HxAss & P, E by KM
HxAss & P, E by KM
HxAss & P, E by KM
1 Nursing HA 05/23/2021
ASSESSMENT
University of Gondar
College of Medicine & Health science
Department:Emergency &critical care nursing
Category: BSC Emergency Nursing students(Yr III)
2 Nursing HA 05/23/2021
Assessment
3 Nursing HA 05/23/2021
References
1. Bates’ guide to physical examination and history taking
2. Fente Ambaw:health assessment lecture note for
professional nurses
3. Janet W (1997), nurses’ handbook of health assessment
4. Routh F. Craven(1992), foundamental of nursing
4 Nursing HA 05/23/2021
Objectives
At the end of this session the students will be able to:
1. Define health assessment
2. List the components of the comprehensive history
taking
3. Elucidate the purpose of history taking
4. Identify the techniques of skilled interview
5. Differentiate the role of the nurse in health
assessment
6. Perform/assist physical examination techniques
5 Nursing HA 05/23/2021
Nursing?
Health?
Health assessment?
6 Nursing HA 05/23/2021
Nursing
Definition
It is the provision of optimal conditions to enhance the
person’s reparative process and prevent the reparative
process from being interrupted (F.Nightingale)
7 Nursing HA 05/23/2021
Health
“A state of complete mental, physical and social
wellbeing and is not merely as the absence of disease
or infirmity” (WHO).
8 Nursing HA 05/23/2021
Holism health model
Interdependence of body, mind and sprit.
interaction with environment.
9 Nursing HA 05/23/2021
Health Assessment
Definition
Health assessment is a process by which one
analyze collected information in order to make
judgments about health problems or determine
a person’s need for nursing care.
It is also described as the foundation of nursing
process.
It’s process is an independent nursing
activity.
10 Nursing HA 05/23/2021
Assessment Data Obtained From
History
Physical examination
Laboratory & other diagnostic tests
11 Nursing HA 05/23/2021
The role of the nurse in health assessment
12 Nursing HA 05/23/2021
Cont…
Educative –nurse teaches self care activities for example:
-Self medication
-Health promotion
-Health screening
Managerial role-nurse under takes a range of administrative
activities by exercising managerial skills
Providing high quality and safe care
Preventing harm and medication errors
13 Nursing HA 05/23/2021
General Approaches in health Ass’t
Avoid “leading” questions, which suggest a desired or
expected answer
Avoid questions leading to “yes” or “no” response.
Keep note-taking to essentials during the interview.
14 Nursing HA 05/23/2021
The Techniques Of Skilled Interviewing
Active listening
Adaptive questioning
Non-verbal communication
Facilitation
Echoing
Empathic responses
Reassurance
Summarization
Highlighting transitions from Hx--- PE
15 Nursing HA 05/23/2021
The Techniques Of Skilled Interviewing
1. Active Listening.
Active listening is the process of
-Fully attending to what the patient is
communicating
- Being aware of the patient’s emotional state
-Using verbal and nonverbal skills to encourage the
speaker to continue and expand.
16 Nursing HA 05/23/2021
The Techniques Of Skilled Interviewing..
2. Adaptive Questioning
Directed questioning—from general to specific.
*This is useful for drawing the patient’s attention to
specific areas of the history
17 Nursing HA 05/23/2021
Cont…
Questioning to elicit a graded response
Offering multiple choices for answers
Asking a series of questions, one at a time
Clarifying what the patient means
18 Nursing HA 05/23/2021
The Techniques Of Skilled Interviewing…
3. Non-verbal Communication
Communication that does not involve speech occurs
continuously and provides important clues to
feelings and emotions.
20 Nursing HA 05/23/2021
The Techniques Of Skilled Interviewing…
4. Facilitation
You use facilitation, by posture, actions, or words, you
encourage the patient to say more but do not specify the
topic.
Leaning forward
Making eye contact
5. Echoing (Reflection)
Simple repetition of the patient’s words to encourages
the patient to give you more detail both factual and
feelings, as in the following Example:
Patient: The pain got worse and began to spread.
(Pause)
Response: Spread? (Pause)
22 Nursing HA 05/23/2021
The Techniques Of Skilled Interviewing…
6. Emphatic responses
This is the recognition of feelings such as:
Embarrassment
Shame/suffering and
Responding to patient in a way that shows
understanding and acceptance.
