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The first assessment begin in (1992) by American medical association
• In (1995) health assessment considered as basic human right
• Preventive health care divided in three categories, primary, secondary and tertiary prevention
• periodic health assessment needed to be performed by a physician, or nurses
Objectives and types of assessment
• surveillance of health status, identification of occult disease, screening, and follow-up care
• The periodic assessment, at regular intervals
• Increasing client participation in health care
• Accurately define the health and risk care needs for individuals
• Health assessment is shared with the client in a clearly and understandable manner
• The client must share in decision making for his own care.
Frequency of assessment
• The persons under (35) years every (4 – 5) years
• The persons from (35 – 45) every (2 – 3) years.
• Persons from (45-55) years of age undergo a thorough health assessment every year.
• Persons over (55) years may needs assessment every 6 months or less
Importance of nursing health assessment
1. systematic and continuous collection of client data
2. It focus on client responses
to health problems.3. The nurse carefully examine the client’s body parts to
determine any abnormalities
4. The nurse relies on data from different sources which can indicate significant clinical
problems. 5. Health assessment provides a
base line used to plan the
clients care 6. Health assessment helps the nurse to diagnose client’s problem & the intervention
8. Health assessment influence, the choice of therapies & client's responses
7. Complete health assessment involves a more detailed review of client’s condition.
Purposes of health assessment
1. Gather data
2. confirm, or refuse data obtained in the health history. 3. To confirm identify
nursing diagnoses
4. To make clinical judgments about client's changing health
5.To evaluate bio-psycho-social and spiritual outcomes of care.
Nursing and medical diagnosis
There is a big Difference
* Nursing diagnosis independent role of the nurse * Nursing diagnoses
depends on the client's problems associated with specific disorder
* Any problem must notice from a holistic view e.g. bio-psycho-social and spiritual
relations * Medical diagnoses depends on clinical picture and laboratory findings
*The specialist doctor has a right to diagnose not elseExample: DM is medical diagnoses (hypo or hyperglycemia)* Nursing diagnoses in this case e.g. Impaired skin integrity R/T poor circulation, Knowledge deficit R/T…
Health history
1.The interview 2.Psychosocial
assessment 3.Nutritional
assessment 4.Assessment of sleep-
wakefulness patterns5.The health history.
Interview
*Definition: communication process focuses on the client's development, psychological, physiological, socio cultural , and spiritual
•Major purpose: To obtain health history & to identify development of symptomsComponents of nursing
interview 1. Introductory phase2. working phase and 3. termination phase
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
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
Communications techniques during
interview 1.Types of questions :•Use 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 2. Types of statements to use:clarify information, and encourage verbalization
3. Accept the client use silence to recognize thoughts. 4. 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
5.specific age variations :-
- Pediatric clients: validate information from parents.
- Geriatric clients: use simple words, &assess hearing acuity
6. Emotional variations: *Be calm with angry
clients*simply with anxious *interest with depressed
client