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Assessing Clients Health Status 2

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6 views

Assessing Clients Health Status 2

Uploaded by

hd7wwwrzvj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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ASSESSMENT OF

CLIENT’S HEALTH
STATUS
Kevin Michael M. Jasani, RN, MD, MPH
Two aspects of assessing
client’s health status:
• Nursing Health History
• Physical Examination
Nursing Health History
• It paves a way for identifying nursing
problems and gives direction to the
physical examination.

• This will also assist the primary care


provider or the examiner in identifying
the areas of strength and limitation of an
individual’s lifestyle and current health
status.
Physical Assessment /
Examination
• Three types:
– (1) a complete assessment
– (2) examination of the body system
– (3) examination of the body area
Nursing Health History
• Taking health history should begin with
an explanation to the client of why the
information is being requested.

• The health history has 8 sections:


Nursing Health History
• 1. Biographic data
• 2. Reasons for seeking health care
• 3. history of present health concern
• 4. Personal health history
• 5. Family health history
• 6. Review of body systems for current
health problems.
• 7. Lifestyle and health practices
• 8. Developmental levels
1.
BIOGRAPHIC
DATA
BIOGRAPHIC DATA
• This includes information which will
identify the client such as name, address,
phone number, gender, date of birth and
who provided the information.

• Other information such as medical data


record number (if any) or any similar
identifying data may be included.
BIOGRAPHIC DATA
• The following will also help the nurse identify
special needs and practices that may affect the
care plan that will be given to the client:
– Culture
– Ethnicity and subculture
– Date and place of birth
– Nationality
– Marital status
– Religious and spiritual beliefs and practices
– Primary and secondary language spoken, written and
read
BIOGRAPHIC DATA
• Gathering information about the client’s level of
understanding such as educational background
and working status aids the nurse and medical
practitioner if communicating effectively.

• Knowing the people or family members and/or


significant others living with the client provide
information of the availability of possible
caregivers and support person for the client.
2. REASONS
FOR SEEKING
HEALTH CARE
REASONS FOR SEEKING
HEALTH CARE
• Two important questions:
– 1. What is your major health problem
or concerns at this time?
– 2. How do you feel about having to
seek health care?
REASONS FOR SEEKING
HEALTH CARE
• What is your major health
problem or concerns at this
time?
– Chief Complaint (CC)
– the reason why the client is
seeking medical help
REASONS FOR SEEKING
HEALTH CARE
• How do you feel about having to
seek health care?
– Encourages the client to discuss
fears and /or other feelings about
having to see a heath care
provider
3. HISTORY OF
THE PRESENT
HEALTH
CONCERN
HISTORY OF THE PRESENT
HEALTH CONCERN
• History of Present Illness

• Encouraging the client to


explain the health problem or
symptom by giving as much
details as possible
HISTORY OF THE PRESENT
HEALTH CONCERN

• COLDSPA

• PQRST of Pain
COLDSPA
• Character
• Onset
• Location
• Duration
• Severity
• Pattern
• Associated Factors
CHARACTER

• Describe the sign or symptom


– How does the pain feel like?
ONSET

• When did the (sign/symptom)


begin/start?
LOCATION

• Where is it located?
• Can you point to me the
location of the pain?
• Does the pain radiate?
• Does the pain/sign/symptom
occur anywhere else?
DURATION

• How long does the


(sign/symptom) last?
• Does it come and go, or is it
constant?
SEVERITY

• How bad is it?


• How much does is bother you?
• How intense is the pain?
PATTERN

• What makes it better or worse?


• Are there treatments that
you’ve tried and did it alleviate
the pain?
ASSOCIATED FACTORS

• What other symptoms have


occurred with it?
PQRST of Pain
• Provocation / Palliation
• Quality
• Region / Radiation
• Severity
• Timing
PROVOCATION /
PALLIATION
• Aggravating Factors
• Relieving Factors

• What triggers the pain?


• What do you do to alleviate the pain?
QUALITY
• Describe the pain/sign/symptom

• What does the pain feel like?


