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NRS 103: NURSING ASSESSMENT
ANDHEALTH HISTORY
1
Lecture 1 Chapters 1-3.Nancy Sanderson MSN, RN
• Every interaction is part of
the nursing process
• Nursing process = six steps
• First step: Assessment
• ANA definition (Standards
of Practice)
• Components of health
assessment
▫ Health history
▫ Physical examination
▫ Documentation of data 2
Why Learn Health Assessment?
AD PIE:
Full assessment Determine what is
the problem Determine what is
acceptable range, sounds, look, etc
Determine what is not within the acceptable range: crackles in lungs, abnormal heart sounds, distended abdomen, etc 3
Step # 1: Assess
NOT a medical diagnosis The nursing diagnosis helps the student
critical think, determine how to plan, and to make goals
NDX describes the client’s response to actual or potential problems or conditions; changes from day to day within the legal scope of independent nursing practice
4
Nursing Diagnosis (NANDA)
Nursing Diagnosis Made by the nurse Describes clients
response Responses vary
between individuals
Changes as client responses change
Nurse orders interventions
Medical Diagnosis Made by a
physician Refers to the
disease process Somewhat uniform
between clients Remains same
during disease process
Physician orders interventions
Nursing Dx VS Medical Dx
Assessment: Monitor HR/BP; Skin Color and perfusion; peripheral pulses; capillary refill
Nsg Dx: Risk for decreased cardiac output Plan/goal: Cardiac pump effectiveness: VS
and Fluid Balance Intervention: Assess respiratory rate,
rhythm & breath sounds; Urine output; Administer medications & IV fluids as ordered by MD
Evaluation: VS stable; UO > 30 ml/hr; meds/IV’s administered as ordered
6
The Nursing Process: MI
Assessment Nursing diagnosis Goal Implementation Evaluation
7
Health Assessment Class
8
Components of Health Assessment
Three primary components History (subjective data) Examination (objective data) Documentation of data
Data = signs and symptoms Symptom = what client
feels/communicates (subjective)
Sign = clinical finding (objective)
A systematic method of data collection assists the nurse in identifying the client’s health characteristics
Data collected focuses on client’s health compared with ideal—accounting for client’s traits
Collection and analysis of data leading to identification of problems:
Guides nurse in developing care planAssists client to maximize health potential Amount of information gained during
a health assessment depends on several factors including:
Context of careClient needExpertise of the nurse
Example
10
Subjective: “I’ve never had such bad pain in my life”
Objective: Pt is bend over holding abdomen Blood pressure is high Abdomen is rigid Bowel sounds are absent
Types of Health Assessment
Client needs vary widely. Nurse must be prepared to conduct
appropriate level of assessment. Client’s age, general level of health,
presenting problems, knowledge level, and support systems are among the variables that impact client need.
Expertise of the nurse is gained with specialization within a given area of practice; for example:• A nurse in an adult intensive care unit has
expertise assessing a client with hemodynamic instability.
• A family nurse practitioner working in a women’s clinic has expertise in performing routine pelvic examinations. 11
• Data organization involves organizing or clustering data that allows problems to be clearly apparent.
• Data analysis, interpretation, and clinical judgment includes: Identification of
abnormal findings Correctly interpreting
findings to select appropriate interventions
Clinical judgment to interpret or make conclusions regarding patient needs, concerns, or health problems
Health Promotion and Health Protection
• Nurses provide education and care to help meet health promotion needs.
• View health care as holistic: Mind Body Spirit
13
3 Levels of Health Promotion
Primary = preventing disease from developing; promoting healthy lifestyle
Secondary = screening to find early indicators of disease
Tertiary = minimizing disability from acute/chronic illness/injury and allowing for most productive life within limitations
Immunizations, nutrition teaching, exercise
Physical examinations, teaching patient how to do a breast exam
Management of Diabetes Mellitus, Cardiac Rehab
14
Techniques for Specific Populations
Cultural Diversity
•Many cultures are a continuum of diversity in behaviors and beliefs.
•Cultural dynamics mean change.▫Culture = shared beliefs, values, and
behaviors that define right, wrong, abnormal, inappropriate
•Diversity can create challenges.▫When cultures and languages differ▫When caring for individuals by not forcing
compliance, by working with beliefs and value systems 15
Ethnic and Cultural Considerations (Cont’d)
CLAS (Culturally, and Linguistically Appropriate Services) standards to ensure equitable and effective treatment. There are 14 standards.
They are organized around three themes. Culturally-competent care Language access services Organizational supports for cultural
competence
Refer to Boxes 5-1, 5-2, & 5-3 for tools, tips and barriers of assessing spiritual & cultural needs.
16
Nurses and other health care teams are affected by the first standard which states “ Healthcare organizations should ensure that patients /customers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with cultural health beliefs and preferred language.”
