Faculty of Nursing-IUG

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Faculty of Nursing-IUG

• Chapter (2)
• Health Assessment- Holistic Approach

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Holistic approach
1. The interview 2. Psychosocial assessment 3.
Nutritional assessment 4. Assessment of
sleep-wakefulness patterns 5. The health history.
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1. Interview

• Definition communication process focuses on the
  client's development of psychological,
  physiological, sociocultural, and spiritual
  responses, that can be treated with nursing
  collaborative interventions

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• Major purpose
• To obtain health history and to elicit symptoms
  and the time course of their development. The
  interview conducted before physical examination
  is done.
• Components of nursing interview
• 1. Introductory phase
• 2. Working phase
• 3. Termination phase

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• Introductory phase
• Introduce yourself and explains the purpose of
  the interview to the client.
• Before asking questions, Let client to feel
  Comfort, Privacy and Confidentiality

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• Working phase
• The nurse must listen and observe cues in
  addition to using critical thinking skills to
  validate information received from the client.
  The nurse identify client's problems and goals.
• Termination phase
• 1.The nurse summarizes information obtained
  during the working phase
• 2. Validates problems and goals with the
  client.
• 3.Making plans to resolve the problems
  (nursing diagnosis and collaborative problems are
  identified and discussed with the client)

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Communications techniques during interview

• A. Types of questions
• Begin with open ended questions to assess
  client's feelings e.g. what, how, which
• Use closed ended question to obtain facts e.g."
  when, didetc
• Use list to obtain specific answers e.g. "is pain
  sever, dull sharp
• Explore all data that deviate from normal e.g.
  increase or decrease the problem

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• B. Types of statements to be use
• Repeat your perception of client's response to
  clarify information and encourage verbalization
• C. Accept the client silence to recognize
  thoughts
• D. Avoid some communication styles e.g.
• Excessive or not enough eye contact.
• Doing other things during getting history.
• Biased or leading questions e.g. "you don't feel
  bad"
• Relying on memory to recall information

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• E. Specific age variations -
• Pediatric clients validate information from
  parents.
• Geriatric clients use simple words and assess
  hearing acuity
• F. Emotional variations
• Be calm with angry clients and simply with
  anxious and express interest with depressed
  client
• Sensitive issues "e.g. sexuality, dying,
  spirituality" you must be aware of your own
  thought regarding these things.

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• G. Cultural variations
• Be aware of possible cultural variations in the
  communication styles of self and clients
• H. Use culture broker
• Use culture broker as middleman if your client
  not speak your language.
• Use pictures for non reading clients.

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2-Psychosocial assessment

• Psychological assessment involves person's growth
  and development throughout his life.
• Discuss crises with the clients to assess
  relationship between health illness. It
  depends on multiple GD theories e.g. Erickson,
  Piaget, and Freud . etc.

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Stages of Age

• Infancy period birth to 12 months
• Neonatal Stage birth-28 days
• Infancy Stage 1-12 months
• Early childhood Stage Its refers to two
  integrated stages of development
• Toddler 1 - 3years.
• Preschool 3 - 6 years.
• Middle childhood 6-12 years
• Late childhood
• Pre pubertal 10 13 years.
• Adolescence 13 - 19 years
• Young adulthood 20-40 years
• Middle adulthood 40-65years
• Late adulthood 65 and more

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3-Nutritional assessment

• Nutrition plays a major role in the way an
  individual looks, feels, behaves.
• The body ability to fight disease greatly depends
  on the individual's nutritional status

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Major goals of nutritional assessment

• 1. Identification of malnutrition.
• 2. Identification of over consumption
• 3. Identification of optimal nutritional
  status.
• Components of Nutritional Assessment
• 1. Anthropometric measurement.
• 2. Biochemical measurement.
• 3. Clinical examination.
• 4. Dietary analysis

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A. Anthropometric measurement

• Measurement of size, weight, and proportions of
  human body.
• Measurement includes height, weight, skin fold
  thickness, and circumference of various body
  parts, including the head, chest, and arm.
• Assess body mass index (BMI) to shows a direct
  and continuous relationship to morbidity and
  mortality in studies of large populations. High
  ratios of waist to hip circumference are
  associated with higher risk for illness
  decreased life span.
• BMI (Wt. in kilograms)
  60 60 23.4
• (High in meters) 2
  (1.6)2 2.56

