HEALTH ASSESSMENT WEEK-5-AND-6-students-copy.pptx

Collecting of Objective Data

1. COLLECTION OF SUBJECTIVE DATA

2. COLLECTION OF SUBJECTIVE DATA SENSATIONS OR SYMPTOMS FEELINGS PERCEPTIONS DESIRES PREFERENCES BELIEFS IDEAS VALUES PERSONAL INFORMATION

3. PHASES OF THE INTERVIEW Pre introductory Phase Introductory Phase Working Phase Summary and Closing Phase

4. Environmental History Family History Past Personal Health History History of present illness Chief Complaint Biographical Data Psychosocial History Lifestyle and Health practice profile Current Health Information Name Address Phone Gender Provider of history (patient or other) Birth date Place of birth Nationality Primary and secondary l anguages (spoken and read) Marital Status Religion Educational Level Occupation

5. Environmental History Family History Past Personal Health History History of present illness Chief Complaint Biographical Data Psychosocial History Lifestyle and Health practice profile Current Health Information “Reason for Hospitalization”.

6. Environmental History Family History Past Personal Health History History of present illness Chief Complaint Biographical Data Psychosocial History Lifestyle and Health practice profile Current Health Information Gathering information relevant to the chief complaint, and the client's problem, including essential and relevant data, and self-medical treatment Character Onset Location Duration Severity Pattern Associated factors

7. Environmental History Family History Past Personal Health History History of present illness Chief Complaint Biographical Data Psychosocial History Lifestyle and Health practice profile Current Health Information This portion of the health history focuses on questions related to the client’s personal history, from the earliest beginnings Childhood illness Adult illnesses History of accidents and disabling injuries History of hospitalization Gynecologic and obstetric history for female History of operations History of immunizations and allergies. Physical examinations and diagnostic tests.

8. Environmental History Family History Past Personal Health History History of present illness Chief Complaint Biographical Data Psychosocial History Lifestyle and Health practice profile Current Health Information to learn about the general health of the client's blood relatives, spouse, and children and to identify any illness of environmental genetic, or familiar nature that might have implications for the client's health problems. GENOGRAM

9. Environmental History Family History Past Personal Health History History of present illness Chief Complaint Biographical Data Psychosocial History Lifestyle and Health practice profile Current Health Information "To gather information about surroundings of the client", including physical, psychological, social environment, and presence of hazards, pollutants and safety measures."

10. Environmental History Family History Past Personal Health History History of present illness Chief Complaint Biographical Data Psychosocial History Lifestyle and Health practice profile Current Health Information Allergies Medications taken regularly "by doctor or self-prescription Exercise patterns

11. Environmental History Family History Past Personal Health History History of present illness Chief Complaint Biographical Data Psychosocial History Lifestyle and Health practice profile Current Health Information ADLs (Activities of Daily Living) The pattern life (sedentary or active) Description of The Day Sleep patterns (daily routine). Nutrition/problems with diet, weight Habits "alcohol, tobacco, drug, caffeine" Self-concept and Self-care responsibility Social Activities Relationship Values and Belief System Educational Work Stress Levels and Coping Styles Environment

12. Environmental History Family History Past Personal Health History History of present illness Chief Complaint Biographical Data Psychosocial History Lifestyle and Health practice profile Current Health Information How client and his family cope with disease or stress, and how they respond to illness and health. You can assess if there is psychological or social problem and if it affects general health of the client.

13. COLLECTION OF OBJECTIVE DATA

14. PREPARATION

15. PREPARATION Preparing the Client The nurse should explain when and where the examination will take place Instruct the client that all information gathered and documented Health examinations are usually painless; however, it is important to determine in advance any positions that are contraindicated for a particular client. The nurse assists the client as needed to undress and put on a gown. Clients should empty their bladders before the examination.

16. PREPARATION Preparing the Environment The time for the physical assessment should be convenient to both the client and the nurse. The environment needs to be well lighted and the equipment should be organized for efficient use. A client who is physically relaxed will usually experience little discomfort. The room should be warm enough to be comfortable for the client. Providing privacy is important. Culture, age, and gender of both the client and the nurse influence how comfortable the client will be and what special arrangements might be needed. Family and friends should not be present unless the client asks for someone.

17. POSITION

18. PRONE SIMS LITHOTOMY SITTING SUPINE DORSAL RECUMBENT

19. PRONE SIMS LITHOTOMY SITTING SUPINE DORSAL RECUMBENT

20. PRONE SIMS LITHOTOMY SITTING SUPINE DORSAL RECUMBENT

21. PRONE SIMS LITHOTOMY SITTING SUPINE DORSAL RECUMBENT

22. PRONE SIMS LITHOTOMY SITTING SUPINE DORSAL RECUMBENT

23. PRONE SIMS LITHOTOMY SITTING SUPINE DORSAL RECUMBENT

24. PRONE SIMS LITHOTOMY SITTING SUPINE DORSAL RECUMBENT

25. SEMI FOWLERS HIGH FOWLERS

26. Methods of Examining ( Assessment Techniques)

27. Inspection What examiner sees, hears and smells. Observe symmetry. Close and careful visualization of the person as a whole and of each body system Ensure good lighting

28. Palpation technique using fingers and hands to touch. TYPES OF PALPATION TECHNIQUE LIGHT PALPATION MODERATE PALATION DEEP PALPATION DEEP BIMANUAL PALPATION Parts of the hands used during Palpation Palmar Surface Dorsal Surface Ulnar Surface

29. Percussion Eliciting pain Determining location, size, and shape Determining density Detecting abnormal masses Eliciting reflexes

30. Auscultation to listen for heart sounds, movement of blood through the cardiovascular system, movement of the bowel, and movement of air through the respiratory tract high-pitched Diaphragm Bell low-pitched sounds