Improving cultural awareness and meeting Standard 1 requires the nurse to take several steps:
Ethnic and Cultural Considerations (Cont’d)
Ethnic and Cultural Considerations (Cont’d)
1. Become culturally competent through sensitivity to differences between their own culture and that of the patient.
2. Avoid stereo typing and assuming the meaning of others behavior.
3. Develop a template that may be used for cultural and spiritual assessment of patient and their families.
Becoming Culturally Competent
Cultural competence is the ability to communicate among/between cultures and to demonstrate skill in interacting with and understanding people of other cultures.
A culturally-competent nurse: Allows clients to explain meaning of illness Respects concepts of time, space, contact Respects physical/social activities Respects systems of social
organization/provides environmental control
19
Techniques for Specific Populations
Adolescent- Show respect, be totally honest, and
avoid using language that is absurd for your age or professional role.
Use ice breakers and keep questions short and simple.
Don’t assume they know anything about health interviews or physical exams.
Be aware of gestures and expressions. If confidential material is uncovered
consider what can remain confidential and what must share.
20
Techniques for Specific Populations
• Under influence of Drugs/Alcohol▫ Ask simple, direct questions. ▫ Make manner and questions nonthreatening,
and avoid confrontation.▫ Be aware of hospital security or other
personnel who could be called for assistance. • Angry/Violent▫ Deal with the angry feelings first▫ If sense suspicious or threatening behavior
act immediately to defuse situation.Leave the exam room door open and position self between person and door. Speak in quiet, calm voice.
21
Techniques for Specific Populations
Older Adult Always address by last name. Adjust pace of interview and
avoid hurrying them along. Hearing Impaired
Ask preferred way to communicate (i.e. signing, lip reading, or writing).
Acutely Ill In emergency must combine
interview and PE. Pick out points of history most important/relevant and use closed, direct question earlier.
22
Patient Interview
• Orientation / Introduction Phase• Working /Discussion Phase▫Gathering data through health history▫Introduction (Indicate your role in health care team)
▫Addressing the Environment▫Establishing a therapeutic relationship
• Termination / Summary Phase▫Concluding the interview 23
Introduction
Check ID band with 2 identifiersNameIdentification number assigned
by health care agencyTelephone numberDate of birth
State your purpose & obtain consent
24
Addressing the Environment
Make environment comfortable and relaxed Provide privacy, remove distractions Appropriate lighting Provide symptom management
25
• Privacy is essential for sensitive issues.▫Openness and honesty ▫Health care facilities not always conducive to
privacy; draw curtains when available▫HIPAA- Health Insurance Portability and
Accountability Act, 2003▫Physical comfort for client and nurse▫Distance allows conversation, eye contact,
and appropriate personal space
Establishing a Therapeutic Relationship
• Active Listening▫S- Sit facing patient▫O- Observe an
open posture▫L- Lean towards the
patient▫E- Establish and
maintain eye contact
▫R- Relax26
• Single most important factor for successful interviewing is establishing rapport to gain client’s trust.
Affected by numerous factors: physical setting, nurse behaviors, type of questions asked, how questions are asked, as well as:
The personality and behavior of clientsHow client is feeling at the time of interviewNature of information being discussed or problem being confronted
EMPATHY (Identifying with feelings) vs SYMPATHY- (feeling sorry for them) Boundaries!
Empowering vs dependency
Types of Data
• Subjective data What the patient tells you
Health History Symptoms
• Objective data What examiner detects during exam
Physical Examination Signs Labs Non-verbal behaviors
28
Subjective or Objective?
• Patient complains of abdominal pain
• Head pain is throbbing
• Facial features are symmetrical
• Heart rate is 80bpm
• Patient feels short of breath29
History of Present Illness
Essential and relevant data about the nature and onset of symptoms for the illness that patient is requesting care for.
Using mnemonic may help to ensure obtain complete history (OLDCARTS)
Onset, Location, Duration, Characteristics, Aggravating/Alleviating, Related, Treatment, Severity
O = Onset When began? Begin suddenly or gradually? What was doing/mechanism?
L = Location Where is pain/complaint located?
30
OLDCARTS D = Duration
Symptoms always present or do they come & go? If come & go, how long last?)
C = Characteristics Describe pain/complaint.
Ie Sharp, dull, throbbing, aching What is pain level at worst? What is it right now?
A = Aggravating & Alleviating Factors What makes it worse? What makes it better? Other symptoms that occurring at same time
that could be associated/Relevant portions of the Review of Systems
31
OLDCARTS R = Radiation
Does pain/complaint radiate? T = Treatments tried
What have tried to treat pain/discomfort? What was outcome?
