
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THANK YOU
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