HEALTH ASSSESSME NT

FUNCTIONALL ASSESSMENT TESTS

It is a formalized, comprehensive review of the older person's daily activities, cognition, continence, special senses, mobility, and specific psychosocial issues. When caring for older adults, health workers need to be aware of the common age and disease related disorders that can negatively affect "functional ability" (e.g., sensory, motor, and cognitive skills).

FUNCTIONALL ASSESSMENT TESTS

Common Tests A. ADULT I. PHYSICAL ACTIVITIES OF DAILY LIVING (PADL) II. INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) III. KATZ INDEX OF INDEPENDENCE IV. BARTHEL INDEX B. NEWBORNS I. APGAR C. INFANTS AND CHILDREN I. MMDS

PHYSCICAL ACTIVITIES OF DAILY LIVING (PADL) term used in healthcare to refer to daily self-care activities within an individual's place of residence, in outdoor 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.

PHYSCICAL ACTIVITIES OF DAILY LIVING (PADL)

PHYSCICAL ACTIVITIES OF DAILY LIVING (PADL)

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (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

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)

KATZ INDEX OF INDEPENDENCE

commonly referred to as the Katz ADL, is the most appropriate instrument to assess functional status as a measurement of the clients ability to perform activities of daily living independently.

KATZ INDEX OF INDEPENDENCE

Activities Points (1 or 0) (1 Point) NO supervision, direction or personal assistance (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 (1 POINT) Get clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes. (1 POINT) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help. (1 POINT) Moves in and out of bed or chair unassisted. Mechanical transfer aids are acceptable (1 POINT) Exercises complete self control over urination and defecation. Dependence (0 Points) WITH supervision, direction, personal assistance or total care (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 (0 POINTS) Needs help with dressing self or needs to be completely dressed.

BATHING Points: __________

DRESSING Points: __________

TOILETING Points: __________ TRANSFERRING Points: __________ CONTINENCE Points: __________ FEEDING Points: __________

(0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or commode. (0 POINTS)Needs help in moving from bed to chair or requires a complete transfer. (0 POINTS) Is partially or totally incontinent of bowel or bladder

(1 POINT) Gets food from plate into (0 POINTS) Needs partial or total help with mouth without help. Preparation of food feeding or requires parenteral feeding. may be done by another person.

Total Points: ________ Score of 6 = High, Patient is independent. Score of 0 = Low, patient is very dependent

BARTHEL INDEX
Consists of 10 items that measure a person's daily functioning specifically 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.

BARTHEL INDEX

BARTHEL INDEX

BARTHEL INDEX

APGAR
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.)

APGAR
APGAR Skin color or Complexion Pulse rate Reflex irritability Muscle tone Breathing Score of 0 blue or pale all over Absent Score of 1 blue at extremities body pink Score of 2 no cyanosis body and extremities pink Component of backronym

Appearance Pulse

<100 100 grimace/feeble cry or pull away no response to cry when when stimulation stimulated stimulated flexed arms and legs that resist none some flexion extension absent weak, irregular, gasping strong, lusty cry

Grimace

Activity Respiration

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 Filipino children MMDST determines what babies and children can do at certain ages

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

PHYSICAL EXAMINATION

PHYSICAL EXAMINATION

NURSING PROCESS: A ssessment D iagnosis P lanning I mplementation E valuation

PHYSICAL EXAMINATION

Assessment Is the systematic gathering of relevant and important patient information for use in identifying health problems and planning and evaluating nursing care. Purpose of ASSESSMENT: to establish a database

PHYSICAL EXAMINATION

Assessment Through the process of data collection, meaningful information, including health status, actual and potential health problems, and areas of focus for priority health promotion, is identified.

PHYSICAL EXAMINATION
Assessment TYPES 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 data collector. The measurement of objective data is based on accepted standards, like Celsius or Fahrenheit measure of a temperature.

PHYSICAL EXAMINATION
Techniques of Physical Examination IPPA INSPECTION PALPATION PERCUSSION AUSCULTATION

PHYSICAL EXAMINATION

INSPECTION Observation (see, smell); actually starts during the health 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 each area proceeding from the outside to the inside

PHYSICAL EXAMINATION

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.

PHYSICAL EXAMINATION
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 (emphysematous lungs), resonant (healthy lung), dull (liver), flat (muscle)

PHYSICAL EXAMINATION

AUSCULTATION Listening direct (naked ear) and indirect (acoustical stethoscope or Doppler amplification). Analyzes intensity, pitch,duration, quality, and location. The bell analyzes low-pitched sounds and the diaphragm analyzes high-pitched sounds

PHYSICAL EXAMINATION
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.

PHYSICAL EXAMINATION

The nurse must also consider her own understanding of anatomy and physiology, basic nursing 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 physical assessment process.

PHYSICAL EXAMINATION
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

PHYSICAL EXAMINATION
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

PHYSICAL EXAMINATION
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

PHYSICAL EXAMINATION