Health Assessment and Data Gathering in Nursing
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1
M.Sc Hassanain Mohammed Kadhim
Health Assessment:
is the gathering of information
about a patient's
,
,
, and
status in order to identify
actual and potential health problems
The purposes of the health assessment
To obtain baseline data
To identify and manage a variety of patient problems
(actual and potential)
To evaluate the effectiveness of nursing care
To enhance the nurse-patient relationship
To make clinical judgmentsspiritualsociologicalpsychologicalphysiological
2
M.Sc Hassanain Mohammed Kadhim
Preparation for Health assessment
includes the :
1-
Preparation your self
Proper knowledge
Skillful
Clean comfortable uniform
Clean hand ( hand washing )
3
M.Sc Hassanain Mohammed Kadhim
2- Preparation of physical
environment:
•
Clean
•
Quite
•
Warm
•
Ventilation
•
Privacy
•
Proper furniture
•
Proper moisture
•
Proper lighting ( natural &
artificial)
4
M.Sc Hassanain Mohammed Kadhim
3- Preparation of the client :
•
Identify your self
•
Explain the procedure
•
Provide clean gown
•
Explain the types of position
the client may take to
facilitate exam
5
M.Sc Hassanain Mohammed Kadhim
4
-
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:
Be sure that’s the equipments is in
good condition working well
Clean well arranged according to use
All infection control measures should
be taken under consideration
6
M.Sc Hassanain Mohammed Kadhim
G
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1- Subjective data
- Said by the client (S) by
using interview to collect the following data:
Biographical
Present history
Past history
Family history
*Information related to life style &
activities of daily living
2- Objective data
-
Observed by the nurse
(O)
7
M.Sc Hassanain Mohammed Kadhim
-
Objective data - Observed by the nurse (O)
Physical Examination: collection of objective data by
using many techniques such as: The order of
techniques is as follows
(
1
-
Inspection , 2-
Palpation , 3-Percussion , 4-Auscultation
)
A.
Inspection
:critical observation *always first*
1. Take time to “
observe” with eyes, nose
2. Use good lighting
3. Look at color, size, shape, symmetry, position
4. Observe for odors from skin, breath, wound
8
M.Sc Hassanain Mohammed Kadhim
B.
Palpation
:
touch
( finger tips , dorsal
surface of the hand & palm )
Type of palpation
1- light palpation (
1– 2 cm
)
*Pulse * temp * texture * moisture
* pain * tenderness
2- Deep palpation =(
4- 5 cm
)
to assess mass and
organs
3- Bimanual using two hand
(
5-8
)
cm to assess
organs
9
M.Sc Hassanain Mohammed Kadhim
10
M.Sc Hassanain Mohammed Kadhim
-
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M.Sc Hassanain Mohammed Kadhim
C.
Percussion
:
sounds produced by tapping body
surface
Type of percussion
1- direct percussion ----- sinus only
2- indirect percussion
3- blunt percussion ---- liver & spleen
*Produces different sounds depending on underlying
structures
1- Resonance
( air ) ---- lung --- normal
2- Hyper- resonance
( to much air ) abnormal (
emphazema)
3- Flatness
------ bone & muscle
4- Dullness
( fluid ) ----- liver & spleen
5- Drum( tympanic
)---- stomach
12
M.Sc Hassanain Mohammed Kadhim
13
M.Sc Hassanain Mohammed Kadhim
D.
Auscultation
: listening to sounds
produced by the body by using
stethoscope
1. Flat diaphragm picks up high-pitched
respiratory sounds best ( high density
sound ).
2. Bell picks up low pitched sounds such
as heart murmurs ( low density sound ).
14
M.Sc Hassanain Mohammed Kadhim
Instruments, or “equipments” used during physical assessment should be
readily accessible, clean, in proper working order.
1.
Ophthalmoscope:
"lighted instrument for visualization of the eye".
2.
Otoscope:
for examination of the ear.
3.
Snellen eye chart:
TO exam visual acuity .
4.
Nasal speculum:
used for assessment of the nose.
5.
Vaginal speculum:
examination of the vaginal canal and cervix.
6.
Tuning fork:
for testing auditory function and vibratory perception.
7.
Percussion hammer:
“reflex hammer” used to test reflexes and
determine tissue density.
15
15
Instrumentation used in
assessment
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M.Sc Hassanain Mohammed Kadhim
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M.Sc Hassanain Mohammed Kadhim
Health assessment involves gathering information about a patient's physiological, psychological, sociological, and spiritual status to identify health problems. Preparation includes self-care, environment setup, client preparation, and equipment readiness. Data collection involves subjective information from the patient and objective observations by the nurse.