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BMI RANGE
Condition Rang kg/m2
Very thin less than 16.0
Thin 16.0 - 18.4
Average 18.5- 24.9
Overweight 2529.9
Obese 30-34.9
Highly obese 35
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B. Biochemical Measurement

• Useful in indicating malnutrition or the
  development of diseases as a result of over
  consumption of nutrients. Serum and urine are
  commonly used for biochemical assessment.
• In assessment of malnutrition, commonly tests
  include total lymphocyte count, albumin, serum
  transferrin, hemoglobin, and hematocrit etc.
  These values taken with anthropometric
  measurements, give a good overall picture of an
  individual's skeletal and visceral protein status
  as well as fat reserves and immunologic response.

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C. Clinical examination

• Involves, close physical evaluation and may
  reveal signs suggesting malnutrition or over
  consumption of nutrients.
• Although examination alone doesn't permit
  definitive diagnosis of nutritional problem, it
  should not be overlooked in nutritional
  assessment

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Nutritional assessment technique for clinical
examination

• a. Types of information needed
• Diet Describe the type regular or not, special,
  "e.g. teeth problem, sensitive mouth.
• Usual mealtimes How many meals a day when?
  Which are heavy meals?
• Appetite "Good, fair, poor, too good".
• Weight stable? How has it changed?

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• Food preferences e.g." prefers beef to other
  meats"
• Food dislike What Why? Culture related?
• Usual eating places Home, snack shops,
  restaurants.
• Ability to eat describe inabilities, dental
  problems "ill fitting dentures, difficulties
  with chewing or swallowing
• Elimination" urine stool nature, frequency
  problems
• Exercise physical activity how extensive or
  deficient

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• Psycho social - cultural factors Review any
  thing which can affect on proper nutrition
• Taking Medications which affect the eating habits
• Laboratory determinations e.g. Hemoglobin,
  protein, albumin, cholesterol, urinalyses"
• Height, weight, body type "small, medium, large"
• After obtaining information, summarize your
  findings and determine the nutritional diagnosis
  and nutritional plan of care.
• Imbalanced nutrition Less than body
  requirements, related to lack of knowledge and
  inadequate food intake
• Risk for infection, related to protein-calorie
  malnutrition

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b. Signs symptoms of malnutrition

• Dry and thin hair
• Yellowish lump around eye, white rings around
  both eyes, and pale conjunctiva
• Redness and swelling of lips especially corners
  of mouth
• Teeth caries abnormal missing of it
• Dryness of skin (xerosis) sandpaper feels of
  skin
• Spoon shaped Nails " Koilonychia anemia
• Tachycardia, elevated blood pressure due to
  excessive sodium intake and excessive
  cholesterol, fat, or caloric intake
• Muscle weakness and growth retardation

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D. Dietary analysis

• Food represent cultural and ethnic background and
  socio- economic status and have many emotional
  and psychological meaning
• Assessment includes usual foods consumed habits
  of food
• The nurse ask the client to recall every thing
  consumed within the past 24 hour including all
  foods, fluid, vitamins, minerals or other
  supplements to identify the optimal meals
• Should not bias the client's response to
  question based on the interviewer's personal
  habits or knowledge of recommended food
  consumption

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Diseases affected by nutritional problems

• 1- Obesity excess of body fat.
• 2- Diabetes mellitus.
• 3- Hypertension.
• 4- Coronary heart disease.
• 5- Cancer.

