Transcript Faculty of Nursing-IUG Chapter (2) Health Assessment- Holistic Approach

Chapter (2)
Health Assessment- Holistic Approach
Faculty of Nursing-IUG
Holistic approach
1. The interview
2. Psychosocial assessment
3. Nutritional assessment
4. Assessment of sleep-wakefulness patterns
5. The health history.
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1. Interview
 Definition: communication process focuses on the
client's development of psychological, physiological,
sociocultural, and spiritual responses, that can be
treated with nursing & collaborative interventions
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Major purpose:
 To obtain health history and to elicit symptoms and the time
course of their development. The interview conducted before
physical examination is done.
Components of nursing interview
1. Introductory phase
2. Working phase
3. Termination phase
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Introductory phase:
 Introduce yourself and explains the purpose of the
interview to the client.
 Before asking questions, Let client to feel Comfort,
Privacy and Confidentiality
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Working phase:
The nurse must listen and observe cues in addition to using critical
thinking skills to validate information received from the client. The
nurse identify client's problems and goals.
Termination phase:
1.The nurse summarizes information obtained during the working
phase
2.Validates problems and goals with the client.
3.Making plans to resolve the problems (nursing diagnosis and
collaborative problems are identified and discussed with the client)
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Communications techniques during interview
A. Types of questions :
 Begin with open ended questions to assess client's feelings e.g.
what, how, which“
 Use closed ended question to obtain facts e.g." when,
did…etc
 Use list to obtain specific answers e.g. "is pain sever, dull
sharp
 Explore all data that deviate from normal e.g. “increase or
decrease the problem
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B. Types of statements to be use:
 Repeat your perception of client's response to clarify
information and encourage verbalization
C. Accept the client silence to recognize thoughts
D. Avoid some communication styles e.g.
 Excessive or not enough eye contact.
 Doing other things during getting history.
 Biased or leading questions e.g. "you don't feel bad"
 Relying on memory to recall information
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E. Specific age variations : Pediatric clients: validate information from parents.
 Geriatric clients: use simple words and assess hearing acuity
F. Emotional variations:
 Be calm with angry clients and simply with anxious and
express interest with depressed client
 Sensitive issues "e.g. sexuality, dying, spirituality" you must
be aware of your own thought regarding these things.
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G. Cultural variations:
 Be aware of possible cultural variations in the communication
styles of self and clients
H. Use culture broker:
 Use culture broker as middleman if your client not speak
your language.
 Use pictures for non reading clients.
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2-Psychosocial assessment
 Psychological assessment involves person's growth and
development throughout his life.
 Discuss crises with the clients to assess relationship
between health & illness. “It depends on multiple G&D
theories e.g. Erickson, Piaget, and Freud …. etc.
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Stages of Age
 Infancy period: birth to 12 months
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Neonatal Stage: birth-28 days
Infancy Stage: 1-12 months
Early childhood Stage: It’s refers to two integrated stages of development
Toddler:
1 - 3years.
Preschool: 3 - 6 years.
Middle childhood
6-12 years
Late childhood:
Pre pubertal: 10 – 13 years.
Adolescence: 13 - 19 years
Young adulthood
20-40 years
Middle adulthood
40-65years
Late adulthood
65 and more
3-Nutritional assessment
 Nutrition plays a major role in the way an individual
looks, feels,& behaves.
 The body ability to fight disease greatly depends on
the individual's nutritional status
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Major goals of nutritional assessment
1. Identification of malnutrition.
2. Identification of over consumption
3. Identification of optimal nutritional status.
Components of Nutritional Assessment
1. Anthropometric measurement.
2. Biochemical measurement.
3. Clinical examination.
4. Dietary analysis
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A. Anthropometric measurement
 Measurement of size, weight, and proportions of human body.
 Measurement includes: height, weight, skin fold thickness, and
circumference of various body parts, including the head, chest,
and arm.
a direct and continuous
relationship to morbidity and mortality in studies of large
populations. High ratios of waist to hip circumference are associated
 Assess body mass index (BMI) to shows
with higher risk for illness & decreased life span.
