Health Assessmsent (Nursing 146) Study Guide

The client interview involves two types of communication—nonverbal and verbal.

Collecting subjective data is an integral part of nursing health assessment. Subjective data consist of

• Sensations or symptoms

• Feelings

• Perceptions

• Desires

• Preferences

• Beliefs

• Ideas

• Values

• Personal information

subjective types of data can be elicited and verified only by the client.

Subjective data provide clues to possible physiologic, psychological, and sociologic problems

*They also provide the nurse with information that may reveal a client's risk for a problem as well as areas of strengths for the client

1. Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information and

2. Gathering information on the client's developmental, psychological, physiologic, sociocultural, and spiritual statuses to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nurse- client collaboration

The nursing interview has three basic phases:

1. introductory

2. working

3.summary and closing phases

introductory phase

After introducing himself to the client, the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential. The nurse also makes sure that the client is comfortable (physically and emotionally) and has privacy. It is also essential for the nurse to develop trust and rapport at this point in the interview. This can begin by conveying a sense of priority and interest in the client. Developing rapport depends heavily on verbal and nonverbal communication on the part of the nurse

Working Phase

During this phase, the nurse elicits the client's comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level. The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client. The nurse and client collaborate to identify the client's problems and goals. The facilitating approach may be free-flowing or more structured with specific questions, depending on the time available and the type of data needed.

Summary and Closing Phase

During the summary and closing, the nurse summarizes information obtained during the working phase and validates problems and goals with the client (see Chapter 5). She also identifies and discusses possible plans to resolve the problem (nursing diagnoses and collaborative problems) with the client (see Chapter 6). Finally, the nurse makes sure to ask if anything else concerns the client and if there are any further questions

The client interview involves two types of communication—nonverbal and verbal.

appearance

demeanor

facial expression

attitude

*Being nonjudgmental involves not "preaching" to the client or imposing your own sense of ethics or morality on him

silence

listening

Nonverbal Communication to Avoid

-Excessive or Insufficient Eye Contact

-Distraction and Distance

-Standing

Verbal Communication

-open-ended questions

-closed-ended questions

-laundry list

For example, "Is the pain severe, dull, sharp, mild, cutting, or piercing?" "Does the pain occur once every year, day, month, or hour?"

-rephrasing

-well-placed phrases

*phrases such as "um-hum," "yes," or "I agree"

-inferring

-providing information

*If you do not know the answer, explain that you will find out for the client. The more clients know about their own health, the more likely they are to become equal participants in caring for their health.

Effective verbal communication is essential to a client interview. The goal of the interview process is to elicit as much data about the client's health status as possiblere

open-ended questions (verbal communications)

Open-ended questions are used to elicit the client's feelings and perceptions. They typically begin with the words "how" or "what."

*These types of questions are important because they require more than a oneword response from the client and, therefore, encourage description. Asking open-ended questions may help to reveal significant data about the client's health status

closed-ended questions (verbal communication)

Use closed-ended questions to obtain facts and to focus on specific information. The client can respond with one or two words. The questions typically begin with the words "when" or "did."

Verbal Communication to Avoid

-Biased or Leading Questions

-Rushing Through the Interview

-Reading the Questions

Special Considerations during the Interview (3):

Three variations in communication must be considered as you interview clients: gerontologic, cultural, and emotional.

* cultural (If misunderstanding or difficulty in communicating is evident, seek help from an expert, what some professionals call a "culture broker.")

-This is someone who is thoroughly familiar not only with the client's language, culture, and related health care practices but also with the health care setting and system of the dominant culture

INTERACTING WITH CLIENTS WITH VARIOUS EMOTIONAL STATES:

When Interacting With an Anxious Client:

• Provide the client with simple, organized information in a structured format.

• Explain who you are and your role and purpose. • Ask simple, concise questions.

• Avoid becoming anxious like the client.

• Do not hurry and decrease any external stimuli.

When Interacting With an Angry Client:

• Approach this client in a calm, reassuring, in-control manner.

• Allow him to ventilate feelings. However, if the client is out of control, do not argue with or touch the client.

• Obtain help from other health care professionals as needed.

• Avoid arguing and facilitate personal space so the client does not feel threatened or cornered.

INTERACTING WITH CLIENTS WITH VARIOUS EMOTIONAL STATES:

When Interacting With a Depressed Client:

• Express interest in and understanding of the client and respond in a neutral manner.

• Do not try to communicate in an upbeat, encouraging manner. This will not help the depressed client

When Interacting With a Manipulative Client:

• Provide structure and set limits.

• Differentiate between manipulation and a reasonable request.

• If you are not sure whether you are being manipulated, obtain an objective opinion from other nursing colleagues.

INTERACTING WITH CLIENTS WITH VARIOUS EMOTIONAL STATES:

When Interacting With a Seductive Client:

• Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors.

• Encourage client to use more appropriate methods of coping in relating to others.