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4-Assessment of sleep-wakefulness patterns

• Normal human has homeostasis (ability to
  maintain a relative internal constancy)
• Any person may complain of sleep-pattern
  disturbance as a primary problem or secondary due
  to another condition
• 1/4 of clients who seek health care complain of a
  difficulty related to sleep

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Factors affecting length and quality of sleep

• 1. Anxiety related to the need for meeting a
  tasks, such as waking at an early hour for work.
• 2. The promise of pleasurable activity such as
  starting a vacation.
• 3. The conditioned patterns of sleeping.
• 4. Physiologic wake up.
• 5. Age differences.
• 6. Physiologic alteration, such as diseases

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• Good sleep depends on the number of awakenings
  and the total number of sleeping hours
• The nurse can assess sleep pattern by doing
  interview with the client or using special charts
  or by EEG
• Disorders related to sleep
• 1.Sleep disturbances affects family life,
  employment, and general social adjustment
• 2. Feelings of fatigue, irritability and
  difficulty in concentrating
• 3. Difficulty in maintaining orientation

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• 4. Illusions, hallucination (visual tactile).
• 5. Decreased psychomotor ability with decreased
  incentive to work.
• 6. Mild Nystagmus.
• 7. Tremor of hands.
• 8. Increase in gluco-corticoid and adrenergic
  hormone secretion.
• 9. Increase anxiety with sense of tiredness.
• 10. Insomnia "short end sleeping periods.
• 11. Sleep apnea "periodic cessation of breathing
  that occurs during sleep.

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• 12. Hypersomnia "sleeping for excessive periods
  the sleep period may be extended to 16-18 hours a
  day
• 13. Peri-hypersomnia. "Condition that is
  described as an increased used for sleep "18-20
  hours a day" lasts for only few days
• 14. Narcolepsy "excessive day time drowsiness or
  uncontrolled onset of sleep.
• 15. Cataplexy abrupt weakness or paralysis of
  voluntary muscles e.g. arms, legs face last
  from half second to 10 minutes, one or twice a
  year
• 16. Hypnagogic hallucinations " Disturbing or
  frightening dream that occur as client is a
  falling a sleep

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Assessment of sleep habits

• Let the client record the times of going to sleep
  and awakening periods, including naps.
• Allow client to described their sleep habits in
  their own words
• You can ask the following questions
• How have you been sleeping??
• Can you tell me about your sleeping
  habits?"
• Are you getting enough rest?"
• Tell me about your sleep problem"
• Good History includes a general sleep history,
  psychological history, and a drug history

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5-Health History

• Systematic collection of subjective data which
  stated by the client, and objective data which
  observed by the nurse.
• Used to determine a client functional health
  pattern status.

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Phases of taking health history

• Two phases
• The interview phase which elicits the information
  (primary sources)
• The recording phase (secondary sources).

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Guidelines for Taking Nursing History

• Private, comfortable, and quiet environment.
• Allow the client to state problems and
  expectations for the interview.
• Orient the client the structure, purposes, and
  expectations of the history.

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Guidelines for Taking Nursing History cont..

• Communicate and negotiate priorities with the
  client.
• Listen more than talk.
• Observe non-verbal communications e.g. "body
  language, voice tone, and appearance".

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Guidelines for Taking Nursing History cont..

• Review information about past health history
  before starting interview.
• Balance between allowing a client to talk in an
  unstructured manner and the need to structure
  requested information.
• Clarify the client's definitions (terms
  descriptions).

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Guidelines for Taking Nursing History cont..

• Avoid yes or no question (when detailed
  information is desired).
• Write adequate notes for recording?
• Record nursing health history soon after
  interview.

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Types of Nursing Health History

• Complete health history taken on initial visits
  to health care facilities.
• Interval health history collect information in
  visits following the initial data base is
  collected.
• Problem-focused health history collect data
  about a specific problem.

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Components of Health History

• 1-Biographical Data This includes
• Full name
• Address and telephone numbers (client's permanent
  contact of client)
• Birth date and birth place
• Sex
• Religion and race
• Marital status
• Social security number
• Occupation (usual and present)
• Source of referral
• Usual source of healthcare
• Source and reliability of information
• Date of interview

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2- Chief Complaint Reason For Hospitalization

• Examples of chief complaints
• Chest pain for 3 days.
• Swollen ankles for 2 weeks.
• Fever and headache for 24 hours.
• Pap smear needed.

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SYMPTOM ANALYSIS

• P Q R S T
• a. Provocative or Palliative
• First occurrence
• What were you doing when you first experienced or
  noticed the symptom?
• What to trigger it ? stress?, position?,
  activity?
• What seems to cause it or make it worse? For a
  psychological symptom.
• What relieves the symptom change diet? change
  position ? take medication? being active?
• Aggravation what makes the symptom worse?

