Health History Taking, General Survey, and Mental Health Status Assessment Flashcards
Biomedical approach to health
- Dominated most of the 20th century
- Emphasized health as the absence of disease
- No health promotion/health prevention strategy
Behavioural approach to health
- Emerged in the 1970s
- Lalonde Report (1974)
- First modern government in the Western world that acknowledged the missing parts in the biomedical approach
- Wanted to decrease behavioural factors that compromised health
- Social campaigning about health and lifestyle
Socio-environmental approach to health
- Mid 1980s
- Realization that these “healthy lifestyle changes” were only being made by those in upper brackets
- Concept that there are socioeconomic factors that influence health and decisions regarding health
Ottawa Charter
- Recognized health as a fundamental human right
- Identified 9 pre-requisites for health
- peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice, equity
WHO definition of health
- Health seen as a resource for everyday life
- Not he objective of living
- Positive concept emphasizing social and personal resources as well as physical capabilities
- Not just the absence of disease
What is health assessment
“Assessment is the collection of data about an individual’s health status”
- Involves both subjective (symptoms) and objective data (signs)
Types of assessment
1) Complete health assessment
- Complete head to toes exam
- Also includes full health history; physical exam; family history
2) Episodic or Problem based assessment (Focused assessment)
- For a limited or short term problem, usually directed at one issue at a time
3) Follow up assessment
- Already an identified issue and following or re-evaluating how the patient is doing
4) Emergency assessment
- Very rapid collection of assessment data usually done to ensure live saving measures
Why is health assessment important
- Collecting all the pieces to make the big picture
- The hallmark of what nurses do
- It’s from gathering the data that we can make our judgements
- Other healthcare professionals will be making judgements based off our data
- Always assessing, always investigating
Nursing Process
Assess
- Gather information about the client’s condition
Diagnose
- Identify the client’s problem
Plan
- Set goals of care and desired outcomes and identify appropriate nursing actions
Implement
- Perform the nursing actions identified in planning
Evaluate
- Determine if goals met and outcomes achieved
The complete health history: Subjective assessment
- Biographical data
- Source of history
- Reason for seeking health care
- History of current illness (PRQRTU-AAA)
- Past health
- Family history
- Review of systems
- Functional assessment (ADLs)
PQRSTU-AAA
P - provokes Q - quality and/or quantity R - region and/or radiation S - severity T - timing U - understanding the patient's perspective A - associated factors A - alleviating factors A - aggravating factors
Past health
- Childhood illnesses
- Accidents/injuries
- Serous/chronic illness
- Hospitalizations
- Operations
- Obstetrical history
- Immunizations
- Last exam date
- Allergies
- Current medications
Review of systems
- General overall health
- Skin, hair
- Eyes, ears, nose, mouth and throat
- Neck
- Breasts
- Axilla
- Respiratory system
- Cardiovascular system
- Peripheral vascular system
- GI systen
- Urinary system
- Genital system
- Sexual health
- Musculoskeletal system
- Neurological system
- Hematological system
- Endocrine system
Functional Assessment (ADLs)
- Self esteem/self concept
- Financial resources
- Activity/mobility
- Sleep/rest
- Nutrition and elimination
- Relationships/support systems
- Spiritual resources
- Coping and stress management
- Alcohol, tobacco, substance use
- Environmental hazards
- Violence in the home
- Occupational health
- Perception of health
The physical assessment: objective data
- Vital signs
- Measurements
- IPPA
IPPA
I - inspection
P - palpation
P - percussion
A - auscultation
Insepection
- “Concentrated watching”
- Compare side to side
- Expected vs unexpected findings
Palpation
- Using your sense of touch to assess the client
- Texture, temperature, moisture, organ location and size, vibrations, pulsations
- Systematic, calm and gentle
- Palpate tender areas last
- Start with light palpation and move to deep palpation
- Fingers palpation to discriminate fine things, swelling or pulses
- Back of hand good for assessing temperature
- Ulnar surface of hand good for vibrations
Percussion
- A method of tapping on a surface to determine the density of the underlying structure
used to: - Map out the location/size of an organ - Provide information regarding the density of a structure ▪Detecting a mass ▪Elicit pain ▪Elicit deep tendon reflexes
Common Percussion Notes:
▪Resonant- hollow, air-filled
▪ Dullness- muffled thud (not air-filled, could be filled with something else like fluid, a mass, etc.)
Ascultation
▪ Listening to sounds produced by the body
▪ Important to have a good quality stethoscope
▪ Diaphragm – bigger, flatter side; used to hear high-pitched sounds
▪ Bell – smaller, concave piece; best for low-pitched sounds
Common issues when auscultating:
▪ Extra room noise
▪ Shivering – can sound like an unexpected sound
▪ Hair – makes sound similar to fluid in lungs
▪ Listening over clothes/gowns
▪ Tubing rubbing against objects (or itself)
▪ Poorly fitting earpieces
▪ Incorrect placement of earpiece
▪ Poor quality stethoscope
Social and cultural considerations in health assessment
Consider the following:
▪Social determinants of health
▪Dangers of “culturalism”
- Assuming a person has a certain set of beliefs because they belong to a certain cultural and look/claim to be a part of a certain culture
▪ We all have a cultural orientation
- Family background, socioeconomic status, spiritual orientation, etc. affects how we view the world
In your practice:
▪ Approach from a position of curiosity, reflexivity and empathy
▪With all clients it is important to:
▪ Build trust – genuine trust
▪ Listen – actively listen
▪ Convey respect – even when people are making choices and decisions that you wouldn’t make or contradicts their health
▪ Promote client comfort, dignity and safety
The general survey
▪ Is a survey of the overall impression or appearance of the client
▪ Should occur each time you meet the client
Consists of 4 areas: ▪ Physical Appearance ▪ Body Structure ▪ Mobility ▪ Behaviour
General survey: Physical appearance
▪ Level of consciousness (LOC)
▪ Skin condition
▪ Facial features
▪ Acute signs of distress
General survey: Body structure
▪ Symmetry
▪ Posture
▪ Position
