1.Introduction & interview.pptx

1. Health
Assessment
Ass.Lect. MUSTAFA
ALISHLASH
Course: Health Assessment
Trimester 1, 2022-2023

2. Objective
s
At the end of lecture students will be able to:
 Describe the nursing process and its
components and apply on simulated patient.
 Perform health assessment on patients.
 Differentiate between objective and subjective
data.
 Describe the purpose of health assessment.
 List the types of health assessment .
 Describe the purpose of health assessment.
 Conduct health assessment interview for the
client.

3. Objectives of health
assessment
 Surveillance of health status, identification of occult disease,
screening, and follow-up care.
 The periodic assessment, at regular intervals.
 Increasing client participation in health care.
 Accurately define the health and risk care needs for
individuals.
 HA is shared with the client in a clearly & understandable
manner  The client must share in decision making for his
own care

4. INTRODUCTION
You conduct many informal assessments every
day. For example:
• check the weather
• assess whether you are hungry
• assess the physical condition of your skin.
• The framework used to collect nursing health
assessment data is the nursing process.

5. NURSING PROCESS
Is a problem-solving approach to clinical
judgments.
It helps to organize the information and
promotes the collection of holistic data.

6. Phases of Nursing Process
Assessment
Diagnosis
Outcomes
Planning
Implementation
Evaluation
Collect data
Interpret & cluster data
Identify expected outcome
Set priority & objective
Identify intervention
Evaluate patient's condition

7. ASSESSMENT
It is step one of nursing process
The purpose of a nursing health assessment:
• to collect subjective and objective data
• to determine a client's overall level of functioning
• to make a professional clinical judgment.
The nurse collects physiologic, psychological,
sociocultural, developmental, and spiritual data
about the client.

8. 1. Systematic and continuous collection of client data.
2. Focus on client's responses to health problems.
3.The nurse carefully examine the client's body parts to
determine any abnormalities.
4.The nurse relies on data from different sources which
can indicate significant clinical problems.
5. Provides a baseline used to plan the clients care.
6.Helps the nurse to diagnose client's problem & the
intervention.
Importance of nursing health assessment

9. TYPES OF ASSESSMENT
1. Initial comprehensive assessment
[Includes detailed health history and physical examination and
examine the client's overall health status]
2. Ongoing or partial assessment
3. Focused or problem-oriented
assessment
4. Emergency assessment [quick assessment]

10. Preparing for the Assessment
• Review the client’s record, if available
gives an opportunity to verify what you
read with what patient tells.
• Know the client’s basic biographical data
(age, gender, religion, and occupation) 
– provides background about chronic diseases;
– gives clues to how a present illness may impact the client’s
activities of daily living (ADL).

11. Preparing for the Assessment
• Give yourself time to educate yourself about
the client’s diagnoses or tests performed.
• Remember to obtain and organize materials
that you will need for the assessment.
• Gather any equipment (e.g., stethoscope,
thermometer, etc.) necessary to perform a
nursing health assessment

12. STEPS OF HEALTH ASSESSMENT
The assessment phase: 4 major steps:
1.Collection of subjective data
2.Collection of objective data
3.Validation of data
Methods of validation
4.Documentation of data

13. Types of Data
Subjective database
(Symptoms)
• Refers to what the
patient says about
himself/herself
• Obtained through
interview
Objective database
(Signs)
• Refers to the data that
collected by the nurse
through physical
examination
• Obtained through
physical assessment
techniques

14. SUBJECTIVE DATA
CONSISTS OF

15. Types of Data
• Subjective database
(Symptom)
Subjective data is gathered
from the patient telling you
something that you cannot
use your five senses to
measure.
Pain
is subjective
Objective database
(Sign)
• Heart rate
• Blood pressure
• Respirations
• Wound appearance
• Ambulation description.

16. Assessment
1 Review of clinical record
2 Interview
3 Health history
4 Physical examination
5Functional assessment
6- Review of literature
27-16

17. n
• Definition: a planned communicatio
(meeting) or a conversation
• The purpose is to:
–get or give information,
–identify problems of mutual concerns,
–evaluate change,
–teach,
–provide support, counseling or therapy
(Kozier, 2021)
2- INTERVIEW

18. • Formal contract between you and your client.
• Concerns what the person needs and expects from the health care
and what you, the health care professional, have to offer.
• The contract’s terms include:
– Time and place of the interview and succeeding physical exam
– Introduction of yourself and a brief explanation of your role
– The purpose of the interview
– The length of time it will take to conduct the interview and physical
examination
– Expectation of participation of each person
– Presence of any other people ( client’s family, other health care
professionals, students)
– Confidentiality and to what extent it may be limited
– Any costs that the client must pay
27-18
2- INTERVIEW

19. Interview Contract
Time and Place
Introductions
Purpose
Length
Expectations
Presence of others
Confidentiality
Costs

20. Interview Approach
Privacy
Interruptions
Physical Environment
Dress
Note taking
Biases and misconceptions

21. Techniques of Communication
• Phases (1)  introduction
• Phases (2)  a working phase
• Phases (3) a termination (closing)

22. Techniques of Communication

23. Techniques of Communication

24. Types of Questions to use
A.Open-ended questions
B. Close-ended questions
C. Laundry list

25. Therapeutic Interviewing Techniques
A. Open-ended questions
B. Closed ended questions

26. c. Laundry list (scrambled words)
• Use list approach to obtain specific
answers:
• “Is the pain severe, dull, sharp, mild,
cutting?”
• “Does the pain occur once every year,
day, month, hour?”
26

27. Types of statements to use
A. Rephrase or repeat your perception of client’s response
to reflect or clarify information shared. “you feel you
have a serious illness?”
B. Encourage verbalization of client by saying “ Um Hum”,
“Yes,” or “I agree,” or nodding.
C. Describe what you observe in the client. For example: “It
seems you have difficulty on the right side.”

