NURSING HEALTH ASESSMENT AND DIFFRENT SCALES .pptx
- 1. HEALTH ASSESSMENT OF PATIENTS,HISTORY TAKING AND ASSESSMENT SCALE MS.CHANDRAMUKHI MEDICAL SURGICAL SPECIALITY
- 2. Outline/objectives Definition of health Definition of Assessment. List indication of health assessment. List the purpose of health assessment. List Basic guidelines for conducting a health assessment Explain Ethical use of history Explain the health history taking. Explain the components of history taking. List equipment for physical examination Explain the major techniques for physical examination. Method of nutritional assessment List and explain different types of assessment scale. Research finding about Development and importance of health needs assessment Conclusion Summary references
- 3. Health:- Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. - W.H.O
- 4. ASSESSMENT: Assessment is a systematic, dynamic process by which the nurse through interaction with client, significant others and health care provides, collect and analyze data about client. - American nurses association
- 5. HEALTH ASSESSMENT: Health assessment is an organized systematic assessment of human body which involves the use of one’s sense to determine the general physical and mental condition of the body by collecting both subjective and objective data.
- 11. GUIDELINES FOR CONDUCTING A HEALTH ASSESSMENT: People who seek health care for a specific problem often feel anxious. Their anxiety may be increased by fear about potential diagnoses, possible disruption of lifestyle $ other concerns.so with this in mind should attempts to Establish rapport gather baseline data about the patient’s health status. Supplement ,confirm or refute data obtained in the history confirm $ identify nursing diagnosis Make clinical judgment about a patient’s changing health status $management Evaluate the outcome Put the patient at ease(comfort, console) Encourage honest communication.
- 12. Make eye contact Listen carefully to the patient’s responses to questions about health issues. The nurse must be aware of his /her own non-verbal communication, as well as that of the patient. Should take consideration of patient education $ cultural background as well as language proficiency Technical and medical jargon (terms) are avoided. Must take into consideration the patient with disabilities or impairment and physical limitations. At end of assessment nurse may summarize $ clarify the information obtained and ask the patient if he /she has any question
- 13. ETHICAL USE OF HISTORY TAKING: HISTORY TAKING IMPORTANCE OF HISTORY TAKING
- 14. COMPONENTS OF HISTORY TAKING: Patient’s profile Chief complaint History of the Past medical
- 17. CHIEF COMPLAINT: What brings your here? How can I help you? What seems to be the problem? If there is more than one complaint, it should be written according to chronological order
- 19. HISTORY OF THE PRESENT ILLNESS Time of onset mode of evolution any investigation; treatment &outcome Any associated +’ve or -’ve symptoms. Avoid medical terminology and make use of a descriptive language that is familiar to patients. Sequential presentation Always relay story in days before admission Narrate in details history of the present illness gather information history of the present illness with
- 20. SOCRAT S •SITE o •ONSET C •CHARACTER R •RADIATION A •ALLEVIATING FACTOR T •TIME
- 21. EXAMPLE: The patient was apparently well 1 week before the admission when the patient fell while gardening and cut his foot with a stone. By that evening, the foot became swollen and patient was unable to walk. Next day patient attended a private clinic where they gave him some oral medicines. The patient doesn’t know the name of the medicines given but says that he was told the medicine would suppress his leg pains.However There was no improvement in his condition. Two days prior to admission in Safdarjung, The swelling in the foot started to discharge pus. There is high fever and rigors with nausea and vomiting.
- 23. PAST MEDICAL HISTORY - Any chronic disease present like hypertension, diabetes etc. - Past hospitalizations and past surgeries - Medications if any taken in the past (dosage and duration) - Allergies - Pediatric: Birth history,Developmental Milestones, Immunizations Gyane/Obstetric history if female.
- 25. FAMILY HISTORY: It is important to establish whether there are any genetically transmitted diseases within families. Any illness runs in the family? Similar history in the family, Parents and siblings suffering with any chronic illness, Parents if died, how old and reason of death. Should be able to collect relevant family history Depending upon the present illness. Example, Patient has come due anemia, Try to rule out sickle cell, thalassemia/ G6PD deficiency.
- 27. SOCIOECONOMIC HISTORY Smoking history - amount, duration and type of Drinking history; amount, duration and type Any drug addiction Sexual history if suspected STI. Occupation, social and education background, financial situation
- 28. SYSTEM REVIEW
- 29. TECHNIQUES: INSPECTION PALPATION PERCUSSSION AUSCULTATION FOUR MAJOR TECHNIQUES ARE USED IN PERFORMING THE PHYSICAL EXAMINATION.
