How to Assess a Patient in the Hospital/ Nursing Assessment of a Patient
A Health Assessment is
Øa plan of care
Øidentifies the specific needs of
a person
Øhow those needs will be addressed by
the healthcare
system or skilled health care provider facility.
Øevaluation of the health status by performing a
physical exam after taking a health history.
Ødetect diseases early in people
that may look and feel well.
Øevaluation of the health status of an individual
along the health
continuum.
§ The purpose of the assessment is to establish where on the health continuum the individual is because this guides how to approach and treat the individual.
§ The
health continuum approaches range from preventative, to treatment,
to palliative
care in relation to the individual's status on the
health continuum.
§ It
is not the treatment or treatment plan.
§ The
plan related to findings is a care plan which is preceded by the specialty such
as medical,physical therapy, nursing,
etc.
§ Health
assessment of patients falls under the purview of both physicians and
nurses
and midwives.
While
some nurses
practice in extended roles (Advanced Nurse
Practitioners), others maintain a more traditional role in the acute care
setting.
§Assessment of patients varies based on both role
and setting.
§A cardiac care nurse will be more
familiar with and attuned to cardiac issues.
§A nurse on a neurologic unit will be more familiar with a more complex neuro exam.
§Nursing assessment
is the gathering of information about a patient’s physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse and midwifery.
§Nursing assessment is the first step in the nursing process.
§A section of the nursing assessment may be
delegated to certified nurses aides.
§In some instances, the nursing assessment is very broad in scope and in other cases it may focus on one body system or mental health.
§Nursing assessment is used to identify current and future patient care needs.
§It incorporates the recognition of normal versus
abnormal
body physiology.
§Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions.
An assessment format may already be in place to be used at specific facilities and in specific circumstances.
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.
Listen more than talk.
Observe non verbal communications
e.g.
"body
language, voice tone, and appearance".
Balance between allowing a client to talk in an unstructured manner and the need to structure
requested information.
Clarify the client's definitions
(terms & descriptors)
Avoid yes or no question (when
detailed information is desired).
Write adequate notes for recording
Record nursing health history soon
after interview.
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
COMPONENTS
OF HEALTH HISTORY
1-Biographical Data:
2- Chief Complaint: “Reason For Hospitalization”.
3- History of present illness
4- Past
Health History.
5- Family History
6-Environmental History
7- Current Health Information
8- Psychosocial History
9- Review of Systems (ROS)
10-
Nutrition History
11-
Assessment
of Interpersonal Factors.
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.
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.
Physical examination needed for
camp.
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.
COMPONENT 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".
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
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.
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.
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, uncles…etc.".
Cause of death of the family members
"immediate and extended family".
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."
7- CURRENT HEALTH INFORMATION
The purpose
is to record major, current, health related information.
Allergies: environmental, ingestion, drug, other. 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)
8- PSYCHOSOCIAL HISTORY:
Includes :
How client and his family cope with
disease or stress, and how they responses to illness and health.
You can assess if there is
psychological or social problem and if it affects general health of the client.
9- REVIEW OF SYSTEMS (ROS)
§Collection of data about the past and the present of each of
the client systems.
§(Review of the client’s physical, sociologic, and psychological health status may identify hidden problems and provides an opportunity to indicate client strength and liabilities.
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 nervous system.
Assessment of integumentary system.
Assessment of circulatory system.
10- NUTRITIONAL HEALTH HISTORY
ØBefore attempting to improve patients' dietary
habits or offer them nutritional guidance,
it is necessary to assess their usual daily food intake.
ØFor example, when asking about medications, physicians could also ask patients if they are taking any vitamins, minerals, laxatives or other supplements.
10- 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.
BASIC ASSESSMENT ON A PATIENT
§Vital signs ØTemperature ØPulse ØRespiration ØBlood pressure ØRBS ØSPO2 ØECG
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