health assessment, nursing process, and interview/health history

purpose of health assessment

systematic method of collecting and analyzing data

informs a patient-center plan of care

nursing process

assessment

diagnosis

planning

implementation

evaluation

assessment

inspection, auscultation, percussion, palpation

subjective data - reported by the patient

• based on feelings, perceptions, and experiences

• cannot be measured directly

objective data - observed, measured, and verified

• collected using senses or instruments

• observable and quantifiable

complete health database

describes current and past health problems, provides baselines

focused/problem-centered/episodic

gathering only data needed for a short-term problem

follow-up

update status of current problems

emergency

rapid collection of data, usually associated with life saving measures

diagnosis

process of analyzing health data and drawing conclusions to identify diagnoses

cluster data that is connected

abductive reasoning

use incomplete data to make initial diagnosis and find simplest solution

deductive reasoning

apply physiology and pathophysiology; top-down

inductive reasoning

use signs and symptoms of disease; bottom-up

planning

first-level priority - emergent, life-threatening, and immediate

second-level priority - next in urgency, requiring attention to avoid further deterioration

third-level priority - important to patient’s health but can be addressed after more urgent problems

interdisciplinary approach - to improve outcomes for complex care problems

therapeutic communication techniques

respecting the patient, their culture, and beliefs

empathy - ability to understand and be sensitive to others

listening requires complete and focused attention

self-awareness - personal, biases, prejudices, and stereotypes

no interruptions

open physical positioning

children → focus more on caregiver, but kids pick up on non-verbal

adolescent - need to be seen and given information, assure to them what is important for health, explain what is confidential

older adults → more information; consider hearing and visual impairments

types of questions

open-ended questions - ask for narrative information

close-ended questions - ask for specific information leading to a forced choice (yes or no)

communication barriers and traps

providing false assurance and reassurance

giving unwanted advice

using authority

using avoidance language

distancing

using professional jargon

using leading or biased questions

talking too much

interupting

using ‘why’ questions

functional assessment

activities of daily living (ADLs)

• bathing, toileting, eating, ambulating

instrumental activities of daily living (iADLS) - needed to live independently

• housekeeping, shopping, cooking, laundry, finances, social interaction

self-concept, activity/exercise, sleep/rest, nutrition/elimination, interpersonal relationships

coping and stress management

drug and alcohol use

environment/hazards - safety, adequate heat and utilities, transportation, community

intimate partner violence

occupational health

tobacco use

type, length of use, packs per day

assess nicotine, vaping

assess readiness to quit

marijuana use

frequency, type, source

medicinal or recreational

alcohol use

amount, frequency, last drink

CAGE screening

• cut down

• annoyed

• guilty

• eye opener

FICA screening

spiritual assessment tool

Faith - does religious faith or spirituality play an important role

Influence - how does faith influence health and care

Community - are you part of religious/spiritual communitu

Address - would you like me (nurse) to address religious or spiritual concerns