learning Objectives - Demonstrate skill in conducting health assessment and physical examination
Hours - 4
Teaching and Learning Activities - Lecture cum discussion Demonstration Simulation
Assessment Methods - Short answer Objective type Return demonstration
Content of the chapter
a) Health Assessment
- Health history
- Physical examination
- Nutritional assessment
- General clinical investigations
Health Assessment
Health assessment is a systematic method of collecting and analyzing data about an individual’s health status. It forms the foundation for nursing diagnosis, planning, and delivery of effective nursing care.
1. Health History
Health history involves the collection of subjective information provided by the patient or family. It helps in identifying present and past health problems.
Components of Health History:
- Personal data (name, age, sex, occupation)
- Chief complaints
- History of present illness
- Past medical and surgical history
- Family history
- Personal habits (diet, sleep, exercise, smoking, alcohol)
- Socioeconomic and environmental history
2. Physical Examination
Physical examination is a systematic assessment of the body to identify signs of disease or abnormality.
Methods of Physical Examination:
- Inspection
- Palpation
- Percussion
- Auscultation
Types of Physical Examination:
- General survey
- System-wise examination (respiratory, cardiovascular, abdominal, neurological, etc.)
3. Nutritional Assessment
Nutritional assessment is the evaluation of a patient’s dietary intake and nutritional status to identify deficiencies or excesses.
Components:
- Dietary history
- Anthropometric measurements (height, weight, BMI)
- Clinical signs of malnutrition
- Laboratory investigations (hemoglobin, serum albumin)
4. General Clinical Investigations
Clinical investigations assist in confirming diagnosis and monitoring patient progress.
Common Investigations:
- Blood tests (Hb, TLC, DLC, blood sugar)
- Urine examination
- Stool examination
- X-ray, ECG (basic level)
- Other routine diagnostic tests