(Sharp, stabbing, burning, dull
aching pain)
REGION / RADIATION
• Where the pain/sign/symptom
occurs

• Where is the pain located? Does


it radiate or spread to other
parts of the body?
SEVERITY

• How severe is the pain? (from 1


– 10)
TIMING

• When does the pain occur?

• How long does the pain occur?


4. PERSONAL
HEALTH
HISTORY
PERSONAL HEALTH HISTORY
• Childhood illnesses and Immunizations up
to date

• Adult illnesses (physical, emotional,


psychological)
PERSONAL HEALTH HISTORY
• Past surgeries and accidents

• Allergies

• Use of medications (prescribed/OTC)


5. FAMILY
HEALTH
HISTORY
FAMILY HEALTH HISTORY
• Conditions which are hereditary

• HEREDOFAMILIAL DISEASES
– Hypertension
– Diabetes Mellitus
– Asthma
– Cancer
6. REVIEW OF
SYSTEMS FOR
CURRENT HEALTH
PROBLEM
REVIEW OF SYSTEMS
• General:
– Weight (gain/loss)
– Weakness
– Fatigue
– Fever
REVIEW OF SYSTEMS
• Integumentary (Skin, Hair,
Nails):
– Moles (change in color/pigmentation)
– Pruritus (Itching)
– Birthmarks
– Changes in color of hair and nails
REVIEW OF SYSTEMS
• HEENT
• Head:
– Headache
– Dizziness
– Vertigo
REVIEW OF SYSTEMS
• HEENT
• Eyes:
– Pain
– Blurring of Vision
– Photophobia
– Color blindness
– Diplopia
REVIEW OF SYSTEMS
• HEENT
• Ears:
– Pain
– Hearing loss
– Tinnitus
REVIEW OF SYSTEMS
• HEENT
• Nose/Sinuses:
– Pain
– Epistaxis
– Rhinorrhea
REVIEW OF SYSTEMS
• HEENT
• Throat/Mouth:
– Pain
– Sores/Ulcers
– Tooth decay/loss
– Hoarseness of voice
REVIEW OF SYSTEMS
• Neck
– Pain
– Stiffness
REVIEW OF SYSTEMS
• Breast
– Pain
– Swelling
– Redness
REVIEW OF SYSTEMS
• Respiratory (Thorax and Lungs)
– Dyspnea (difficulty breathing)
– Shortness of breath
– Hemoptysis
REVIEW OF SYSTEMS
• Cardiovascular (Heart)
– Chest pain
– Palpitations
– Dyspnea
– Orthopnea (difficulty breathing
while lying down)
REVIEW OF SYSTEMS
• Gastrointestinal
– Change in appetite Abdominal Pain
– Diarrhea Constipation
– Melena Hematochezia
– Hematemesis Nausea
– Vomiting
REVIEW OF SYSTEMS
• Genitourinary
– Dysuria
– Hematuria
– Changes in color of urine
– Flank pain
– Suprapubic pain
REVIEW OF SYSTEMS
• Endocrine
– Hot/Cold Intolerance
– Tremors
– Sweating
– Polydipsia
– Polyuria
– Polyphagia
REVIEW OF SYSTEMS
• Musculoskeletal
– Muscle pain
– Joint pain
– Swelling
– Redness
REVIEW OF SYSTEMS
• Hematologic
– Bruising
– Bleeding
REVIEW OF SYSTEMS
• Neurologic
– Seizures
– Dizziness
– Syncope
– Vertigo
– Weakness
7. LIFESTYLE
AND HEALTH
PRACTICES
PROFILE
LIFESTYLE AND HEALTH
PRACTICES PROFILE
• Nutritional habits
• Activity and exercise patterns
• Sleep and rest patterns
• Self-concept and self-care activities
• Social and community activities,
• Relationship, values and belief system
• Education and work, stress level, coping
style and environment.
8.
DEVELOPMEN
TAL LEVELS
DEVELOPMENTAL LEVELS
• Growth
– physical change and can be
measured quantitatively
• Development
– increase in the complexity of
function and skill progression
DEVELOPMENTAL LEVELS
• Theories on Growth and Development
– Sigmund Freud
– Erik Erikson
SIGMUND FREUD
ERIK ERIKSON

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