Health Assessment 

 is that the gather information about as patient's physiological, psychological, sociological, and spiritual status inorderto identify actual and potential health problems

The purposes of the health assessment

 Obtain baseline data and expand the info base from which

subsequent phases of the nursing process can evolve

 to spot and managea sort of patient problems (actual and

potential)

 Evaluate the effectiveness of medical care 

 Enhance the nurse-patient relationship

 Make clinical judgments

Therapeutic relationship 

Therapeutic communication defined as apurposeful sort of conversation, serving as some extent of human

contact between nurse and client allowing them to succeed in common health-related goal

Phases of communication

 Introductory

 Working

 Termination–closing

Preparation for Health assessment includes the 

A-Preparation for the nurse

Wearproper comfortable uniform

 Should be knowledgably: know disease process, physiological mental and psychological changes which can effects client's condition and has scientific background to gather complete

accurate data

 Skillful: skills to perform physical examination and use

tools

 Receiving requesttoper form physical examination

 Working associated with professional nursing issues as (confidentiality, respect and following infection control measures–handwashing)

B-Preparation of physical environment

a- Clean wells furnished place

b- Quiet

c- Proper temperature

d- Proper ventilation

e- Proper humidity

f- Proper light–natural and artificial light may used

C-Preparation of Client

 The nurse identify herself\his tot he client

Explain thepurpose for examination and therefore the procedures which can 

perform

 Explain the necessity for changing position during examination asking the client ifhe\she has the power to try to to so

Maintain the client privacy

 Provide the client with clean gown

D-Preparation of the equipments

 Besure that’s the equipments is in fitness working well

 Clean well arrange daccording to use

 All infection control measures should bevtaken into account 

—Gathering Data

—Subjective data-Said by the client(S) by using interview to gather the subsequent data

—Biographical

—Past history

—Present history

—Family history

—Information associated with lifestyle& activities of daily living

Objective data -Observed by the nurse(O)

—Physical Examination: collection of objective data by using

many techniques such as: The order of techniques is as

follows (Inspection-Palpation-Percussion-

Auscultation)

—A. Inspection : critical observation* always first *

. Take time to“observe”with eyes, nose

. Use good lighting

. Look at color , shape , symmetry, position

. Observe for odors from skin, breath, wound

—B. Palpation : light and deep touch

. Back of hand(dorsal aspect) to assess skin

temperature

. Fingers (light) within1-2cm to assess texture,moisture, areas often derness, pain and assess size,shape, and consist encyoflesions

. Deep palpation= 4-5cm to assess mass and organs

. Bimanual using two hand 5-8 cm to assess organs

—C. Percussion : sound sproduced by striking or tapping body surface

. Produces different sounds counting on underlying structures (dull, resonant, flat, and tympanic)

. wont to determine under lying structures

. Action is perform edin the wrist.

—D. Auscultation : taking note of sound sproduced by the

body

. Flat diaphragm picksup high-pitched respiratory

sounds best

. Bell picks uplow pitched sounds like heart murmurs

.