When Discussing Sensitive Issues (for example, Sexuality, Dying, Spirituality)

• First be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then recognize that these factors may affect the client's health and may need to be discussed with someone. • Ask simple questions in a nonjudgmental manner. • Allow time for ventilation of client's feelings as needed. • If you do not feel comfortable or competent discussing personal, sensitive topics, you may make referrals as appropriate, for example, to a pastoral counselor for spiritual concerns or other specialists as needed.

COMPLETE HEALTH HISTORY

(The health history is an excellent way to begin the assessment process because it lays the groundwork for identifying nursing problems and provides a focus for the physical examination.

*The importance of the health history lies in its ability to provide information that will assist the examiner in identifying areas of strength and limitation in the individual's lifestyle and current health status

The health history has eight sections:

• Biographic data

• Reasons for seeking health care

• History of present health concern

• Past health history

• Family health history

• Review of body systems (ROS) for current health problems

• Lifestyle and health practices profile

• Developmental level

When a client is having a complete, head-to-toe physical assessment, collection of subjective data usually requires that the nurse take a complete health history

Taking a health history should begin with an explanation to the client of why the information is being requested, for example, "so that I will be able to plan individualized nursing care with you."

This can be used as a guide for collecting subjective data from the client. (information comes from the client)

This can be used as a guide for collecting subjective data from the client.

Reason(s) for Seeking Health Care

This category includes two questions: "What is your major health problem or concerns at this time?" and "How do you feel about having to seek health care?" The first question assists the client to focus on his most significant health concern and answers the nurse's question, "Why are you here?" or "How can I help you?" Physicians call this the client's chief complaint (CC), but a more holistic approach for phrasing the question may draw out concerns that reach beyond just a physical complaint and may address stress or lifestyle changes.

The second question, "How do you feel about having to seek health care?" encourages the client to discuss fears or other feelings about having to see a health care provider

History of Present Health Concern (use mnemonic COLDSPA for this section)

*This portion of the health history focuses on questions related to the client's past, from the earliest beginnings to the present.

see handout in gold folder (for COLDSPA)

*

These questions elicit data related to the client's strengths and weaknesses in her health history. The client's strengths may be physical (e.g., optimal body weight), social (e.g., active in community services) emotional (e.g., expresses feeling openly), or spiritual (often turns to faith for support)

Family Health History

The family history should include as many genetic relatives as the client can recall. Include maternal and paternal grandparents, aunts and uncles on both sides, parents, siblings, and the client's children. Such thoroughness usually identifies those diseases that may skip a generation such as autosomal recessive disorders.

Review of Systems (ROS) for Current Health Problems

In the review of systems (or review of body systems), each body system is addressed and the client is asked specific questions to draw out current health problems or problems from the recent past that may still affect the client or that are recurring

Physical Assessment

systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care, usually performed in a head-to-toe format; a collection of objective data about changes in the patient's body systems

Skin, hair, and nails: Skin color, temperature, condition, excessive sweating, rashes, lesions, balding, dandruff, condition of nails

• Head and neck: Headache, swelling, stiffness of neck, difficulty swallowing, sore throat, enlarged lymph nodes • Eyes: Vision, eye infections, redness, excessive tearing, halos around lights, blurring, loss of side vision, moving black spots/specks in visual fields, flashing lights, double vision, and eye pain

• Ears: Hearing, ringing or buzzing, earaches, drainage from ears, dizziness, exposure to loud noises

• Mouth, throat, nose, and sinuses: Condition of teeth and gums; sore throats; mouth lesions; hoarseness; rhinorrhea; nasal obstruction; frequent colds; sneezing or itching of eyes, ears, nose, or throat; nose bleeds; snoring

• Thorax and lungs: Difficulty breathing, wheezing, pain, shortness of breath during routine activity, orthopnea, cough or sputum, hemoptysis, respiratory infections

• Breasts and regional lymphatics: Lumps or discharge from nipples, dimpling or changes in breast size, swollen or tender lymph nodes in axilla

• Heart and neck vessels: Last blood pressure, ECG tracing or findings, chest pain or pressure, palpitations, edema

• Peripheral vascular: Swelling, or edema, of legs and feet; pain; cramping; sores on legs; color or texture changes on the legs or feet

• Abdomen: Indigestion, difficulty swallowing, nausea, vomiting, abdominal pain, gas, jaundice, hernias

• Male genitalia: Excessive or painful urination, frequency or difficulty starting and maintaining urinary stream, leaking of urine, blood noted in urine, sexual problems, perineal lesions, penile drainage, pain or swelling in scrotum, difficulty achieving an erection and/or difficulty ejaculating, exposure to sexually transmitted infections

• Female genitalia: Sexual problems; sexually transmitted diseases; voiding problems (e.g., dribbling, incontinence); reproductive data such as age at menarche, menstruation (length and regularity of cycle), pregnancies, and type of or problems with delivery, abortions, pelvic pain, birth control, menopause (date or year of last menstrual period), and use of hormone replacement therapy

