Focused Assessment – focus on particular needs. Time-lapsed Assessment several months after initial assessment - reassessment Emergency- rapid assessment to client who is experiencing a life threatening problems/crisis. Health Assessment Interview – time limited verbal interaction between between the nurse and the patient. * collect specific information regarding the patient and patient’s health status. 3 stages of interview Orientation Phase -nurse and patient establish trust and get to know one another -introducing, explanation of the purpose and establish goal - client begin to feel comfortable talking with the nurse - nonverbal behavior conducive to the nurse-client relationship *eye contact head nodding *sit facing pts. touch *smiling lean forward Working Phase -time for gathering information on client’s health status, health history and biographical - reasoning for seeking health care Closed-ended question –question that can be answer briefly or with one word response. *frequently answerable with yes or no ex: have you been hospitalized before? Open-ended question- encourage client to elaborate about a particular concern/problem. ex: how do you typically deal with your asthma attack? Focused Question- asked to obtained information that is more specific about a problem or condition. - usually begin with words such as describe, explain , tell Termination Stage last stage of interview process which information is summarize and validated as well as planning for future interview. HEALTH HISTORY- provides the subjective database for your assessment allowing you to see your patient through his eyes. PURPOSE: *provide subjective data base *identify patient strength *identify patient health problems both actual and potential *identify support *identify teaching needs, discharge needs and referral needs. HEALTH HISTORY CONSIST: *Biographical Data patient’s name occupation age contact person gender health insurance birthday race birth place religion marital status address education SSS number *Chief Complaints/ reason for seeking health care *Present Health History major health concern *Past Health History to identify any health factors from the past that may have a direct relationship to your patient current health status assess childhood illness immunization hospitalization allergies surgeries medication serious injuries recent travel *Family History provides clues to genetically linked or familial disease that may be risks factor for your patients. *Psychosocial History gives a picture of your patient’s health promotion and preventive pattern. *Activities of Daily Living *Review of Systems- provides a comprehensive assessment to determine your patients psychological status *Psychological Profile *Psychological Profile health practice developmental task health belief sexuality pattern nutritional pattern emotional health activity pattern status recreational pattern self-concept rest/sleep pattern support personal habits role and relation- socioeconomic status ship occupational/environmental risk factors religious/cultural influence FUNCTIONAL ASSESSMENT measures a person’s self-care ability in the areas of general physical health or absence of illness. This includes the following: * activities of daily living – ADL - bathing, dressing, eating, walking *instrumental activities of daily living- IADL’s or those needed for independent living such as house- keeping, shopping, cooking, nutrition home environment, daily laundry, using the telephone, managing finances, social relationship. Self-concept and coping stress. *KATZ INDEX OF INDEPENDENCE IN ADL commonly referred as KATZ ADL has appropriate instrument to assess functional status as a measurement of patient’s ability to perform ADL indecently. 6 functions for older adult bathing transferring dressing continence toileting feeding Score- yes / no for independence 6 indicates full function 4 indicates moderate impairment 2 less indicates severe functional impairment KATZ Instrument Activities of Daily Living *heavy housework *shopping *managing finances *telephoning Barthel Activities of Daily Living Index consist of 10 items that measures a person's daily functioning specifically the ADL and mobility. *feeding * moving from wheelchair to bed and return *grooming *transferring to and from a toilet *bathing *walking on level surface * going up and down stairs *dressing *continence of bowel and bladders Highest the score the more “independent” the person independence means the person needs no assistance at any part of the task. Additional Information for Health History for Pediatric Patients *reason for seeking care *present health or history of present illness *past health *labor and delivery *post natal status *childhood illness *serious accidents or injuries *serious or chronic illness - age of onset, is it treated, any complication *operations or hospitalization *immunization *allergies *medication - family history *developmental history -growth -milestone -current development _nutritional history Additional information for health history in pregnancy *age *family history *women’s medical history *women’s past obstetrical history *woman’s present obstetrical history Gravida- woman who is or has been pregnant, regardless of pregnancy of the number of fetuses. Para- refers to the past pregnancies that have reached viability Nulligravida- woman who is not now and never has been pregnant . Primigarida- woman pregnant for the first time. Multigravide- woman who has been pregnant more than once. Nullipara- woman who has never completed a pregnancy to the period of viability (capability of living 24 weeks) Primipara- woman who has completed one pregnancy to the period of viability regardless of the number of infants delivered and regardless of the infant’s live or stillborn. Multipara- woman who has completed two or more pregnancies to the stage of viability *date of the last menstrual period (LMP) *estimated date of birth , expected date of confinement,/ delivery . *signs and symptoms *rest and sleep pattern *activity and employment *sexual activity *diet history *psychosocial status Steps of Health Assessment A-Collection of subjective data through interview and health history. *biographical data *reasoning for seeking health care *chief complaint *history of: - present illness -past health history - family health history -current medication -life style -developmental level - psychosocial history B. Collection of Objective Data a. physical examination -preparation- *environment –adjust for the equipment placement. -rooms need to be quiet, warm clean, well ventilated, well lighted -all equipment's should be working/functioning *positioning it is important to consider client’s energy level and privacy. client’s who is weak may require assistance with positioning uncomfortable and embracing positions should not be maintained for longer periods examination should be organizes so that several body system can be assessed with the client in one position. different positions sitting position supine position dorsal recumbent position Sims position prone position lithotomy position knee-chest position Technique 4 specific diagnostic technique in physical assessment * inspection *percussion *palpation *auscultation