28. Responses
1 Encourage
2 Facilitation
3 Silence
4 Reflection
5 Empathy
6 Clarification
7 Confrontation
8 Interpretation
9Explanation
10-Summary

29. 12 TRAPS OF INTERVIEWING
1.Providing False
Reassurance
2. Giving Unwanted Advice
3. Using Authority
4.Using Avoidance
Language
5. Engaging in Distancing
6. Using Professional Jargon
“terminology or language”
7.Using Leading or Biased
Questions
8. Talking Too Much
9.Interrupting or Rushing the
client
10. Using "Why" Questions
11.Excessive or insufficient eye
contact
12.Doing other things while
taking the history & being
mentally distant

30. • Physical /professional appearance
 name tag & credentials clearly visible; dress code
• Posture
• Demeanor/conduct display self-
control; focus on the client; do not
enter the room laughing loudly,
yelling to a coworker. Greet the
client calmly and full attention
focus. Do not be overwhelmingly
friendly or “touchy;” many clients
are uncomfortable with this type
of behavior. Maintain a
professional distance.
• Gesture
• Facial expression
• Attitude
• Eye contact
• Voice
• Touch
• Silence
• Listening
• Equal-status seating
• Close placement to
patient
• Relaxed open posture
• Leaning slightly
toward person
Occasional facilitation
gestures
• Appropriate smiling
• Moderate tone of
voice
Nonverbal Skills

31. How to deal with …
27-32

32. ….. How to deal with
27-33

33. ASSESSMENT
1 Review of clinical record
2 Interview
3 Health history
4 Physical examination
5Functional assessment
6- Review of literature

34. Complete Health History
1. Biographical data
2. Reason for Seeking Care
3. History of Present Illness
4. Past Health
5. Family History
6. Review of Systems
7. Functional Assessment (Activities of Daily Living)
8. Lifestyle & health practices profile
9. Developmental level

35. Elements Of A Comprehensive Health History
Biographical Data
Name address
Age
Birthday, year of
birth
Gender
Marital status
Race
Ethnic origin
Occupation
Chief Complaint
A brief spontaneous
statement in the person's
own words that describes the
reason the client is seeking
medical care.
Whatever the client states is
the reason for seeking care
is DOCUMENTED IN
QUOTES

36. 3- There are many cues for collecting data
PQRST
CLIENT OUTCOMES
COLDSPA
Complete Health History

37. 3- History of Present Illness
P Q R S T
P Provokes
Q Quality
R Region/Radiation
S Severity Scale
T Time
Understand patient's perception of the problem
Complete Health History

38. CLIENT
C Character of symptoms
L Location & Radiation
I Impact of illness on ADL
E Expectation of patient &
family
N Neglect any physical or
emotional
T Timing
OUTCOMES
O Other symptoms
U Understanding cause of
illness
T Treatment medications &
other therapy
C Complementary
alternative medicine
O Options for care that
important to patient
M Modulating factors
E Exposure to infectious
agents, toxic materials
S Spirituality
Complete Health History
3- History of Present Illness: CLIENT OUTCOMES

39. 3- History of Present Illness
COLDSPA
C Character: describe signs & symptoms
O Onset: when did it begin?
L Location: where? Dose it radiate?
D Duration: how long does it last?
S Severity: how bad? Scale of 1-10
P Pattern: what makes it better or worse?
A Associated factors: what other symptoms occur
with it? How it affects client?
Complete Health History
27-40

40. 27-41

41. History of Past Illnesses
 Childhood illnesses
 Accidents or injuries
 Serious or chronic illnesses
 Hospitalizations
 Operations
 Obstetric history
 Immunizations
 Last examination date
 Allergies
 Current Medications
 Family History
Elements of a Comprehensive Health History

42. Family History
 Any significant genetic basis: Sickle cell ,
G6PD
 May include Epilepsy, HT, DM, CV disease
Personal History
Habits, Addictions, smoking, sleep habits,
food preferences
Elements Of A Comprehensive Health History

43. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.
Chapter 4: The Complete Health History
The Health History
Family tree
or genogram

44. The Genogram 2

45. Referenc
es
Jarvis, C. (2016). Physical Examination
and Health Assessment, (7th ed.) St. Louis,
Missouri, Saunders Elsevier.
Chapters 2, 3, 4
AudreyT.Berma; Shirlee Snyder; Geralyn
Frandsen (2021). Fundamentals of Nursing,
11th edition.