NRS 103: NURSING ASSESSMENT

ANDHEALTH HISTORY

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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

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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

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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

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The Nursing Process: MI

Assessment Nursing diagnosis Goal Implementation Evaluation

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Health Assessment Class

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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

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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

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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

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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.

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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

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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.

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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.

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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

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Introduction

Check ID band with 2 identifiersNameIdentification number assigned by

health care agencyTelephone numberDate of birth

State your purpose & obtain consent

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Addressing the Environment Make environment comfortable and relaxed

Provide privacy, remove distractions Appropriate lighting Provide symptom management

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• 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

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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?

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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

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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

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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

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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?

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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

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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

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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.

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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

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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.

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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

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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

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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

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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”

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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?)

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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.

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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

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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.

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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

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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

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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

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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

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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.

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Review of Systems (Cont’d) General symptoms Integumentary Head and neck Breasts Respiratory Cardiovascular Gastrointestinal Urinary system Reproductive Musculoskeletal Neurologic system

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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.

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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.