Chapter-3

Health Assessment

INTRODUCTION

• Health is a state of physical, mental, social and spiritual wellbeing not merely an absence of any disease.

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• Health assessment refers to the measurement of the health status of an individual, a family, group of people and community.

PURPOSES OF HEALTH ASSESSMENT

• Provides opportunity to develop good relationship with the individual and community.
• It enables the assessor to determine the holistic needs of the individual.
• Evaluates the progress of the treatment given.
• Helps in collecting the data for research.

COMPONENTS OF HEALTH ASSESSMENT

DOMAINS OF ASSESSMENT

• Physiological
• Psychological
• Social
• Cultural
• Spiritual
• Developmental

CHARACTERISTICS OF A HEALTHY INDIVIDUAL

• Physical characteristics

• Social characteristics

• Spiritual and cultural characteristics

• Mental characteristics

Physical Characteristics

• General physical appearance
• Mental status
• Head and neck
• Chest
• Breast
• Abdomen
• Upper extremities
• Lower extremities
• System review

HEALTH ASSESSMENT ACCORDING TO VARIOUS AGE GROUPS

• Health Assessment of an Infant

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• Personal data
• Reason for seeking health care
• Past medical history
• Natal history
• Child's nutrition
• Immunization record
• Assessment of development
• Family history
• Safety history
• Chief complaints

Infant Assessment Format

• Demographic data
• Obstetric history
• Physical examination

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Health Assessment of Preschool Child

• Personal history
• Family history of child
• Past medical history of child
• Immunization record
• Growth and development

Health Assessment of School Going Child

• Nutritional assessment
• Daily Examination
• Personal and Family History
• Past Medical History
• Nutrition Evaluation
• Family Health History
• Child History
• Physical Examination
• Screening

Health Assessment of Adolescents

• T he children between age group of 13-18 years are adolescent children.

• Personal Biodata
• Sexual Development
• Social History
• Present Illness
• Physical Examination

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1. General appearance
2. Nutritional problems
3. Sexuality related problems

Health Assessment of an Adult

• Complete physical examination
• General overview
• Skin
• Head
• Eyes
• Ears
• Thyroid gland
• Musculoskeletal system
• Neurological system
• Genitourinary system

Present and past health history

• Psychosocial development: It includes individual feels more guilt about not having the abilities to do what they once did, feels less competent compared with others, loose a sense of identity, mistrustful.

• Cognitive development: It includes mood swings, socially in appropriate behavior, check for any difficulty in storing or retrieving the information, problem in verbal fluency.

• Moral and spiritual development: It includes respect, responsibility, reverence for self and others, an interest in learning about cultures and beliefs., a sense of social justice and fairness.

• Lifestyle assessment: It includes sleeping pattern, sedentary activities, i.e., sitting, lying, type of living standard, dietary pattern.

Breast Examination

• The goal of the breast examination is to determine if the breasts are normal or abnormal.

• Time

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• Technique

• Inspection • Palpation

• Breast size and symmetry
• Color of the skin and areola
• Nipple size and shape
• Color of areola

• Breast Palpation

Steps of Breast Self Examination

Health Assessment of Elderly

• The individual in the age group of 60 years and above is referred as an old person.
• The health assessment of elderly includes:

• Personal biodata:
• Name
• Age
• Education
• Occupation
• Marital status
• Cultural background

Present Illness and Chief Complaints

• Substance abuse:-Use of alcohol or taking any drugs, any side effects of taking drugs.
• Physical examination:-
• General appearance
• Musculoskeletal system
• Neurological system
• Genitourinary system
• Assessment of disabilities
• Past medical history
• Nutritional status
• Social aspects

Review of All Systems

• Activities of daily living:-It include all those tasks which are performed by an individual to maintain personal hygiene, autonomy, and mobility inside and outside the house.
• Cognitive abilities: It include ability to remember, understand and explain, follow commands make judgement etc.

Health Assessment of an Antenatal Woman

:-Health assessment of an antenatal woman can be carried out by doctor or jointly by doctor and midwife.

Components of Antenatal Health Assessment

• History Collection

• Personal history
• Obstetric history

• Family history
• Medical surgical history
• Nutrition
• Partner’s health history

General Physical Examination

• Abdomen examination

• Inspection
• Palpation
• Auscultation

Lab Investigations

:-It includes hemoglobin, blood group, VDRL, CBC, HIV, RBC, RBS, OGTT, etc.

Detection of High Risk Pregnancy

• Bad obstetric history

• Pre-eclampsia and eclampsia

• Antepartum hemorrhage

• Anemia

• Elderly primi more than 30 yrs of age or very young less than 15 years of age.

• Hydramnios

Postnatal Health Assessment

• Mothers’ health is assessed generally till one year of delivery.

Aims

• To protect the mother and child from complications during the postnatal period.

• To provide care to the mother and the child so that mother can return back to optimum health as early as possible.

• Provide health education to the mother regarding care of child, breast care, personal hygiene.

• To provide family planning services.

Components of Postnatal Assessment

• History collection
• Physical examination

• General observation
• Assessment of vital signs
• Abdominal examination
• Breast examination
• Uterus examination
• Bladder examination
• Pelvic examination

Lab investigations:

• Blood investigation
• Urine investigation
• Sonography if required

• Psychological response of mother

Methods of Assessment

The primary method used to assess client's are as follow:

• Observing

• Interviewing

• Examining

• Observation
• Interviewing
• Examining