S= Severity How severely does this interfere with your
life? Describe how many, the size, the amount
32
Termination/Summary Phase
Give patient a clue that interview coming to end
Summarize important points and ask if summary is accurate
Address any plans for action If you need anything else just press
the call light. Otherwise I will be back in 1 hour to check on you and give you more pain medication if you need it 33
34
The Art of Asking Questions
• Essential competency of nurses▫ Ask clear-spoken questions▫ Define words, avoid using
technical/medical definitions, and use slang only if necessary for certain conditions. Adapt questions consistent with client level
of understanding and knowledge.▫ Encourage clients to be specific and
clarify meanings.▫ Ask one question at a time and wait for
reply.▫ Be attentive to client feelings that may
indicate need for additional data.
Health History Questions
• Begin health history with open ended questions▫ Ask for narrative information• What brings you to the hospital today?• How can I/we help you today?• What concerns do you have today?
• Continue with closed or direct questioning▫ Ask for specific information that elicits a 1 or 2 word response• Are you having any pain?• How would you describe your pain?
35
36
Techniques That Enhance Data Collection
• Active listening concentrates on client responses and subtleties.▫ Avoid formulating next question
during responses.▫ Avoid making assumptions about
client responses.• Facilitation uses phrases to
encourage clients to continue talking further.▫ Verbal: “What do you mean?”, “Go
on,” “Uh-huh,” “Then…?”▫ Nonverbal: head nodding or shifting
forward to listen more intently
37
Techniques That Enhance Data Collection (Cont’d)
Interpretation is used to share conclusions drawn from data. Client may then confirm, deny, or
revise.
Summary condenses and orders data to clarify sequence of events for client’s clarity. Emphasizes data related to health
promotion, disease protection, and resolving health problems
38
Managing Awkward Moments
• Displays of emotion▫Crying is natural and should be
expected. It may indicate need for follow-up. A compassionate response enhances
relationship.▫Anger is uncomfortable for client and
nurse. Deal with it directly. Identify source of anger: you or another
person. Discuss approaches and acknowledge feelings. If client unable to continue, honor request to
work with another nurse.
39
Challenges to the Interview Managing overly talkative clients
Overly detailed problems may become distraction.
Re-focus interview on events relative to present.
Re-direct conversation with close-ended questions that may help reduce distractions.•Silence
Necessary for clients to reflect and gather courage to address painful topics or issues
Feedback that client is not ready to discuss topic or that the approach needs to be evaluated
Become comfortable with silence
40
Challenges to the Interview (Cont’d)
Others in the room Don’t assume relationships, best to
clarify. Parent or guardian may answer for
child. Interview adolescents directly. For adults unable to answer, another
person may assist. Client should be involved to the extent
of capabilities. When able to answer, direct questions
to client. If others in room, obtain client’s
permission.
41
The Health History
1. Types of health histories2. Components of the health
history3. Personal and psychosocial
history4. Review of systems5. Health history based on
functional health patterns
42
Types of Health Histories (Cont’d)
Comprehensive health history
History for problem-based or focused health assessment
Episodic or follow-up assessment Focuses on specific
problems for which client is already receiving treatment
Assesses for changes since last visit
Components of the Complete Health History
Biographical
Information
Reason for Seeking Care
Client expectations
History of Present
Illness/Present Health
Status 43
Past Health History
Family History
Environmental
History
Personal &
Psychosocial History
(Spiritual)
Review of Systems
Types of Health Histories
CompleteGeneralizedComprehensive
FocusedProblem oriented
On-going
44
45
Health History Based on Functional Health Patterns (Cont’d)
Health perception–health management
Nutrition-metabolism,nutrition-metabolic
Elimination Activity-exercise Cognitive-
perception Sleep-rest
Self-perception– self-concept
Role-relationship
Sexuality-reproduction
Coping-stress tolerance
Values-belief
Biographical Information
Factual demographic data about the patientNameAgeMarital StatusAddressOccupationPrimary Care ProviderPrimary Language Spoken
46
47
Reason for Seeking Care
Chief complaint or presenting problem Brief statement regarding purpose for
visit Recorded in direct quotes from client Multiple reasons: list and prioritize Client may not give reasons until
comfortable Client condition determines next step
Urgencies requires expediency Bibliographic data delayed Data analysis to determine cause and
develop plan
“I’ve had pains in
my stomach for
the past 3 days”
48
Present Health Status
Focus on client conditions. Health conditions, acute and chronic
Duration and impact on daily lives For example, diabetes, hypertension,
heart disease, sickle cell anemia, cancer, seizures, pulmonary disease, arthritis, mental illness
Medications and reasons for taking each Prescriptions Over-the-counter Herbal preparations
Allergies (true reaction or sensitivity?)
49
Present Health Status (Cont’d)
Allergies Foods Medications Environmental factors Contact substances Specifically ask about substances client
could be exposed to in health care setting, such as latex and iodine.
