HEALTH ASSESSMENT OF PATIENTS�

A presentation by Mr. Prince Attah Obeng

HEALTH ASSESSMENT OF PATIENTS

• Assessment is an interactive process of gathering information by a professional nurse to identify strength of the patient, his potential and actual health problems, as well as to evaluate the effectiveness of the care rendered.
• It is the first step in the nursing process

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HEALTH ASSESSMENT OF PATIENTS CONT’D

• It is considered critical because it is the only step that helps in obtaining subjective data (data provided by the patient) and objective data (data obtained through physical examination) that will lead to effective planning of care for the patient.

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Components of Health Assessment�

• It is made up of:
• Health history
• Physical assessment/ physical examination

Health history�

• It is subjective data gathered about the client’s present and past health status
• It includes the following:

1. biographic data (identifying data)

2. chief complaint

3. history of present illness

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Health history cont’d

4. past health history

5. family history

6. social history

7. psychological history

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1.Biographic data (identifying data) �

• Biographic data consists of identifying data such as:
• Name
• Sex
• Age/ date of birth
• Next of kin
• Marital status
• Occupation
• Address
• Religion

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�2. Chief Complaint (CC)�

• It is the term used to describe what has motivated the client to seek health care.
• It should be recorded in the patient’s own words whenever possible.
• Quotation marks can be used to indicate that client’s own words have been used.

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Chief Complaint (CC) cont’d�

• When a health problem is involved, the chief CC should state the problem and its duration. E.g. ‘‘diarrhoea and vomiting for 48 hours’’.

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3. History of Present illness (HPI)�

• The history of present illness provides detailed data about CC.
• The nurse should be quite directive in this phase.
• The nurse then gathers very specific information about the client’s symptoms.

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History of Present illness (HPI) cont’d�

• This is done in a systematic fashion and is referred to as investigation of symptom.
• Information obtained helps to determine the cause of the problem.
• The nurse finds out if client has received any treatment in connection with the CC.
• If yes, history on drugs taken is obtained.

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History of Present illness (HPI) cont’d

•  Example
• Madam Batse went to the hospital with CC of “diarrhoea and vomiting”
• A nurse took the history of present illness of Madam Batse as:
• How many times have you vomited today?
• What was the colour of the vomitus?
• How many times of diarrhoea stools have you passed today?

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History of Present illness (HPI) cont’d

• Was the stool bloody?
• Was it mucoid?
• Was it so offensive?
• Do you feel abdominal pain?
• Where do you feel the pain?
• Have you taken any drug?
• If yes, what drug did you take?
• Did the condition improve after taken the drug?

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4. Past Medical History�

• It provides information on client’s state of health and illness before the current illness.
• The client is specifically questioned about major childhood and adult illnesses, immunizations, injuries, hospitalizations, therapeutic regimens, allergies and the use of supportive devices like eyeglasses’ hearing aid, walker, etc.

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Past Medical History Cont’d�

• If the client has history of any illness, it must be found out how it was treated.

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5. Family history�

• It provides information about illnesses which have a genetic or familial tendency
• A genetic chart of three generations should be developed to ascertain health information on the family in terms of chronic illnesses like Diabetes, Hypertension, Asthma, Sickle cell disease and epilepsy.

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 Example of Genetic Chart�

Ellen 70 A&W

Ken 75 heart disease

John 45 Asthma

C YNTHIA 50 ASTHMA

Rich 55 A&W

Lucy 36 ASTHMA

Steve 24 A&W

Sylvia 27 A&W

Joe 32 A&W

6. Social History�

• This presents a profile of the client in his social and personal world.
• The information provided here are so personal and private to the client.
• The nurse must therefore assure the client the maximum confidentiality to every private matter.
• Information obtained under social history include:

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Social History cont’d�

1. Family relationships

i.e. number of persons in household, positive and negative relationships, expectations for children and support system in times of stress.

2. Educational background i.e. level of education attained 3. Ethnic affiliation i.e. beliefs, customs, cultural practices that may affect health

Social History cont’d

• 4. Sexuality i.e. number of sexual partners, information on any sexual dysfunction
• 5. Occupation i.e. type, duration of work, satisfaction, stressors, health hazard

Social History cont’d

6. Economic status Ability to pay medical bills, any financial constraints, any debt, any remittance from elsewhere?

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7. Psychological assessment�

• This is concerned about the mental status of the client.
• Information is obtained about how he copes with stressors.
• The perception about the illness.
• Gestures of the client is assessed to find out whether agitated or not.
• An assessment is also made on how the client is able to communicate effectively

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Preamble

• Akua Sekyewaa, an 18-year old girl comes to the Emergency ward with a history of productive cough for 3 days and a recent onset of dyspnoea.
• What is her chief complaints?
• What histories would you take from the patient and why?
• What physical examination would you conduct?

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THANK YOU FOR YOUR ATTENTION