BMI
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=
(Wt. in kilograms) =
(High in meters) 2
60
(1.6)2
=
60
2.56
= 23.4
BMI RANGE
Rang kg/m2
less than 16.0
16.0 - 18.4
18.5- 24.9
25–29.9
30-34.9
≥ 35
Condition
Very thin
Thin
Average
Overweight
Obese
Highly obese
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B. Biochemical Measurement
 Useful in indicating malnutrition or the development of diseases
as a result of over consumption of nutrients. Serum and urine
are commonly used for biochemical assessment.
 In assessment of malnutrition, commonly tests include: total
lymphocyte count, albumin, serum transferrin, hemoglobin, and
hematocrit …etc. These values taken with anthropometric
measurements, give a good overall picture of an individual's
skeletal and visceral protein status as well as fat reserves and
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immunologic response.
C. Clinical examination
 Involves, close physical evaluation and may reveal signs
suggesting malnutrition or over consumption of
nutrients.
 Although examination alone doesn't permit definitive
diagnosis of nutritional problem, it should not be
overlooked in nutritional assessment
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Nutritional assessment technique for clinical examination
a. Types of information needed
 Diet: Describe the type: regular or not, special, "e.g.
teeth problem, sensitive mouth.
 Usual mealtimes: How many meals a day: when?
Which are heavy meals?
 Appetite: "Good, fair, poor, too good".
 Weight: stable? How has it changed?
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 Food preferences: e.g." prefers beef to other meats"
 Food dislike:What & Why? Culture related?
 Usual eating places: Home, snack shops, restaurants.
 Ability to eat: describe inabilities, dental problems: "ill
fitting dentures, difficulties with chewing or swallowing
 Elimination"
urine & stool: nature, frequency
problems
 Exercise & physical activity: how extensive or
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deficient
 Psycho social - cultural factors: Review any thing which can
affect on proper nutrition
 Taking Medications which affect the eating habits
 Laboratory
determinations
e.g.:
“Hemoglobin,
protein,
albumin, cholesterol, urinalyses"
 Height, weight, body type "small, medium, large"
After obtaining information, summarize your findings and
determine the nutritional diagnosis and nutritional plan of
care.
Imbalanced nutrition: Less than body requirements, related to lack of
knowledge and inadequate food intake
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Risk for infection, related to protein-calorie malnutrition
b. Signs & symptoms of malnutrition
 Dry and thin hair
 Yellowish lump around eye, white rings around both
eyes, and pale conjunctiva
 Redness and swelling of lips especially corners of mouth
 Teeth caries & abnormal missing of it
 Dryness of skin (xerosis): sandpaper feels of skin
 Spoon shaped Nails " Koilonychia “ anemia
 Tachycardia, elevated blood pressure due to excessive
sodium intake and excessive cholesterol, fat, or caloric
intake
 Muscle weakness and growth retardation
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D. Dietary analysis
 Food represent cultural and ethnic background and socio-
economic status and
psychological meaning
have
many
emotional
and
 Assessment includes usual foods consumed & habits of food
 The nurse ask the client to recall every thing consumed
within the past 24 hour including all foods, fluid, vitamins,
minerals or other supplements to identify the optimal
meals
 Should not bias the client's response to question based on
the interviewer's personal habits or knowledge of
recommended food consumption
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Diseases affected by nutritional problems
1- Obesity: excess of body fat.
2- Diabetes mellitus.
3- Hypertension.
4- Coronary heart disease.
5- Cancer.
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4-Assessment of sleep-wakefulness patterns
 Normal human has “homeostasis” (ability to maintain a
relative internal constancy)
 Any person may complain of sleep-pattern disturbance as
a primary problem or secondary due to another
condition
 1/4 of clients who seek health care complain of a
difficulty related to sleep
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Factors affecting length and quality of sleep
1. Anxiety related to the need for meeting a tasks, such as waking
at an early hour for work.