E.g. “I understand your problem” or it may be
behavioral such as providing a piece of soft for a
patient in tears or gently placing your hand on the
patient’s arm to show understanding.
23 Nursing HA 05/23/2021
The Techniques Of Skilled Interviewing…
7. Reassurance
When you are talking with patients who are anxious or
upset, it is tempting to reassure them.
“Don’t worry. Everything is going to be all right.”
The first step to effective reassurance is identifying and
accepting the patient’s feelings without offering
reassurance at that moment.
The actual reassurance comes much later after you
have completed the interview, the physical
examination, and perhaps some laboratory studies.
24 Nursing HA 05/23/2021
The Techniques Of Skilled Interviewing…
8. Summarization
Clarify or interpret what has been said.
It indicates to the patient that you have been listening
carefully.
It can also identify what you know and what you
don’t know.
9. Highlighting transition
From Hx--- PE…????
25 Nursing HA 05/23/2021
The “SOAP” Format
S – Subjective
Symptoms that the patient reports
What the patient feels
The history
O – Objective
Signs that can be observed by the examiner
Physical examination findings
Laboratory data & other diagnostic tests
26 Nursing HA 05/23/2021
The “SOAP” Format..
A – Assessment
Interpretation
& evaluation of data
Differential diagnosis
Medical diagnosis
Problem list
P - Plan
Diagnostic studies
Therapeutic regimen
Patient education
27 Nursing HA 05/23/2021
Group work
Think of symptoms that are assigned both in
subjective and objective data
present to the class.
5 min
28 Nursing HA 05/23/2021
Purpose of nursing assessment/Assessement.
To gather data about the client that can be used in
diagnoses, identifying the outcomes, planning and
implementing care.
29 Nursing HA 05/23/2021
Types of Assessment
1. Initial assessment
Performed at the time the patient enters the health care
facility.
30 Nursing HA 05/23/2021
Types of Assessment…
2. Focused Assessment
Determines status of specific problems identified
during previous assessment.
To helps to identify overlooked problems.
It leads us to the general condition of the specific
diagnosis.
31 Nursing HA 05/23/2021
Types of Assessment…
3. Time lapsed assessment (after several months of
initial assessment).
It is the final assessment done after a period of time.
This assessment is focused type.
32 Nursing HA 05/23/2021
Types of Assessment…
4. Emergency assessment
Assessment done on the life treating situation
This assessment should be done quickly, and leading to
aggressive management.
33 Nursing HA 05/23/2021
Ass’t setting and Environment
In any setting where nurses care for clients and their
family members.
Conducive environmental factors to the collection of
accurate and complete assessment data.
Quite, private setting
Restrict/secluded to prevent the clients undue
embarrassment during interview & P/examination.
Ask visitors and family members to leave the room.
34 Nursing HA 05/23/2021
Assessment skills
1. Observation: ability to observe and identify problems.
vision, smell, hearing and touch
3. Physical examination
To verify & expand the data gathered during interview
using techniques of IPPA.
35 Nursing HA 05/23/2021
Assessment Activities (Components)
Collect data: Gathering information about the patient
Validate data: double checking, the process of
confirming the accuracy of assessment data collected.
e.g. “ I feel hot” check body temperature how is it?
Organize data
Recording data
36 Nursing HA 05/23/2021
Types of data
Subjective data
Also known as symptoms or covert data, include the patients
feeling and statements about his or her health problems
Obtained through interview
It should always be taken by the patient own words
E.g-I haven’t felt good for the last couple of months
E.g. -“I get sharp pain in my chest.”
37 Nursing HA 05/23/2021
Types of data…
Objective data
38 Nursing HA 05/23/2021
Source of Data
Primary sources
The patient
Secondary sources
Family members or significant others
Health record, literature review
Laboratory test
39 Nursing HA 05/23/2021
Characteristics of data
Complete
Relevant
40 Nursing HA 05/23/2021
Comprehensive Health Assessment
It includes:
History taking
Physical examination and
Laboratory investigation
41 Nursing HA 05/23/2021
The Health History
Definition:
42 Nursing HA 05/23/2021
Purposes of history taking
To establish trusting relationship between the nurse
and the patient.
