Health history and general survey (class slides)

Nursing process definition

dynamic continuous client centered problem solving & decision-making framework

3 purposes for the nursing process

1. Identify client's health status and actual or potential healthcare problems of needs

2. Establish plans to meet needs

3. Deliver care to meet the need by developing specific interventions

Assessing/Recognizing Cues example

Nurse notes a new area of skin breakdown caused by the tape when changing addressing on a wound

Diagnosing/Analyzing Cues is defined as

Develop a list of problems; Identify client strengths; Identify problems that can be prevented

Example of taking action/implementation

giving a pt a backrub

Evaluating can be defined in what 3 ways

1. Evaluating Outcomes

2. Identifying outcomes, in between diagnosing and planning

3. Overlapping (in the phases), continuing processes

example of evaluation

after 2 weeks of wound not healing nurses seeks a different type of wound care

2 characteristics of the nursing process

1. Cyclic & dynamic rather than static

2. Client centered

name the 4 types of assessment

1. Initial nursing assessment - (baseline data)

2. Problem-focused assessment

3. Emergency assessment

4. Ongoing assessments

example of an emergency assessment

the nurse notes that the client has become unresponsive & respirations have become shallow.

Why do nurses use COLDSPA (Character, Onset, Location, Duration, Severity, Pattern & Associated Factors)?

to assess the problem

3 examples of questions using coldspa

1. Exact location

2. when symptoms began?

3. things that aggravate the problem?

Initial assessment the nursing should obtain what 2 things?

1. Health History

2. physical examination

what does a physical examination involve?

Assess exact location of problem; when symptoms began & things that aggravate the problem

When should documentation and tasked be performed during the initial assessment?

within 24hrs of admission

Effective Communication guidelines include what 3 things?

1. Looking directly at the client to ensure good eye contact

2. Sitting in a chair next to the client who is in bed

3. Keeping arms unfolded and in a relaxed position

Primary source

client

Secondary source

parents, caregivers or children of older clients

Subjective data

coming from the patient

example of subjective data

pt says, "leave me alone"

objective data

observations the nurse has made (or physical examination)

True or false: Can objective data be seen, heard, felt, or smelled?

True

Best source of data comes from who?

the client

Name 3 support people

1. family members

2. friends

3. caregivers

6 Components of a Database

1. Documentation of the nurse's physical assessment

2. A list of current medications

3. Family History

4. Life style

5. Past Medical History

6. Demographics

example of past medical history

Reports from physical therapy the client received as an outpatient

demographics should include what 8 things?

1. Name

2. date of birth

3. address

4. phone number

5. email address

6. sex

7. race

8. client's cultural preferences

observation of a nervous person and alone

Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff.

observation of a "happy" person with someone

Is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse

nursing interview: example of how you should close the interview?

"I'm going to set up your physical assessment now. Do you have any questions?"

Example of a Focused interview

Nurse asks the client specific questions to collect information related to the client's problem

Example of a direct interview

what questions do you have about your procedure?

4 components of a Nondirective or Indirect interview

1. Rapport

2. Understanding between two or more people

3. Client controls the purpose, subject matter, and pacing.

4. Combination of directive & nondirective approaches usually appropriate during information-gathering interview.

Example of Understanding between two or more people•

when nurse enters room introduces themselves saying "Hello, I am your nurse & I will be taking care of you today"

4 Types of interview questions

1. closed questions

2. open-ended questions

3. neutral questions

4. leading questions

example of an open-ended question

1. Describe what you are feeling

2. "Tell me how the symptoms you are describing affect your daily activities."

3. "Describe measures that you use to alleviate the symptoms."

4. "How has the pain impacted your life?"

5. "How would you describe your sleep?

6 ways to set up an Interview setting

1. time

2. place

3. setting arrangement

4. distance

5. comfortable

6. language

Interview setting: time component

After client has settled & oriented to the room

Interview setting: distance component

Sit next to the client, a few feet apart

Interview setting: comfortable components (3)

1. Draw curtains around the client and nurse to provide as much privacy as possible

2. Keeping arms unfolded & relaxed position

3. Maintain eye contact

Interview setting: language component

Interpreter or translator

ROS uses what 5 things

1. observation (pt laughing with spouse but vague with professional staff)

2. inspection

3. auscultation

4. palpation

5. Percussion

During ROS you should do what 3 things

1. Carefully assess each area for normal & abnormal findings

2. Use Critical Thinking (your findings with textbook finding)

3. head to toe progression

True or false: 1st Encounter with the client = 1st Impression of the Client

true

5 Components of the General Survey

1. Physical Appearance

2. Body structure

3. Mobility

4. Behavior

5. Vital signs

A.J. is a 47 yr-old black female appears healthy & her stated age. She is well-groomed, fit & cheerful. She is alert & oriented, cooperative, with no signs of pain or difficulty breathing. TPR (temperature, pulse, respirations) 98.6o F, P-76-Reg, RR-14, BP 146/84 right arm, sitting. Is an example of what?

Healthy, general survey charting

A.J. is an 88 yr-old Caucasian male who appears pale & chronically ill. He is alert with eye contact but unable to speak more than 2 or 3 words at a time due to shortness of breath (SOB). He is thin, with diffuse muscle wasting. TPR - 101.2o F, 108-Irreg, RR- 32 labored, BP 160/95 right arm, sitting. Is an example of what?

Sick, general survey charting

Gordon's functional health pattern framework - 10 functional health patterns

1. health perception & management

2. nutrition

3. elimination

4. activity

5. sleep

6. cognitive

7. self-perception/self-concept

8. role relationship

9. sexuality

10 coping/stress & value/belief systems

Definition of a Coping/stress and value/belief system

care does not fit into client's life goals

Wellness models definition (4)

health behaviors, beliefs, values, and attitudes

True or false: A review of systems is similar to a head to toe assessment

true

5 components of Maslow's Hierarchy of Needs

1. Physiological (survival) needs

2. safety and security

3. love and belonging

4. self-esteem

5. self-actualization

name 1 Non-nursing Models

developmental theories

Developmental theories includes what?

Erikson's eight stages of development

True or false: Address every Client problem using COLDSPA?

True

What does COLDSPA stand for?

C-character

O-onset

L-location

D-duration

S-severity

P-pattern

A-associated factors

Validate the data with the client definition

The act of "double-checking," verifying data to confirm it is accurate and factual

example of validating the data

retaking vital signs

True or false: cues can be directly observed/measured

true

Inferences definition

interpretation or conclusion based on cues

Example of a nurse using inferences

if pt in pain & sweating- nurse will expect BP & Pulse to be or pt with hx of injuries could be a victim of abuse

True or false: record factual manner without stating interpretations

true

True or false: record subjective data with quotes in client's own words

true

True or false: Record all information obtained from the health history & physical assessment.

True

Immediate recording definition

Report & record information that requires immediate action

True or false: Share only information that is of benefit to the nursing & medical team for planning care

True

True or false: Do NOT leave notes at site of interview

True

What does HIPPA stand for

Health insurance portability and accountability act (must be followed)

Concept map definition

a graphic depiction, a visual tool

8 components of concept mapping

1. Shows a linear relationship between multiple problems & determine care based on complexity of problems (Maslow hierarchy)

2. Allows immediate visualization of pt problems & relationships between the problems with the use of connecting lines or arrows

3. Allows nurse to focus on concepts & relationships

4. Quicker than note taking & highlight key ideas

5. Provides a link between existing nursing knowledge & new information

6. Enhances critical thinking process

7. Valuable to improve critical thinking

8. Creative endeavors