Health Asssessment

8/6/2019 Health Asssessment

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HEALTH

ASSSESSMENT


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FUNCTIONALLFUNCTIONALL

ASSESSMENT TESTSASSESSMENT TESTSIt is a formalized, comprehensive review of the

older person's daily activities, cognition,

continence, special senses, mobility, andspecific psychosocial issues.

When caring for older adults, health workers

need to be aware of the common age anddisease related disorders that can negatively

affect "functional ability" (e.g., sensory, motor,

and cognitive skills).


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FUNCTIONALLFUNCTIONALL

ASSESSMENT TESTSASSESSMENT TESTSCommon Tests

A. ADULT

I. PHYSICAL A

CTIVITIES OF DAILY LIVING(PADL)

II. INSTRUMENTAL ACTIVITIES OF DAILY

LIVING (IADL)

III. KATZ INDEX OF INDEPENDENCE

IV. BARTHEL INDEXB. NEWBORNS

I. APGAR

C. INFANTS AND CHILDREN

I. MMDS


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PHYSCICAL ACTIVITIES OF DAILYLIVINGPHYSCICAL ACTIVITIES OF DAILYLIVING(PADL)(PADL)

term used in healthcare to refer to daily self-care

activities within an individual's place of residence, inoutdoor environments, or both

"the things we normally do...such as feeding ourselves,

bathing, dressing, grooming, work, homemaking,

and leisure.

refers to six activities: (bathing, dressing, transferring,

using the toilet, eating, and walking) that reflect the

patient's capacity for self-care.


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INSTRUMENTAL ACTIVITIES OF DAILYLIVINGINSTRUMENTAL ACTIVITIES OF DAILYLIVING(IADL)(IADL)

refers to six daily tasks: (light housework,

preparing meals, taking medications,shopping for groceries or clothes, using the

telephone, and managing money) that

enables the patient to live independently in

the community


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KATZ INDEX OF INDEPENDENCEKATZ INDEX OF INDEPENDENCE

commonly referred to as the Katz ADL, is the most

appropriate instrument to assess functional status as ameasurement of the clients ability to perform activities of

daily living independently.


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KATZ INDEX OF INDEPENDENCEKATZ INDEX OF INDEPENDENCEActivities

Points (1 or 0) (1 Point)

NO supervision, direction or personal

assistance

Dependence

(0 Points)

WITH supervision, direction, personal

assistance or total care

BATHING

Points: __________

(1 POINT) Bathes self completely or

needs help in bathing only a single part

of the body such as the back, genital

area or disabled extremity

(0 POINTS) Need help with bathing more

than one part of the body, getting in or out

of the tub or shower. Requires total bathing

DRESSING

Points: __________

(1 POINT) Get clothes from closets and

drawers and puts on clothes and outer

garments complete with fasteners. Mayhave help tying shoes.

(0 POINTS) Needs help with dressing self

or needs to be completely dressed.

TOILETING

Points: __________

(1 POINT) Goes to toilet, gets on and

off, arranges clothes, cleans genital area

without help.

(0 POINTS) Needs help transferring to the

toilet, cleaning self or uses bedpan or

commode.

TRANSFERRING

Points: __________

(1 POINT) Moves in and out of bed or

chair unassisted. Mechanical transfer

aids are acceptable

(0 POINTS)Needs help in moving from bed

to chair or requires a complete transfer.

CONTINENCE

Points: __________

(1 POINT) Exercises complete self

control over urination and defecation.

(0 POINTS) Is partially or totally

incontinent of bowel or bladder

FEEDING

Points: __________

(1 POINT) Gets food from plate into

mouth without help. Preparation of food

may be done by another person.

(0 POINTS) Needs partial or total help with

feeding or requires parenteral feeding.

Total Points: ________

Score of 6 = High, Patient is independent.

Score of 0 = Low, patient is very dependent


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BARTHEL INDEXBARTHEL INDEX

Consists of 10 items that measure a person's daily functioningspecifically the activities of daily living and mobility.

The assessment can be used to determine a baseline level of

functioning and can be used to monitor improvement in

activities of daily living over time.

The higher the score the more "independent" the person.

Independence means that the person needs no assistance at

any part of the task.

If a persons does about 50% independently then the "middle"

score would apply.


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APGARAPGAR

The Apgar score is determined by evaluating the newborn

baby on five simple criteria on a scale from zero to two,

then summing up the five values thus obtained. The

resulting Apgar score ranges from zero to 10.

The five criteria are summarized using words chosen to

form a backronym

(Appearance, Pulse, Grimace, Activity, Respiration.)