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Health Assessment Prof Dr. Salma Khadim Jehad Dr. Ali Faris M.Sc Hassanain Mohammed Kadhim Lecture -1- M.Sc Hassanain Mohammed Kadhim 1
Health Assessment: is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status in order to identify actual and potential health problems The purposes of the health assessment To obtain baseline data To identify and manage a variety of patient problems (actual and potential) To evaluate the effectiveness of nursing care To enhance the nurse-patient relationship To make clinical judgments M.Sc Hassanain Mohammed Kadhim 2
Preparation for Health assessment includes the : 1- Preparation your self Proper knowledge Skillful Clean comfortable uniform Clean hand ( hand washing ) M.Sc Hassanain Mohammed Kadhim 3
2- Preparation of physical environment: Clean Quite Warm Ventilation Privacy Proper furniture Proper moisture Proper lighting ( natural & artificial) 4 M.Sc Hassanain Mohammed Kadhim
3- Preparation of the client : Identify your self Explain the procedure Provide clean gown Explain the types of position the client may take to facilitate exam M.Sc Hassanain Mohammed Kadhim 5
4- Preparation of the equipments: Be sure that s the equipments is in good condition working well Clean well arranged according to use All infection control measures should be taken under consideration M.Sc Hassanain Mohammed Kadhim 6
Gathering Data 1- Subjective data - Said by the client (S) by using interview to collect the following data: Biographical Present history Past history Family history *Information related to life style & activities of daily living 2- Objective data - Observed by the nurse (O) M.Sc Hassanain Mohammed Kadhim 7
-Objective data - Observed by the nurse (O) Physical Examination: collection of objective data by using many techniques such as: The order of techniques is as follows (1-Inspection , 2- Palpation , 3-Percussion , 4-Auscultation) A. Inspection :critical observation *always first* 1. Take time to observe with eyes, nose 2. Use good lighting 3. Look at color, size, shape, symmetry, position 4. Observe for odors from skin, breath, wound M.Sc Hassanain Mohammed Kadhim 8
B. Palpation : touch( finger tips , dorsal surface of the hand & palm ) Type of palpation 1- light palpation ( 1 2 cm) *Pulse * temp * texture * moisture * pain * tenderness 2- Deep palpation =( 4- 5 cm )to assess mass and organs 3- Bimanual using two hand (5-8) cm to assess organs M.Sc Hassanain Mohammed Kadhim 9
-Organ assessment *Size *Shape -Mass assessment *Size *Shape *Location *Consistency *Boarder *Mobility *Painful M.Sc Hassanain Mohammed Kadhim 11
C. Percussion : sounds produced by tapping body surface Type of percussion 1- direct percussion ----- sinus only 2- indirect percussion 3- blunt percussion ---- liver & spleen *Produces different sounds depending on underlying structures 1- Resonance ( air ) ---- lung --- normal 2- Hyper- resonance ( to much air ) abnormal ( emphazema) 3- Flatness ------ bone & muscle 4- Dullness( fluid ) ----- liver & spleen 5- Drum( tympanic)---- stomach 12 M.Sc Hassanain Mohammed Kadhim
D. Auscultation : listening to sounds produced by the body by using stethoscope 1. Flat diaphragm picks up high-pitched respiratory sounds best ( high density sound ). 2. Bell picks up low pitched sounds such as heart murmurs ( low density sound ). M.Sc Hassanain Mohammed Kadhim 14
Instrumentation used in assessment Instruments, or equipments used during physical assessment should be readily accessible, clean, in proper working order. 1. Ophthalmoscope: "lighted instrument for visualization of the eye". 2. Otoscope: for examination of the ear. 3. Snellen eye chart: TO exam visual acuity . 4. Nasal speculum: used for assessment of the nose. 5. Vaginal speculum: examination of the vaginal canal and cervix. 6. Tuning fork: for testing auditory function and vibratory perception. 7. Percussion hammer: reflex hammer used to test reflexes and determine tissue density. 15 15 M.Sc Hassanain Mohammed Kadhim
General Appearance OR General survey 1- Body Built (weight & height) Normal ----- even , proper to age & life style Abnormal ------ excessive thin OR obese 2- Personal hygiene & grooming ( cleanliness & grooming ) Normal ------ clean & neat Abnormal ----- dirty and unkempt M.Sc Hassanain Mohammed Kadhim 16
3- Odor Normal ------ no body odor related to working or activity , with out breathing odor Abnormal ----- foul odor or ammonia odor or acetone odor 4- Dressing Normal ----- proper for occasion Proper for situation Proper for weather Abnormal ----- not proper for occasion Not proper for situation Not proper for weather M.Sc Hassanain Mohammed Kadhim 17
5- Posture & gait ( setting & standing ) Normal ---- relaxes & erect , coordinated movement Abnormal ----- band , shrank movement , not coordinated 6- Attitude Normal ---- cooperative Abnormal ----- not cooperative ( withdrawn)or ( hostile) M.Sc Hassanain Mohammed Kadhim 18
7- Speech Normal ---- clear , understand able , moderate pace Abnormal ----- not understandable , rapid pace or slow pace 8- Thought Normal ----- logic , sequence has sense of reality & clear Abnormal ----- illogical , flitting of idea or confuse M.Sc Hassanain Mohammed Kadhim 19
Thank you M.Sc Hassanain Mohammed Kadhim 20