2.The promise of pleasurable activity such as starting a vacation.
3.The conditioned patterns of sleeping.
4. Physiologic wake up.
5. Age differences.
6. Physiologic alteration, such as diseases
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 Good sleep depends on the number of awakenings and the total
number of sleeping hours
 The nurse can assess sleep pattern by doing interview with
the client or using special charts or by EEG
Disorders related to sleep
1.Sleep disturbances affects family life, employment, and general social
adjustment
2. Feelings of fatigue, irritability and difficulty in concentrating
3. Difficulty in maintaining orientation
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4. Illusions, hallucination (visual & tactile).
5. Decreased psychomotor ability with decreased incentive to
work.
6. Mild Nystagmus.
7.Tremor of hands.
8. Increase in gluco-corticoid and adrenergic hormone secretion.
9. Increase anxiety with sense of tiredness.
10. Insomnia "short end sleeping periods“.
11. Sleep apnea "periodic cessation of breathing that occurs during
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sleep.
12. Hypersomnia: "sleeping for excessive periods” the sleep
period may be extended to 16-18 hours a day
13. Peri-hypersomnia. "Condition that is described as an
increased used for sleep "18-20 hours a day" lasts for only
few days
14. Narcolepsy "excessive day time drowsiness or uncontrolled
onset of sleep.
15. Cataplexy: abrupt weakness or paralysis of voluntary muscles
e.g. arms, legs & face last from half second to 10 minutes,
one or twice a year
16. Hypnagogic hallucinations: " Disturbing or frightening
dream that occur as client is a falling a sleep
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Assessment of sleep habits
 Let the client record the times of going to sleep and awakening
periods, including naps.
 Allow client to described their sleep habits in their own words
You can ask the following questions:
How have you been sleeping?‖
Can you tell me about your sleeping habits?"
Are you getting enough rest?"
Tell me about your sleep problem"
Good History includes: a general sleep history, psychological
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history, and a drug history
5-Health History
Systematic collection of subjective
data which stated by the client,
and objective data which
observed by the nurse.
Used to determine a client functional
health pattern status.
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Phases of taking health history
Two phases:
The
interview
phase
which
elicits
information (primary sources)
The recording phase (secondary sources).
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the
Guidelines for Taking Nursing History
Private,
comfortable,
environment.
and
quiet
Allow the client to state problems and
expectations for the interview.
Orient the client the structure, purposes,
and expectations of the history.
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Guidelines for Taking Nursing History cont..
Communicate and negotiate priorities
with the client.
Listen more than talk.
Observe non-verbal communications e.g.
"body language, voice tone, and
appearance".
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Guidelines for Taking Nursing History cont..
Review information about past health history
before starting interview.
Balance between allowing a client to talk in an
unstructured manner and the need to structure
requested information.
Clarify
the
descriptions).
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client's
definitions
(terms
&
Guidelines for Taking Nursing History cont..
Avoid yes or no question (when detailed
information is desired).
Write adequate notes for recording?
Record nursing health history soon after
interview.
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Types of Nursing Health History
Complete health history: taken on initial visits
to health care facilities.
Interval health history: collect information in
visits following the initial data base is collected.
Problem-focused health history: collect data
about a specific problem.
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Components of Health History
1-Biographical Data: This includes
Full name
Address and telephone numbers (client's permanent
contact of client)
Birth date and birth place
Sex
Religion and race
Marital status
Social security number
Occupation (usual and present)
Source of referral
Usual source of healthcare
Source and reliability of information
Date of interview
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2- Chief Complaint: “Reason For Hospitalization
Examples of chief complaints:
Chest pain for 3 days.
Swollen ankles for 2 weeks.
Fever and headache for 24 hours.
Pap smear needed.
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SYMPTOM ANALYSIS
P
Q R ST
a. Provocative or Palliative
 First occurrence :
 What were you doing when you first experienced or noticed
the symptom?
 What to trigger it ? stress?, position?, activity?