Clarify and distinguish between side-effect and allergy.
50
History of Present Illness Nurse documents present illness or
problem.
Further investigation of presenting problem Symptom analysis is a systematic
collection of data about history of symptom status.
Various formats include onset, location, duration, characteristics, severity, associated symptoms, alleviating and aggravating factors, and any self-treatments.
If general visit and no presenting problem, focus interview on current state of health.
Past Health History
Childhood Illnesses Accidents / injuries Chronic illness Medications Previous Medical Conditions/Problems Previous Hospitalizations /Surgeries
Include type, year, and residual problems for all above
Immunizations Include dates and reactions
51
52
Family History (Cont’d)
Narrative form or illustrated Genogram to document presence of
condition Tool consisting of a family tree diagram
depicting members within a family over several generations
Useful in tracing diseases with genetic links Symbols are used to indicate men and
women and those who are alive and deceased.
Include current ages of those who are alive, and cause of and age at death of those who are deceased.
53
Family History
Blood relatives: biologic parents, aunts, uncles, siblings, children, and including spouse
Identify genetic, familial, environmental factors that might affect current or future health status.
Trace back two generations to parents and grandparents.
Personal & Psychosocial History
• Mental Health▫ Mental illnesses (anxiety, depression, etc.)▫ Stressful events
Describe stresses in life now What methods do you use to relieve stress and are
they effective?▫ Personal coping strategies
Do you have a social support network (family, friends, coworker, church?
• Personal Habits▫ Tobacco (packs/day, how long?)▫ Alcohol (drinks/day, how long?)▫ Illicit Drugs (name of drug, how often, how long?)54
Personal & Psychosocial History This information may help identify unique
patient needs, areas for patient education, and the need for non-nursing type interventions
Family/Social Relationship Role in the family How getting along? Domestic Violence
Diet and Nutrition Record 24 hour diet recall Who buys and prepares food for patient?
Functional Ability Ability to perform self-care activities
55
Personal & Psychosocial History
• Mental Health▫ Mental illnesses (anxiety, depression, etc.)▫ Stressful events
Describe stresses in life now What methods do you use to relieve stress and are
they effective?▫ Personal coping strategies
Do you have a social support network (family, friends, coworker, church?
• Personal Habits▫ Tobacco (packs/day, how long?)▫ Alcohol (drinks/day, how long?)▫ Illicit Drugs (name of drug, how often, how long?)56
Personal & Psychosocial History
• Sleep patterns▫ Short-term sleep deprivation associated with
Delay of wound healing Decreased performance and alertness Memory and cognitive impairment Stressed relationships Decreased quality of life Occupational and automotive injury
▫ Long-term Increased BP, heart attack, heart failure, stroke,
obesity, diabetes mellitus, psychiatric problems, ADD, mental impairment
▫ Note: Alcohol, nicotine & caffeine are stimulants and should be avoided 4-6 hours before bed
57
Personal & Psychosocial History
Health Promotion Exercise
Type & frequency Self-examination
Type & frequency Oral hygiene practices
Frequency of brushing/ flossing Date of last screening examination
i.e. BP, breast, prostate, glucose, colon Immunizations
58
Personal & Psychosocial History
Environment (living & work environment) Housing & Neighborhood
Type of structure, live alone, safety Hazards at workplace or home? Use of seat belt? Use of sun block? Cigarette smoke? How are medications stored in the house? Own a gun?
If yes, how stored?
59
Personal & Psychosocial History
Environment (living & work environment) Housing & Neighborhood
Type of structure, live alone, safety Hazards at workplace or home? Use of seat belt? Use of sun block? Cigarette smoke? How are medications stored in the house? Own a gun?
If yes, how stored?
60
Review of Systems
Purpose is to: Evaluate past and present health states
for each body system Double check that no data were
omitted in the present illness section Evaluate health promotion practices
61
62
Review of Systems
Past and present health of each body system
Conduct symptom analysis when clients indicate presence of symptoms.
Medical terms Define for client understanding. Use for documentation and
communication with health team. Avoid repeating review of systems if
present health status section data is sufficient.
63
Review of Systems (Cont’d) General
symptoms Integumentary Head and neck Breasts Respiratory Cardiovascular Gastrointestinal Urinary system Reproductive Musculoskeletal Neurologic system
64
Review of Systems (Cont’d)
Additional health promotion data may be collected during review of systems.
In a comprehensive health assessment, you ask most of the questions.
In a focused health assessment, you ask questions about systems related to reasons for seeking care.
65
Summary
Collecting a thorough history accomplishes several goals. Establishes a therapeutic relationship
with the client Provides a snapshot of client and
identifies problems mentioned by client that can be confirmed or refuted during exam
Data must be organized, synthesized, and documented.
Organized collection of data makes documentation easier.