Health Assessment. Objectives. Health Assessment 6/27/13. n Discuss purpose of health assessment. n Describe components of health assessment

Transcription

1 Health Assessment Objectives n Discuss purpose of health assessment n Describe components of health assessment n Discuss or perform focused health assessment Health Assessment n Determine strengths n Identify needs, clinical problems, or nursing diagnoses 1

2 Data Collection n Process of obtaining data n Sources n Client n Record n Other health care professionals n Others Techniques & Tools n Interviewing n Observing n Touching n Listening n Physical exam n Reviewing records and tests Data n Subjective n Objective 2

3 Assessment n Initiates nursing process n Systematic, deliberate, and interactive n Focuses on specific individual characteristics n Data from several sources and methods n Includes n Data collection n Validation of perception n Diagnostic judgment Components of Nursing Assessment (OSPI Staffing Model) n Patient interview n Review of physical systems n Family history n Physical examination n Psychosocial nursing assessment n Review of support systems, mental health assessment, etc. Components of Nursing Assessment (cont.) n Patient s compliance history n Understanding of procedures and outcomes n Physical environmental assessment n Functional assessment n Review of current medical diagnoses n Developmental assessment 3

4 Components of Nursing Assessment (cont.) n Review of medications, interpretation of side effects, Identification of effects on patient outcome (pharmacological assessment) n Identification and interpretation of deviations from physiological norms Components of Nursing Assessment (cont.) n Interpretation of the impact of patient s medical history and treatment modalities on patient s current condition n Evaluation of effectiveness of current treatment modalities Results of Nursing Assessment n Nursing diagnoses n Plan of care specific to student n Implementation of plan of care n Ongoing evaluation n Individualized healthcare plan (IHP) n Emergency Care Plan (ECP) 4

5 Gordon s Patterns Ranges of Nursing Actions n Health promotion n Health protection n Problem intervention n Works well w/ school nursing n Healthy populations n Often use anticipatory guidance as intervention strategy Patterns n Health perception/ maintenance n Nutrition/metabolism n Elimination n Activity/exercise n Cognition Perception n Sleep/Rest n Self-perception/selfconcept n Role/Relationships n Coping/stress n Sexuality/ reproduction Value/belief 5

6 Assessment Outcomes n Wellness is affirmed n Strengths are identified n Nursing dx formulated n Collaborative problems identified Assessment n Comprehensive n Focused Assessment Tool Adaptation of Gordon n Demographics n Vital signs n Allergies 6

7 Health Perception/Health Management n Health status n Health practices n Worries or concerns about health n Personal responsibility Health Perception/Health Management n Chief complaint n Recent illnesses/exposure n Previous hospitalizations/surgeries n Other health problems n Things done to manage health n General appearance n Alcohol, smoking, medications, drugs Nutrition/Metabolic n Diet n Pattern of intake n Appetite n Nausea/vomiting n Weight loss/gain n Oral health n Skin/wounds 7

8 Elimination n Abdominal tenderness n Bowel patterns n Urinary patterns n Bed wetting n Skin Abdominal Assessment n Auscultation n 4 quadrants n Epigastric n Inspect n Light palpation Activity/Exercise Cardiovascular n Energy n Exercise 8

9 Activity/Exercise Cardiovascular (cont.) n Peripheral pulses n Neurovascular checks (capillary refill) n Neck vein distention n Heart sounds n Monitor Activity/Exercise Respiratory n Respiratory pattern n Lung sounds n Cough Production n Accessory muscle use n Oxygen supplement Lung Sounds n Normal breath sounds 9

10 Activity/Exercise ADL/Mobility n Feeding n Grooming n Toileting n Mobility Cognitive/Perceptual Sensorium n Eyes/sight n Ears/hearing n Nose/smell n Tongue/taste n Skin/touch n Numbness/tingling Cognitive/Perceptual Pain n Location n Type n Onset n Duration n Intensity n Method of management n Memory 10

11 Cognitive/Perceptual Cognition n Primary language n Learning difficulties n Education level n Speech or communication deficit n Judgment/mental status Cognitive/Perceptual n Reflexes n Pupil n Hand grasp Sleep/Rest n Usual pattern n Naps n Methods to promote n Hx of disturbances n Sleep apnea 11

12 Self-Perception/Self-Concept n Feeling n Body image n Emotional state n Differences in self-feelings since illness n Description of non-verbals Role/Relationship n Lives with whom? n Who helps you? n Family variables n School roles n Finances n Play groups Sexuality/Reproductive n Pubertal changes n Sexual relations n Contraceptives 12

13 Coping/Stress n Stress tolerance n Understanding stressors n Coping strategies n Problem management skills Values/Belief n Spiritual n Cultural n Family traditions 13