- 30. SYSTEM REVIEW: GENERAL EXAMINATION CARDIOVASCULAR:- RESPIRATORY SYSTEM:- GASTROINTESTINAL/ALIMENTARY:- URINARY SYSTEM : GENITAL SYSTEM :- NERVOUS SYSTEM:- MUSCULOSKELETAL SYSTEM :-•
- 31. Direct Methods of Nutritional Assessment A •ANTHROPOMETRIC METHODS B •BIOCHEMICAL, LABORATORY METHODS C •CLINICAL METHODS D •DIETARY EVALUATION METHODS
- 32. Anthropometric methods Body Mass Index is a simple calculation using a person's height and weight.The formula is BMI = kg/m2 Where kg is- a person's weight in kilograms and M2 is their height in meters squared., A BMI of 25.0 or more is overweight, while the healthy range is 18.5 to 24.9.Evidence shows that high BMI (obesity level) is associated with type 2 diabetes & high risk of cardiovascular morbidity & mortality Mid-arm circumference (MAC): It is an easy-to-obtain anthropometric measure as well as a good predictor of risk of imminent death;It has been used for monitoring the nutritional status of patients in emergency situations and recommended for the assessment of acute malnutrition in adults.
- 33. BMI (WHO - Classification) BMI < 18.5 = Under Weight BMI 18.5-24.5= Healthy weight range BMI 25-30 = Overweight (grade 1 obesity) BMI >30-40 = Obese (grade 2 obesity) BMI >40 =Very obese (morbid or grade 3 obesity)
- 34. DIFFERENT TYPE OF SCALE 1.GLASGOW COMA SCALE 2.VISUAL ANALOGUE SCALE 3.MORSE FALL ASSESSMENT 4.BRADEN SCALE 5.VIP SCORE
- 38. BRADEN SCALE
- 40. Health needs assessment is the systematic approach to ensuring that the health service uses its resources to improve the health of the population in the most efficient way It involves epidemiological, qualitative, and comparative methods to describe health problems of a population; identify inequalities in health and access to services; and determine priorities for the most effective use of resources Health needs are those that can benefit from health care or from wider social and environmental changes Successful health needs assessments require a practical understanding of what is involved, the time and resources necessary to undertake assessments, and sufficient integration of the results into planning and commissioning of local services DEVELOPMENT AND IMPORTANCE OF HEALTH NEEDS ASSESSMENT John Wright, consultant in epidemiology and public health medicine, Rhys, professor of epidemiology and public health, and John R Wilkinson, deputy director of public health
- 41. CONCLUSION Health assessments are a key part of a nurse's role and responsibility. The assessment is a tool to learn about your patient's concerns, symptoms and overall health. "It is a critical step because this is where comprehensive data including physiological, psychological, socioeconomic, social determinants of health, spiritual and lifestyle information is gathered to help determine nursing diagnoses, which are used to develop nursing care plans that aim to improve health outcomes,“ Hence, HEALTH ASSESSMENT OF PATIENTS,HISTORY TAKING is Important
- 42. SUMMARIZATION We learnt today about Health,Assessment. indication of health assessment., purpose of health assessment., Basic guidelines for conducting a health assessment , Ethical use of history, health history taking. components of history taking. Techniques for physical examination. Method of nutritional assessment, different types of assessment scale and seen a Research finding about Development and importance of health needs assessment
- 43. GROUP EVALAUATION a) DEFINE HEALTH ASSESSMENT?
- 44. WHAT SOCRAT STANDS FOR?
- 45. WHAT ARE ETHICAL USE OF HISTORY TAKING?
- 46. WHAT ARE THE DIFFERENT TYPE OF SCALE?
- 47. REFERENCES: Lewis, Dirksen,Heitkemper,Bucher (2015). Lewis’s Medical-Surgical Nursing Assessment and Management of Clinical Problems (2nd ed.).ELSEVIER. P.g;31-41 Suzanne C.Smeitzer ,Brenda G. Bare,Janice L. Hinkle, Kerry H. Cheever.(2009).Brunner $ Siddarth’s Text Book Of Medical-Surgical Nursing,(11th ed.).Wolter Kluwer. P.g;63-85 Carol Taylor,Carol Lillis ,Priscilla.(2006).Fundamental of Nursing The Art and Science of Nursing Care.(5t ed.).Lippincott Williams $ Wilkin. P.g;1205-1212 Janet Weber,Jane Kelley.(2010).Health Assessment in Nursing(4th e.d).Wolter Kluwer Health.P.g;64-66,100-102,183- 187,759 Seidel,Ball,Dains,Benedict.( ).Mosby’s Guide to Physical Examination.(2nd ed.).P.g;1-46 Malasanos,Barkauskas,Moss,Stolenberg-Allen(1981).Health Assessment(2nd ed.).The C.V. Mosby CompanyP.g;35-57 The American Journal of Nursing vol.102,No.10(Oct.,2002)p.p 55-56+58 Published by Lippincott Williams $ Wilkins American Family Physician www.aafp.org/afp.Copyright©2008American Academy of Family Physician
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