Faculty of Nursing-IUG Chapter (2) Health Assessment- Holistic Approach

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

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 3

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 4

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 5

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) 6

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, did…etc 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 7

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 8

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. 9

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. 10

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 G&D theories e.g. Erickson, Piaget, and Freud …. etc. 11

Stages of Age Infancy period: birth to 12 months Neonatal Stage: birth-28 days Infancy Stage: 1-12 months Early childhood Stage: It’s refers to two integrated stages of development Toddler: 1 - 3years. Preschool: years. Middle childhood 6-12 years Middle childhood 6-12 years Late childhood: Pre pubertal: 10 – 13 years. Adolescence: years Young adulthood years Young adulthood years Middle adulthood 40-65years Middle adulthood 40-65years Late adulthood 65 and more Late adulthood 65 and more 12

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 13

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 14

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)

BMI RANGE Condition Rang kg/m 2 Very thin less than 16.0 Thin Average Overweight25–29.9 Obese Highly obese≥ 35 16

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. 17

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 18

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? 19

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 20

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 21

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 22

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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 24

Diseases affected by nutritional problems 1- Obesity: excess of body fat. 2- Diabetes mellitus. 3- Hypertension. 4- Coronary heart disease. 5- Cancer. 25

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 26

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 27

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 28

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. 29

12. Hypersomnia: "sleeping for excessive periods” the sleep period may be extended to 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 30

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 31

32 5-Health History Systematic collection of subjective data which stated by the client, and objective data which observed by the nurse. U sed to determine a client functional health pattern status.

Phases of taking health history Two phases: The interview phase which elicits the information (primary sources) The recording phase (secondary sources). 33

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. 34

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". 35

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). 36

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. 37

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. 38

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 39

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. 40

SYMPTOM ANALYSIS P Q R S T a. Provocative or Palliative First occurrence : 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: Aggravation: what makes the symptom worse? 41

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? 42

SYMPTOM ANALYSIS P Q R S T c. Region Or Radiation Region : Region :  Where does the symptom occur? Radiation : Radiation :  Does it travel down your back or arm, up your neck or down your legs? 43

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? 44

SYMPTOM ANALYSIS P Q R S T e. Timing Onset : Onset :  On what date did the symptom first occur? Type of onset :  How did the symptom start; suddenly? gradually? Frequency : Frequency :  How often do you experience the symptom; hourly? daily? weekly? Monthly? Duration : Duration :  How long does an episode of the symptom last? 45

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. 46

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". 47

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. 48

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. 49

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. 50

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, uncles…etc.". Cause of death of the family members "immediate and extended family". 51

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." 52

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). 53

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. 54

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 disabilities). 55

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. 56

10- Nutritional Health History “Discussed Before” 57

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. 58