unit 8 health assessment notes bsc nursing

notes

1. NURSING FOUNDATION UNIT – 8 HEALTH ASSESSMENT SET 1

2. DEFINITION : Health assessment is an essential nursing function which provides foundation for quality nursing care and interventions. • It helps to identify the strength of the clients in promoting health.

3. Health assessment is refers to systematic appraisal of all factors relevant to client’s health. OR • Health assessment includes collecting subjective data through interviewing the client and obtaining objective data by physically examining the client.

4. Indication of health assessment : • On admission • On discharge • On follow up • Health camps • Before and after diagnostic and therapeutic procedure.

5. PURPOSE Gather baseline data about the patient’s health status. • Supplement, confirm, or refute data obtained in the history . • Confirm and identify nursing diagnoses. • Make clinical judgement about a patient’s changing health status and management. • Evaluate the outcomes of care.

6. Principles of Health Assessment : • An accurate and timely health assessment provides foundation for nursing care & intervention. • Go for comprehensive assessment. • The health assessment process should include data collection, documentation and evaluation of the client’s health status . • All documents should be objective, accurate, clear, concise, specific and current. • It should be practiced in all settings whenever there is nurse-client interaction. • Information gathered should be communicated to other health care professional. • Keep the confidentiality.

7. TYPES OF HEALTH ASSESSMENT : The type of health assessment dependents on several factors like context of care, the patient’s needs and the nurse’s experience. Comprehensive assessment: This involves a detailed history or physical examination performed at the onset of care in a primary care setting or an admission to a hospital or long term carte facility. Problem- based / focused assessment: It involves a history and examination that are limited to a specific problem or complaint. This type of assessment is most commonly used in a walk in clinic or emergency department and out patient departments.

8.   Episodic / Follow-up assessment: This type of assessment is usually done when a patient is following up with a health care provider for previously identified problem. Shift assessment: When individuals are hospitalized, nurses conduct assessment each shift. The purpose is to identify changes in a patient’s condition from baseline . Screening assessment: It is a short examination focused on disease detection. It may be performed in a health care provider’s office or at a health fair.

9. TECHNIQUE/ SKILLS OF PHYSICAL ASSESSMENT: Inspection Palpation Percussion Auscultation Olfaction Other techniques are: Manipulation Reflex Testing

10. INSPECTION It is the use of vision and hearing to distinguish normal from abnormal findings. Inspection is a simple technique, and the quality of an inspection depends upon your willingness to be thorough and systematic . PRINCIPLES: Adequate lighting 2. Position & expose body parts 3 . Inspect each areas 4 . When possible, compare each area with opposite side of the body 5 . Use additional light to inspect cavities 6 . Do not hurry, pay attention to detail

11. GENERAL INSPECTION OF A CLIENT FOCUSES ON • Overall appearance of health or illness • Signs of distress • Facial expression and mood • Body size • Grooming and personal hygiene • Colour , texture, symmetry, movement

12. PALPATION Palpation , which is the act of touching a patient in a therapeutic manner to elicit specific information.   PRINCIPLES OF PALPATION • Perform slowly, gently, and deliberately. • Encourage the patient to continue to breathe normally throughout the palpation. • If pain is experienced during the palpation. discontinue the palpation immediately. • Inform the patient where, when, and how the touch will occur, especially when the patient cannot see what you are doing.

13. Light palpation Deep palpation  Ulnar Surface (Vibration) Caution to be taken • To avoid injuring a patient. • Do not try deep palpation without clinical supervision. • Do not palpate without considering the patient’s condition. • Do not palpate a vital artery with pressure that obstructs blood flow.

14. PERCUSSION Direct percussion is used to assess the sinus or infant thorax. Indirect percussion is used to evaluate abdomen or thorax. Another method of indirect percussion is tapping with the rubber head of the reflex hammer. Fist percussion to evaluate back and kidney for tenderness. Or Plexor TYPE OF PERCUSSION DIRECT PERCUSSION/ Immediate Percussion INDIRECT PERCUSSION/ MEDIATE PERCUSSION

