web intro to health assessment- techniques-general survey

8/12/2019 WEB Intro to Health Assessment- Techniques-General Survey

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INTRODUCTION TOHEALTH ASSESSMENT

NUR123 Spring 2009

K. Burger, MSEd, MSN, RN, CNE

PPP by: Victoria Siegel RN, CNS, MSNSharon Niggemeier RN, MSNRevised by: Kathleen Burger

TECHNIQUES OF PHYSICAL ASSESSMENT

GENERAL SURVEY


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Health Assessment

Is holisticdata collection ANDanalysis

Utilizes the nursing process

Incorporates critical thinking.


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Health Assessment

Includes knowledge of developmentalstages throughout the life cycle

Includes physical,mental,psychosocialassessment along with assessment for

domestic violence, elder abuse andchild abuse
http://www.ocfs.state.ny.us/main/prevention/signs.asphttp://www.ocfs.state.ny.us/main/prevention/signs.asp


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Health Assessment:The Health History

Begins with reason for seeking care(chief complaint is previously used term)

& health history Document using the patients own

words

Elicit a complete description frompatient

Document duration of complaint

What aggravates condition, what

may alleviate it?


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Types of Health Histories

Complete

Interval

Problem focused or chiefcomplaint


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History Taking

Well developed interview skills andcareful documentation

Environment conducive to privacyand comfort

Is the client a good historian?

Reasons for seeking health care Interview- intro, working,

termination phases


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Complete Health History

Biographical

Reason for seeking

health care Present

health/Illness

Past health

Family health

Review of systems

Psychological

FunctionalAssessment

Perception of

health


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Present Health/IllnessReason for seeking care

Onset, duration, precipitatingfactors.

Frequency, duration Associated symptoms i.e. N/V

Alleviating/ aggravating factors

ROS re: CC

Relevant family, occupational orrecreational history.


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Past Health History

Past general health

Childhood illnesses

Accidents/ injuries

Hospitalizations/surgeries

Acute and chronic illnesses

Immunizations

Allergies, medications, transfusions

Obstetric History


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Current Health

Habits

Meds (includingOTC/Herbal/Vitamins)

ExerciseSleep


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Family History

Important to know to determinerisks

Status of family membersParents, siblings, grandparents

Status of spouse/significantother and Children

Construct Genogram


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Review of Systems: ROS

Review past and presenthealth status of each bodysystem.

Review health maintenance.

A Head-to- Toe approach

May elicit new information


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Psychological Function

Cognitive memory,comprehension

Response to illness andhealth

Psych history, meds,anxiety?

Cultural considerations


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Functional Assessment

ADLs

Sleep/rest

Nutrition/problems with diet,weight

Alcohol /Substance abuse

Smoking history (in pack years)

Coping difficulties

Domestic/ child abuse


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Perception of Health

How one defines health

Views on ones health statusWhat are ones expectationspertaining to health and

health care


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Physical Examination (PE)

Goal is to identify variations

from normal.Explain procedure first

Head to Toe

Unaffected areas before affected


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Techniques of PE

Four components used in specificorder:

Inspection

Palpation

PercussionAuscultation


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Techniques of PE

Inspection- First techniques used.What examiner sees, hears and

smells. Observe symmetry.

Palpation- Second technique using

fingers and hands to touch. Lightpalpation first then deep palpation


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Techniques of PE

Percussion- Third techniquetapping onskin surface which creates a vibration ofunderlying structures. The vibration

produces a sound, may aid in diagnosis. Resonant- normal lung.

Hyperresonant- Childs lung oremphysema.

Tympany- Air filled organ, e.g., stomachor intestine.

Dull- Dense organ, e.g., liver or spleen.

Flat- No air present, e.g., bone.


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Techniques of PE

Uses for Percussion: Mapping outlocation and size of an organ

Determining density (air, fluid, solid) ofa structure

Detecting superficial mass (up to 5 cmdeep)

Eliciting pain if underlying structure isinflamed

Eliciting a DTR using a percussion

hammer


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Techniques of PE

Auscultation-Usually last techniqueduring PE (*exception abdomen,

its the 2

nd

technique afterinspection)

Use stethoscope to block sounds notmagnify

Diaphragm-firmly against skin

Bell- lightly against skin


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Auscultation

Description of sounds heard

Pitch- frequency of sound vibrations,

high or low. Intensity- loudness of sound: loud or

soft (amplitude)

Duration- length of sound: short, long

Quality- subjective terms- harsh,tinkling, etc


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Physical Exam

Utilize 4 techniques

Proper settingEquipment

Clean/ safe environment

Remember client comfort


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Summary

Health assessment

includes:Complete health history

ROSPhysical Exam


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General Survey

Study of the whole individual

Overall impression

Begins at the first encounter with aperson

Introduction to the physical

assessment Composed of 4 parts: physical

appearance, body structure, mobility

& behavior


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General Survey Physical

Appearance

Age Sex

LOC

Skin color Facial features

Body Structure

Stature

Nutrition Symmetry

Posture

Position Body contour


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General Survey

Mobility

Gait

Range of

Motion (PROMor AROM)

Behavior

Facialexpression

MoodSpeech

Dress/Hygiene


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General Survey

Includes Height & Weight

Vital signs: Temperature, Pulse,Respiration & Blood Pressure

Recognize transcultural

considerationsNote S/S (signs/symptoms) of

distress/pain


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AssessingDistress/Pain

Assessment includes:

S- SeverityL- Location

I- Influencing factors

D- Duration

A- Associated Symptoms


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Assessing Distress/Pain

Pain assessment = 5thvital sign

Utilize pain scale

Understand chronic vs acutepain

Recognize gender, transculturaland developmental factorseffecting pain

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