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L1 Intro Assessment.rtf

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Dalhousie University
NURS 2200
Cynthia Barkhouse Mckeen

HealthAssessment “The most important practical lesson that can be given to nurses is to teach them what to observe..." Florence Nightingale, 1859 How Do We Define Health? Health is a resource for living and is the ability to realize goals or aspirations, meet personal needs and change or cope with everyday life. (WHO, 1986) Prerequisites for health (determinants of health) – peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice, and equity. (Ottawa Charter for health promotion, 1986) Health: Aculturally defined, valued, and practiced state of well-being reflective of the ability to perform role activities (Leininger, 1991) The actualization of inherent and acquired human potential through goal-directed behaviour, competent self-care, and satisfying relationships with others, while adjustments are made to maintain structural integrity and harmony with relevant environments. (Pender, Mudaugh & Parsons, 2002) HealthAssessment  Acontinuous & systematic process of data collection  Establishes a baseline for nursing care, determines ongoing health status & risks and identifies health promoting activities Factors that Influence Health 1. Developmental Factors (Age, Intellect, Developmental tasks) 2. Psychological and Emotional Factors (Anxiety, Self-esteem, Depression, Grieving) 3. Family Factors (Illness history, Risk for Inheriting disease) Cultural Factors (Language, Expression, Emotional and physical well-being, Health practices ) Types ofAssessments: 1. Comprehensive: initial detailed history & physical examination 2. Focused: problem-oriented, initial or on-going Use of Vital Signs:  Obtain baseline data  Detect or monitor a change  Monitor clients at risk- Chapter 9 in textbook for review of VS  Practice and testing in lab to prepare you for clinical practice Moving & Transferring Clients “Care of the client with a movement or mobility disability is extremely complex” Hoeman, S. (1998). Rehabilitation Nursing. Mosby. p.226 Evidence for MobilityAssessment & Intervention  Improved mobility  Avoidance of shoulder pain  Achievement of self-care  Relief of sensory and perceptual deprivation  Prevention of aspiration  Enhance possibility for bladder & bowel control  Improved thought processes  Maintenance of skin integrity  Improved sexual function  Avoiding complications  Contractures, pain in shoulder/arm, pneumonia Nursing Interventions:  Focus on prevention and safety: falls prevention, medication reconciliation  Splints/positioning/range of motion may be needed to maintain neutral position, prevent contractures ─ Adductor muscles stronger than abductors ─ Flexor muscles stronger than extensors  Assistive devices may be needed for ambulation (e. g. cane, walker, wheelchair)  Inter-professional team collaboration Falls Prevention: Fall Categories: 1. Accidental Falls  14% of falls  Caused by environmental hazards  Prevention interventions designed to ensure environment is free from hazards 2. Unanticipated Falls  8% of all falls  E.g. of causes of these falls: fainting, seizures, pathological factors such as pain or fracture  Likelihood of this occurring again  Interventions aimed at reducing the risk of the fall if event reoccurs (i.e. teach how to rise from lying to sitting to standing if orthostatic hypotension cause of fall) 3. Anticipated Physiological Fall  78% of all falls  6 factors contribute to these falls 1. Comorbidities/Polypharmacy 2. Previous fall (in past 12 months) 3. Weak or impaired gait 4. Lack of realistic assessment of own abilities 5. IV or saline lock 6. Use of ambulatory aids Morse Fall Risk Assessment  Completed on all patients admitted to CDHAfacilities  Collaborative, interdisciplinary approach is used  Regular reassessment of patient’s fall risk, and with changes in patient condition AGS (American Geriatrics Society)/BGS British Geriatrics Society) Clinical Practice Guideline: Prevention of Falls in Older Persons s_recommendations/prevention_of_falls_summary_of_recommendations Falls Prevention  Evidence indicates that an interdisciplinary approach to assessment of risk for falls is best practice  Nsg diagnosis: high risk for injury related to history of falls, use of psychotropic meds, unsteady gait, lower extremity weakness, cognitive impairm
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