Develop understanding about the patient.
Help the patient to feel understood.
Guides on which body part or systems to focus during
physical examination.
Establish a therapeutic relationship
Gather pertinent information
Formulate a treatment plan
43 Nursing HA 05/23/2021
Phase of history taking
History taking has three basic phases:
1. Introductory phase:
In this phase the health personnel (Emergency nurse)
introduce self and explain the purpose of interview to
the patient, an explanation of taking note, assuring
confidentiality, comfort and privacy of the information.
44 Nursing HA 05/23/2021
2.Working phase:
The health professional facilitates the patient’s major
46 Nursing HA 05/23/2021
Biographical data
Name
Age
Sex
Residence
Occupation
Income
Religion
Ethnicity
Marital status…
47 Nursing HA 05/23/2021
Chief complain (c/c)
This is the main reason that the client is seeking
medical advice/care
48 Nursing HA 05/23/2021
History of present illness (HPI)
Including analysis of the symptom like
OPQRST
Onset =the acuteness or chronicity
Provokes =what makes symptom worse/better
Quality =what does pain feels like (colic, throbbing,
cramp…
Radiation = where does pain shift
Severity =on a scale of 0-10 or other scale
Time = when, how often/frequent, how long.
49 Nursing HA 05/23/2021
HPI…
Any intervention made and response it should be
reported
Contact and travel history
50 Nursing HA 05/23/2021
History of past illness
This explores injuries, childhood illness, operations,
51 Nursing HA 05/23/2021
Family history
Outlines or diagrams of age and health, or age and cause
52 Nursing HA 05/23/2021
Review of systems
53 Nursing HA 05/23/2021
Physical Examination
54 Nursing HA 05/23/2021
Introduction
Physical assessment: is an objective data about a client .
PURPOSE:
Gather base line data
Supplement, confirm, or refute (disprove) data in patient’s
history.
Confirm and identify nursing diagnoses.
Make clinical judgment about changing status
55 Nursing HA 05/23/2021
Purpose
To have systematic examination and enable you reach
to meaningful diagnosis.
Evaluate the patient’s current status
56 Nursing HA 05/23/2021
Physical assessment has 4 main parts
1. General survey/GA/
58 Nursing HA 05/23/2021
Cont…
2. Vital signs
It is important method for measuring & monitoring vital body
functions.
Includes To, pulse, respiration & blood pressure and O2
saturation.
Take v/s at least every 4 to 6 hrs for hospitalized pts
In acute situation every 1 to 2 hr
After surgery & any other procedure take v\s every 15
minute.
59 Nursing HA 05/23/2021
Cont…
3. Assessment of height & weight
60 Nursing HA 05/23/2021
Assessment Sequencing
Head – to - Toe Assessment
61 Nursing HA 05/23/2021
Physical Assessment Techniques
62 Nursing HA 05/23/2021
Inspection
Is systemic and deliberate visual observation to determine
health status thorough observation in a head to toe
Fashion
Take time to “observe” with eyes
Perform at every encounter with your client
Good lighting
Position and expose body part with optimal viewing
Inspect for size, shape, color, symmetry and position
63 Nursing HA 05/23/2021
Palpation
64 Nursing HA 05/23/2021
Palpation …
66 Nursing HA 05/23/2021
Palpation …
67 Nursing HA 05/23/2021
Palpation …
Bimanual palpation involves using both hands to trap
a structure between them.
This technique can be used to evaluate the
Spleen
Kidney
Breast, and
Uterus.
68 Nursing HA 05/23/2021
Percussion
69 Nursing HA 05/23/2021
Auscultation
Sounds produced by body
Quiet environment
Good stethoscope
Stethoscope placed next to skin
Diaphragm used for high-pitched sounds
Bell used for low pitched
sounds
70 Nursing HA 05/23/2021
Auscultation…
Auscultation is the skill of listening to body sounds
created in the lungs, heart, blood vessel, and
abdominal viscera by the help of a stethoscope.
Auscultation is usually the last technique used during the
examination.
The sequence usually progress from inspection to
palpation, percussion, and auscultation, except during the
abdominal examination when auscultation is the second
step (following inspection).
71 Nursing HA 05/23/2021
QUESTIONS ?
72 Nursing HA 05/23/2021