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HEALTH ASSESSMENT
in NURSING
N 295 Spring 2012
Revised january 2012 1
ASSESSMENT *WHAT
HOW
WHY
WHERE
WHEN
Revised january 2012 2
Sources of Data *
Primary Source
Secondary Source
Revised january 2012 3
Data Collection Methods *
OBSERVATION
INTERVIEW
PHYSICAL EXAMINATION
Revised january 2012 4
“Why”Leads to Type of Assessment *
CONTINUOUS ?
? SCREENING
! follow-up ??
¿ INTERMITTENT ?
!!? Emergency!!¿ COMPREHENSIVE
..?Functional ¿
FOCUSED ? ¿Revised january 2012 5
NURSING ASSESSMENT
VS
MEDICAL PHYSICAL EXAMINATION
Revised january 2012 6
Steps to Assessment
1.
2.
3.
4.
Revised january 2012 7
Instead: Talk about PARTS of Assessment *
1. Subjective Data Collection
2. Objective Data Collection
3. Validation of Data
4. Documentation of Data
Revised january 2012 8
Subjective Data Where do you get this?
How do you get this information?
Sending and Receiving
Does It Require Skill to obtain data??
Revised january 2012 9
Subjective Data *
Sign or Symptom?
Recognize that all behavior has meaning
Accept the client but set limits on inappropriate behavior
Revised january 2012 10
What do you think?
Identify and face problems honestly
It is best to maintain a professional distance
Revised january 2012 11
COMMUNICATION in the
INTERVIEW*
Internal Factors
External Factors
Revised january 2012 12
INTERVIEW TECHNIQUES
Verbal Communication
Non-Verbal Communication
Revised january 2012 13
Cultural / Diversity Considerations
Language Barriers
Space, Distance & Intimacy Concepts
Variations in Response to Illness
Variation in Non-Verbal Behaviors
Revised january 2012 14
Other Challenging Situations
Anxious Client
Angry Client
Depressed Client
Manipulative Client
Client with Sensitive Issues
Special Situations Revised january 2012 15
Complete Health History
1. Biographic Data2. Reason for Seeking Health Care3. History of Present Illness IF there is an HPI . . .
. . .then do PQRSTIf pain use PQRST or COLDSPA
Revised january 2012 16
EXPLORING S & S
Revised january 2012 17
Precipitating / Palliative Factors
Quality / Quantity
Region / Radiation / Related Symptoms
Severity
Timing
EXPLORING S & SC CharacterO OnsetL LocationD DurationS SeverityP PatternA Associated symptoms
Revised january 2012 18
Complete Health History *1. Biographic Data2. Reason for seeking Health Care3. History of Present Illness4. Past Health History5. Family History6. Review Of Systems 7. ADL & IADL8. Lifestyle & Health Practice Profile9. Developmental Level
Revised january 2012 19
Revised january 2012 20