Health Assessment : is the gather information about as patient's physiological, psychological, sociological, and spiritual status inorderto identify actual and potential health problems
The purposes of the health assessment
1- Obtain baseline data and expand the data base from which
subsequent phases of the nursing process can evolve
2- to identify and managea variety of patient problems (actual and
potential)
3- Evaluate the effectiveness of nursing care
4- Enhance the nurse-patient relationship
5- Make clinical judgments
Therapeutic relationship :
Therapeutic communication defined as apurposeful form of conversation, serving as a point of human
contact between nurse and client allowing them to reach common health-related goal
Phases of communication:
1- Introductory
2- Working
3- Termination–closing
Preparation for Health assessment includes the :
A-Preparation for the nurse:
1- Wearproper comfortable uniform
2- Should be knowledgably: know disease process, physiological mental and psychological changes which may effects client's condition and has scientific background to collect complete
accurate data
3- Skillful: know how to perform physical examination and use
tools
4- Receiving requesttoper form physical examination
5- Working related to professional nursing issues as (confidentiality, respect and following infection control measures–handwashing)
B-Preparation of physical environment:
a- Clean wells furnished place
b- Quiet
c- Proper temperature
d- Proper ventilation
e- Proper humidity
f- Proper light–natural and artificial light may used
C-Preparation of Client:
1- The nurse identify herself\his tot he client
2- Explain thepurpose for examination and the procedures which may
perform
3- Explain the need for changing position during examination asking the client ifhe\she has the ability to do so
4- Maintain the client privacy
5- Provide the client with clean gown
D-Preparation of the equipments:
1- Besure that’s the equipments is in good condition working well
2- Clean well arrange daccording to use
3- All infection control measures should bevtaken under consideration
—Gathering Data
—Subjective data-Said by the client(S) by using interview to collect the following data:
—Biographical
—Past history
—Present history
—Family history
—Information related to lifestyle& activities of daily living
Objective data -Observed by the nurse(O)
—Physical Examination: collection of objective data by using
many techniques such as: The order of techniquesis as
follows (Inspection-Palpation-Percussion-
Auscultation)
—A. Inspection : critical observation* always first *
—1. Taketime to“observe”witheyes, nose
—2. Use good lighting
—3. Lookat color , shape , symmetry, position
—4. Observe for odors from skin, breath, wound
—B. Palpation : light and deep touch
—1. Back of hand(dorsal aspect) to assess skin
temperature
—2. Fingers (light) within1-2cm to assess texture,moisture, areas often derness, pain and assess size,shape, and consist encyoflesions
—4. Deep palpation= 4-5cm to assess mass and organs
—5. Bimanual using two hand 5-8 cm to assess organs
—C. Percussion : sound sproduced by striking or tapping body surface
—1. Produces different sounds depending on underlying structures (dull, resonant, flat, and tympanic)
—2. Used to determine under lying structures
—3. Action is perform edin the wrist.
—D. Auscultation : listening to sound sproduced by the
body
—1. Flat diaphragm picksup high-pitched respiratory
sounds best.
—2. Bell picks uplow pitched sounds such as heart murmurs.
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