15. Percussion Sounds SOUND INTENSITY DURATION PITCH QUALITY NORMAL LOCATION ABNORMAL LOCATION Flatness Soft Short High Flat Muscle (thigh) or Bone Lungs (severe pneumonia Dullness Moderate Moderate High Thud Organs (liver) Lungs (atelectasis) Resonance Loud Moderate- long Low Hollow Normal lungs No abnormal location. Hyper resonance Very loud Long Very low Boom No normal location in adults;normal lungs in children Lungs (emphysema) Tympany Loud Long High Drum Gastric air bubble Lungs (large pneumothorax)

16. AUSCULTATION FOUR CHARACTERISTICS OF SOUND 1.Frequency / Pitch (ranging from high and low):frequency or number of oscillations generated per second by vibrating object. The higher the frequency, the higher the pitch of a sound and vice versa. 2. Loudness (ranging from soft to loud): amplitude of sound wave. 3. Quality (gurgling or blowing): sounds of similar frequency and loudness from different sources. 4. Duration (short, medium or long): length of time that sound vibrations last .

17. Normal Body Sounds • Normal breath sounds are classified as tracheal, bronchial, bronchovesicular , and vesicular sounds. • Tracheal breath sounds are heard over the trachea. These sounds are harsh and sound like air is being blown through a pipe. • Bronchial sounds are present over the large airways in the anterior chest near the second and third intercostal spaces; these sounds are more tubular and hollow- sounding than vesicular sounds, but not as harsh as tracheal breath sounds. Bronchial sounds are loud and high in pitch with a short pause between inspiration and expiration; expiratory sounds last longer than inspiratory sounds.

18.   Bronchovesicular sounds are heard in the posterior chest between the scapulae and in the center part of the anterior chest. Bronchovesicular sounds are softer than bronchial sounds, but have a tubular quality. Bronchovesicular sounds are about equal during inspiration and expiration; differences in pitch and intensity are often more easily detected during expiration. • Vesicular s ounds are soft, blowing, or rustling sounds normally heard throughout most of the lung fields. Vesicular sounds are normally heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration. • In a normal air-filled lung, vesicular sounds are heard over most of the lung fields. • Bowel sound consist of clicks and gurgles and 5-30 per minute. • An occasional borborygmus (loud prolonged gurgle) may be heard. • Heart sound: The first heart sound, or S1, forms the " lub “ The second heart sound, or S2, forms the "dub"

19. Reflex Testing • Means automatic response to a given stimulus. It reveals reflex is present or not, strength and movement of hands and legs.

20. PREPARATION FOR ASSESSMENT Proper preparation of the environment, equipment, and patient ensures a smooth examination with few interruptions. A disorganized approach when preparing for a physical examination causes errors and incomplete findings . It is necessary to wear gloves during palpation and percussion when there is possibility of coming in contact with body fluids 

21. PREPARING THE ENVIRONMENT Requires privacy Well-equipped examination room is preferable Adequate lighting, sound proof Make sure the room is warm enough Special tables to assume positions Special needs of the client Surface for placement of equipment Equipment Perform hand hygiene before equipment preparation Set up in a readily available manner and easy to use Check the functioning Maintenance Isolation precautions Adequate number of gloves

22. PREPERATION OF THE PATIENT Patient’s physical comfort is vital It involves being sure the patient is dressed and draped properly Provide privacy Make sure the patient stays warm Routinely ask if the patient is comfortable Positioning : during examination, ask the patient to assume proper positions so body parts are accessible and patient stays comfortable.

23. EQUIPMENTS • The physical assessment will proceed in an efficient manner if you have gathered all of the necessary equipment beforehand. The equipment needed to perform a complete physical examination of the adult patient includes: • Pen and paper • Marking pen • Tape measure • Clean gloves • Penlight or flashlight • Scale (You may need to walk the patient to a central location if a scale cannot be brought to the patient’s room.) • Thermometer • Sphygmomanometer • Tongue depressor • Stethoscope • Otoscope • Nasal speculum • Ophthalmoscope • Visual acuity charts

24. Tuning fork • Reflex hammer • Sterile needle • Cotton balls • Lubricant • Cervical brush • Odors for cranial nerve assessment(coffee, lemon, flowers, etc.) • Small objects for neurological assessment (paper clip, key, cotton ball, pen, etc.) • Inch tape • Various sizes of vaginal speculums • Cotton-tip applicator • Cervical spatula • Slide and fixative • Specimen cup • Lubricant • Goniometer • Vital signs tray

25. THANK YOU