Health assessment Week 1

Critical Thinking, Health Promotion, Culture, Interviewing & Health History

Subjective and objective data

• structure the interaction

• objective data is taken without a physical exam

Results of a successful interview

• complete accurate data

  • description and timeline

• rapport and trust established

• Pt is taught about their health state

things to consider for the interview

• time

• introduction and explanation

• purpose

• length

• expectations

• presence of others

• confidentiality

• costs

time

• the interview takes lots of time

• ensure everything is set up and people are informed that the interview will be taking place

presence of others

• interviews are usually completed one on one

• if other people need to be involved, the pt should be aware of that before the interview

• family, student, other care providers

sender

• the person doing most of the talking

• this should always be the PT

receiver

• the person doing the listening during the interview

• should be the care providers

• pay attention to the non verbal signs

power differentials

• nurses have a position of power, be aware of how that is expressed when communicating with PT and family

internal factors

• liking others

• expressing empathy

• the ability to listen

external factors

• ensure privacy

• refuse interruptions

• pay attention to the physical environment

• dress

• taking notes

• electronic clinical documentation

• audio recording

attention to the physical env

• PT is warm

• lights are on

• Tv is off

• get rid of distracting equipment

taking notes

• before the interview, explain that you may need to take notes

• try to not take them alot

• all notes should be on paper than changed to electronic later

challenges with note taking

• impedes eye contact

• shifts attention away from the PT

• interruption of the PT flow

• impedes observations of nonverbal behavior

• can be threatening during discussion of sensitive issues

questioning techniques

• use open ended questions

• closed questions should only be used to get more info about something the PT said

open ended questions

• narrative information

• longer answers

• elicits feelings, understandings opinions ideas

• builds and enhances rapport

direct questions

• used for specific information

• calls for short answers

  • one or two words

• facts

• limits rapport and leaves interaction neutral

phases of an interview

• introduction

  • describe what is going to happen

  • ensure pt is comfortable

• working

  • the interview

  • use a mix of open and closed answer questions

• closing

  • signal that the interview is coming to an end

  • summarize the interview

  • state PT goals

  • ask the PT if they wanted to talk about anything else or anything in more detail

communication techniques

• Facilitation

• Silence

• Reflection

• Empathy

• Clarification

• Confrontation

• Interpretation

• Explanation

• Summary

Facilitation, silence, reflection, empathy, clarification

• we react to things the PT says or does

facilitation

• saying yes or nodding

• implies you want the PT to keep talking

silence

• can be awkward

• Pt needs time to think don’t be afraid of it

reflection

• you echo the PT response to understand what they are saying

confrontation, interpretation, explanation, summary

• responses that focus on ur own frame or reference thoughts and feelings

the 10 traps of interviewing

• Providing false assurance or reassurance

• Giving unwanted advice

• Using authority

• Using avoidance language

• Engaging in distancing

• Using professional jargon

• Using leading or biased questions

• Talking too much

• Interrupting

• Using “why” questions

providing false assurance or reassurance

• dont the the PT everything is going to be fine because we dont know that

giving unwanted advice

• taking over the Pt responsibility to make choices

using authority

• tone implies that because you are the nurse the Pt should do something

using avoidance language

• don’t use euphemisms

• just state what is wrong

engaging is distancing

• impersonal speech instead of using my

using professional jargon

• the PT may not know what you are talking about

using leading or biased questions

• asking questions that suggests one answer is better than the other

talking too much

• you should be doing most of the listening

• the PT should be doing the talking

interrupting

• dont cut in

• dont give answers

asking why questions

• can imply blaming

non-verbal skills

• physical appearance

• posture

• gestures

• facial expression

• eye contact

• voice

• touch

closing the interview

• end it gracefully, if you dont the PT wont feel as good about the interview

• ask them if there is anything else you want to say

• ask them if any topics or questions were missed

• highlight their major goals or concerns

communication in special situations

• Developmental Stage

• Hearing impairment

• Acute illness

• Intoxication

• Sexually aggressive

• Angry

• Anxious

• Violent

• Crying

cultural and social considerations

• communicating across cultures

  • cross cultural communication and relational practice

  • language issues

• perspectives on professional interactions

• etiquette

• space and distance

• gender and sexual orientation

translators

• should not be family or friends as they have a bias and they can just say anything

• use a translator from the hospital

Health history

• subjective data

• objective data comes from the physical exam later

• other people are going to use this document when planning care so make sure its clear and complete

• screen for abnormal symptoms

health history

• Biographical data

• Source of Data

• Reason for seeking care

• Current health or history of current illness

• Past health

• Family history

• Review of systems

• Functional assessment and ADLs

biographical data

• Name

• Address and phone number

• Age and birth date

• Birthplace

• Gender

• Marital status

• Ethnocultural background

• Occupation (usual and present)

• Source of information

  • Including primary language and authorized representative

reason for seeking care

• brief statement in Pt words using quotation marks

• symptoms vs signs

• dont ask why they are here instead say, what brings you here

sign

• objective abnormality that we can see when er do a physical exam or through tech

PQRSTU

• P: provocative or palliative

• Q: quality or quantity

• R: region or radiation

• S: severity (0-10)

• T: timing

• U: understand the PT perception

Past health

• Childhood illnesses

• Accidents or injuries

• Serious or chronic illnesses

• Hospitalizations

• Operations

• Obstetrical history

• Immunizations

• Most recent examination date

• Allergies

• Current medications

Gravida

• number of pregnancy’s

Para

• successful births

Family history

• Age and health or cause of death of blood relatives

• Health of close family members (spouse, children)

• Family history of various conditions such as heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, obesity, mental health issues, and others

health history for new immigrants

• past health

  • immunizations in country or origin

• health perception

• nutrition

  • taboo foods/combinations

review of systems

• Review past and current health state of each body system

• double-check for omission of significant data

• evaluate health promotion practices

• not objective or physical examination data

• dont leave anything blank on the form, if they dont have symptoms put in “none”

ADL

• bathing

• toileting

• eating

• walking

IADL

• needed for independent living

• shopping

• housekeeping

• laundry

• phone

• finances

developmental considerations

• children

• adolescents

• older adults

documentation

• accurate

• complete

• specific

• don’t use terms like “normal” “fine” or “good”

• anything that is ID as abnormal must be addressed with referral to appropriate health care provider

• no blanks use “none” or “PT does not recall”

• one line through errors on top of the line add in error and ur initials

critical thinking

• The ability to conduct a high-quality health assessment and physical examination is foundational to nursing practice

why should nurses think critically

• to provide relevant, timely, and appropriate nursing and health care, nurses must be able to accurately describe assessment findings to patients, families, and other members of the interprofessional team

how should assessments be completed

• Assessments must be conducted in ways that convey respect for the whole person, to avoid objectifying people.

• Learning to conduct systematic assessments is integral to developing confidence in clinical abilities and capacity to respond effectively to patients’ need

health promotion

• “the process of enabling people to increase control over, and to improve their health

primary prevention

• people and populations are prevented from becoming ill, sick or injured in the first place

secondary prevention

• early detection of disease, before symptoms emerge

tertiary prevention

• prevention of complications when a condition or disease is present or has progressed

cultural competence

• the ability to communicate between and among cultures and to demonstrate skill in interacting with and understanding people from cultures other than your own.

• Culturally competent nurses allow clients to explain what an illness means, respects the concepts of time, space and contact of the client, and respects physical and social activities of clients