 What seems to cause it or make it worse? For a psychological
symptom.
 What relieves the symptom: change diet? change position ?
take medication? being active?
 Aggravation: what makes the symptom worse?
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SYMPTOM ANALYSIS
P
Q
R ST
b. Quality Or Quantity
 QUALITY:
 How would you describe the symptom- how it feels, looks, or
sounds?
 QUANTITY:
 How much are you experiencing now?
 Is it so much that it prevents you from performing any activity?
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SYMPTOM ANALYSIS
P Q R S T
c. Region Or Radiation
 Region:
 Where does the symptom occur?
 Radiation :
 Does it travel down your back or arm, up your neck or
down your legs?
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SYMPTOM ANALYSIS
P Q R
S
T
d. Severity scale
 Severity
 How bad is symptom at its worst?
 Course
 Does the symptom seem to be getting better, getting worse?
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SYMPTOM ANALYSIS
P Q R S T
e. Timing
 Onset :
 On what date did the symptom first occur?
Type of onset :
 How did the symptom start; suddenly? gradually?
 Frequency :
 How often do you experience the symptom; hourly? daily? weekly?
Monthly?
 Duration :
 How long does an episode of the symptom last?
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3-History of present illness
Gathering information relevant to the
chief complaint, and the client's
problem,
relevant
treatment.
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including
data,
and
essential
self
and
medical
Components of present illness
Introduction: "client's summary and usual
health".
Investigation of symptoms: "onset, date, gradual
or sudden, duration, frequency, location, quality,
and alleviating or aggravating factors".
Negative information.
Relevant family information.
Disability "affected the client's total life".
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4- Past Health History:
The purpose: (to identify all major past
health problems of the client).
This includes:
Childhood illness e.g. history of rheumatic
fever.
History of accidents and disabling injuries.
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Past Health History. Cont…
History of hospitalization (time of
admission, date, admitting complaint,
discharge diagnosis and follow up care).
History of operations "how and why this
done“.
History of immunizations and allergies.
Physical examinations and diagnostic
tests.
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5-Family
History
The purpose: 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.
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Family History. Cont…
Family history of communicable diseases.
Heredity factors associated with causes of some diseases.
Strong family history of certain problems.
Health of family members "maternal, parents, siblings,
aunts, uncles…etc.".
Cause of death of the family members "immediate and
extended family".
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6-Environmental History:
Purpose
“To gather information about surroundings
of
the
client",
including
physical,
psychological, social environment, and
presence of hazards, pollutants and safety
measures."
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7- Current Health Information
Purpose: to record major current health-related
information.
Allergies: environmental, ingestion, drug, others.
Habits "alcohol, tobacco, drug, caffeine"
Medications taken regularly by doctor or self prescription.
Exercise patterns.
Sleep patterns (daily routine).
The pattern life (sedentary or active).
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8- Psychosocial History:
Includes:
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.
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9- Review of Systems (ROS)
Collection of data about the past and the
present of each of the client systems.
(Review of the client’s physical, sociologic, and
psychological health status may identify
hidden problems and provides an opportunity
to indicate client strength and disabilities).
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Physical Systems
Which includes assessment of:
General review of skin, hair, head, face, eyes, ears,
nose, sinuses, mouth, throat, neck nodes and breasts.
Assessment of respiratory and cardiovascular system.
Assessment of gastrointestinal system.
Assessment of urinary system.
Assessment of genital system.
Assessment of extremities and musculoskeletal system.
Assessment of endocrine system.
Assessment of heamatoboitic system.
Assessment of social system.
Assessment of psychological system.
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10- Nutritional Health History
“Discussed Before”
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11- Assessment of Interpersonal Factors
This includes:
Ethnic and cultural background, spoken language, values,
health habits, and family relationship.
Life style e.g. rest and sleep pattern.
Self concept perception of strength, desired changes.
Sexuality developmental level and concerns.
Stress response coping pattern, support system, perceptions
of current anticipated stressors.
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