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APGARAPGAR

APGAR Score of 0 Score of 1 Score of 2Component of

backronym

Skin color or

Complexion

blue or pale all

over

blue at

extremities

body pink

no cyanosis

body and

extremities pink Appearance

Pulse rateAbsent


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METRO MANILA DEVELOPMENTAL SCREENING TEST

(MMDST)

MMDST is a screening test, not and IQ test

MMDST sought to establish baseline information

on the developmental characteristics of Filipinochildren

MMDST determines what babies and children can

do at certain ages


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MMDSTMMDST

Sectors involved:

-first the personal social (the ability to socialize)

-fine-motor adaptive (the ability to use his hands

to pick up objects and draw)

-language (the ability to hear and to followdirections)

-gross motor (the ability to jump, walk and sit).


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EXAMINATION


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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Assessment

Is the systematic gathering of relevant

and important patient information for

use in identifying health problems andplanning and evaluating nursing care.

Purpose of ASSESSMENT:to establish a database


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Assessment

Through the process of data collection,meaningful information, including

health status, actual and potential

health problems, and areas of focus forpriority health promotion, is identified.


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AssessmentTYPES OF DATA:

SUBJECTIVE DATA ( Symptoms, covert data)

this are information from the clients point of view(e.g. pain, dizziness, nausea, sadness,

happiness)

OBJECTIVE DATA (Signs, overt data) this are

observations or measurements made by the datacollector. The measurement of objective data is

based on accepted standards, like Celsius or

Fahrenheit measure of a temperature.


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INSPECTION

Observation (see, smell); actually starts during thehealth history and continues throughout the exam;

always comes first (before you touch or listen), but

continues concurrently with PPA as well. Note

General observations and then specifics of eacharea proceeding from the outside to the inside


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PALPATION

Palpation: Touching; light (1 cm), then deep (4

cm), and rebound (deep with quick release).

Assesses position, texture, size, consistency, fluid,

crepitus, form, structure, vibration, or temperature.


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PERCUSSION

Tactile sensation and sound (to 5 cm deep); direct

or indirect with fingertip pad or fist; more solid:higher pitch, softer intensity, shorter duration;

more air: lower pitch, louder intensity, longer

duration; expected percussion notes: tympanic

(gastric bubble), hyperresonant (emphysematouslungs), resonant (healthy lung), dull (liver), flat

(muscle)


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AUSCULTATION

Listening direct (naked ear) and indirect

(acoustical stethoscope or Doppler amplification).

Analyzes intensity, pitch,duration, quality, and

location. The bell analyzes low-pitched soundsand the diaphragm analyzes high-pitched sounds


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The IPPA organization can be combined by

cephalo-caudal (head-to-toe), general-to-specific,

medial-to-lateral, and external-to-internal

approaches within each category.


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The nurse must also consider her own

understanding of anatomy and physiology, basicnursing skills, and the nursing process. The

educational preparation and clinical expertise of

the nurse may, therefore, influence the extent to

which the nurse participates in the physicalassessment process.


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EQUIPMENT NEEDED

Assessment forms or paper to record notations as well as

document findings Growth charts for height and weight

(and head circumference for infants): age, gender, culture,

and sometimes medical condition Well-lit, warm, private room or space

Gown for client privacy and comfort (swimsuits work well

with children and adolescents)

Drape sheet, or blanket for client privacy and comfort

Thermometer: otic or oral/axillary digital preferred

Stethoscope: acoustical with bell and diaphragm; ideal

tubing less than 35 cm in length


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EQUIPMENT NEEDED Watch with second hand

Sphygmomanometer and blood pressure cuffs twothirds

the size of the client extremity

Ophthalmoscope

Vision charts: Illiterate (matching letters or objects),Snellen (far vision), Rosenbaum (near vision) pocket card,

Ischara (color vision), or Titmus tester (includes all four),

and pupil gauge (in mm)

Otoscope with pneumatic tube

Audio testing equipment: watch, tuning forks (minimum of

one high pitched, 512 Hz, and one low pitched, 128 Hz),

handheld audiometer, tympanometer, or full audiometry

with soundproof room


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EQUIPMENT NEEDED Nasal speculum with illumination. Optional headlamp

with magnification

Penlight

Tongue depressors

Nonsterile gloves (possibly sterile gloves as well) Glass of water

Marking pen

Measuring tape (with cm and inches), preferably cloth or

plastic Water-soluble lubricant

Guaiac card for occult blood

Specimen cup

Reflex hammer


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Health Asssessment

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