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SYMPTOM ANALYSIS

• P Q R S T
• b. Quality Or Quantity
• QUALITY
• How would you describe the symptom- how it feels,
  looks, or sounds?
• QUANTITY
• How much are you experiencing now?
• Is it so much that it prevents you from
  performing any activity?

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SYMPTOM ANALYSIS P Q R S T

• c. Region Or Radiation
• Region
• Where does the symptom occur?
• Radiation
• Does it travel down your back or arm, up your
  neck or down your legs?

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SYMPTOM ANALYSIS P Q R S T

• d. Severity scale
• Severity
• How bad is symptom at its worst?
• Course
• Does the symptom seem to be getting better,
  getting worse?

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SYMPTOM ANALYSIS P Q R S T

• e. Timing
• Onset
• On what date did the symptom first occur?
• Type of onset
• How did the symptom start suddenly? gradually?
• Frequency
• How often do you experience the symptom hourly?
  daily? weekly? Monthly?
• Duration
• How long does an episode of the symptom last?

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3-History of present illness

• Gathering information relevant to the chief
  complaint, and the client's problem, including
  essential and relevant data, and self medical
  treatment.

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Components of present illness

• Introduction "client's summary and usual
  health".
• Investigation of symptoms "onset, date, gradual
  or sudden, duration, frequency, location,
  quality, and alleviating or aggravating factors".
• Negative information.
• Relevant family information.
• Disability "affected the client's total life".

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4- Past Health History

• The purpose (to identify all major past health
  problems of the client).
• This includes
• Childhood illness e.g. history of rheumatic
  fever.
• History of accidents and disabling injuries.

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Past Health History. Cont

• History of hospitalization (time of admission,
  date, admitting complaint, discharge diagnosis
  and follow up care).
• History of operations "how and why this done.
• History of immunizations and allergies.
• Physical examinations and diagnostic tests.

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5-Family History

• The purpose to learn about the general health of
  the client's blood relatives, spouse, and
  children and to identify any illness of
  environmental, genetic, or familiar nature that
  might have implications for the client's health
  problems.

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Family History. Cont

• Family history of communicable diseases.
• Heredity factors associated with causes of some
  diseases.
• Strong family history of certain problems.
• Health of family members "maternal, parents,
  siblings, aunts, unclesetc.".
• Cause of death of the family members "immediate
  and extended family".

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6-Environmental History

• Purpose
• To gather information about surroundings of the
  client", including physical, psychological,
  social environment, and presence of hazards,
  pollutants and safety measures."

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7- Current Health Information

• Purpose to record major current health-related
  information.
• Allergies environmental, ingestion, drug,
  others.
• Habits "alcohol, tobacco, drug, caffeine"
• Medications taken regularly by doctor or self
  prescription.
• Exercise patterns.
• Sleep patterns (daily routine).
• The pattern life (sedentary or active).

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8- Psychosocial History

• Includes
• How client and his family cope with disease or
  stress, and how they respond to illness and
  health.
• You can assess if there is psychological or
  social problem and if it affects general health
  of the client.

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9- Review of Systems (ROS)

• Collection of data about the past and the present
  of each of the client systems.
• (Review of the clients physical, sociologic, and
  psychological health status may identify hidden
  problems and provides an opportunity to indicate
  client strength and disabilities).

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Physical Systems

• Which includes assessment of
• General review of skin, hair, head, face, eyes,
  ears, nose, sinuses, mouth, throat, neck nodes
  and breasts.
• Assessment of respiratory and cardiovascular
  system.
• Assessment of gastrointestinal system.
• Assessment of urinary system.
• Assessment of genital system.
• Assessment of extremities and musculoskeletal
  system.
• Assessment of endocrine system.
• Assessment of heamatoboitic system.
• Assessment of social system.
• Assessment of psychological system.

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10- Nutritional Health History

• Discussed Before

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11- Assessment of Interpersonal Factors

• This includes
• Ethnic and cultural background, spoken language,
  values, health habits, and family relationship.
• Life style e.g. rest and sleep pattern.
• Self concept perception of strength, desired
  changes.
• Sexuality developmental level and concerns.
• Stress response coping pattern, support system,
  perceptions of current anticipated stressors.