• Anus, rectum, and prostate: Bowel habits, pain with defecation, hemorrhoids, blood in stool, constipation, diarrhea

• Musculoskeletal: Swelling, redness, pain, stiffness of joints, ability to perform activities of daily living, muscle strength

• Neurologic: General mood, behavior, depression, anger, concussions, headaches, loss of strength or sensation, coordination, difficulty speaking, memory problems, strange thoughts and/or actions, difficulty learning

Lifestyle and Health Practices Profile

This is a very important section of the health history because it deals with the client's human responses, which include nutritional habits, activity and exercise patterns, sleep and rest patterns, use of medications and substances, self-concept and self-care activities, social and community activities, relationships, values and beliefs system, education and work, stress level and coping style, and environment

Description of Typical Day

Sample questions include

• "What is your daily pattern of activity?"

• "Do you follow a regular exercise plan?

What types of exercise do you do?"

• "Are there any reasons why you cannot follow a moderately strenuous exercise program?"

• "What do you do for leisure and recreation?"

• "Do your leisure and recreational activities include exercise?"

Nutrition and Weight Management

Ask the client to recall what consists of an average 24-hour intake for her with emphasis on what foods are eaten and in what amounts. Also ask about snacks, fluid intake, and other substances consumed.

*Depending on the client, you may want to ask who buys and prepares the food and when and where meals are eaten

*The client's fluid intake should be compared with the general recommendation of six to eight glasses of water or noncaffeinated fluids daily. It is also important to ask about the client's bowel and bladder habits at this time (included in review of symptoms)

nutrition style and weight management sample questions:

• "What do you usually eat during a typical day? Please tell me the kinds of foods you prefer, how often you eat throughout the day, and how much you eat."

• "Do you eat out at restaurants frequently?"

• "Do you eat only when hungry? Do you eat because of boredom, habit, anxiety, depression?"

• "Who buys and prepares the food you eat?"

• "Where do you eat your meals?"

• "How much and what types of fluids do you drink?"

Sleep and Rest

Inquire whether the client feels he is getting enough sleep and rest. Questions should focus on specific sleep patterns such as how many hours a night the person sleeps, interruptions, whether the client feels rested, problems sleeping (e.g., insomnia), rituals the client uses to promote sleep, and concerns the client may have regarding sleep habits

*normal sleep requirement for adults, which is usually between 5 and 8 hours a night.

sleep and rest sample questions

• "Tell me about your sleeping patterns."

• "Do you have trouble falling asleep or staying asleep?"

• "How much sleep do you get each night?"

• "Do you feel rested when you awaken?"

• "Do you nap during the day? How often and for how long?"

• "What do you do to help you fall asleep?"

Medication and Substance Use

*Because many people use vitamins or a variety of herbal supplements, it is important to ask which and how often. Prescription medications and these supplements may interact (e.g., garlic decreases coagulation and interacts with warfarin [Coumadin]).

The information gathered about medication and substance use provides the nurse with information concerning lifestyle and a client's self-care ability. Medication and substance use can affect the client's health and cause loss of function or impaired senses.

Medication and substance sample questions:

• "What medications have you used in the recent past and currently, both those that your doctor prescribed and those you can buy over the counter at a drug or grocery store? For what purpose did you take the medication? How much (dose) and how often did you take the medication?"

• "How much beer, wine, or other alcohol do you drink on the average?"

• "Do you drink coffee or other beverages containing caffeine (e.g., cola)?" If so, how much and how often?

• "Do you now or have you ever smoked cigarettes or used any other form of nicotine? How long have you been smoking/did you smoke? How many packs per week? Tell me about any efforts to quit."

• "Have you ever taken any medication not prescribed by your healthcare provider? If so, when, what type, how much, and why?" "Have you ever used, or do you now use, recreational drugs? Describe any usage."

• "Do you take vitamins or herbal supplements? If so, what?"

Self-Concept and Self-Care Responsibilities

This includes assessment of how the client views herself and investigation of all behaviors that a person does to promote her health. Examples of subjects to be addressed include sexual responsibility; basic hygiene practices; regularity of health care checkups (i.e., dental, visual, medical); breast/testicular self-examination; and accident prevention and hazard protection (e.g., seat belts, smoke alarms, and sunscreen).

Self-Concept and Self-Care Responsibilities sample questions:

"What do you see as your talents or special abilities?"

• "How do you feel about yourself? About your appearance?"

• "Can you tell me what activities you do to keep yourself safe, healthy, or to prevent disease?"

• "Do you practice safe sex?"

• "How do you keep your home safe?"

• "Do you drive safely?"

• "How often do you have medical checkups or screenings?"

• "How often do you see the dentist or have your eyes (vision) examined?"

Social Activities:

Questions about social activities help the nurse to discover what outlets the client has for support and relaxation and if the client is involved in the community beyond family

Social activities sample questions:

• "What do you do for fun and relaxation?"

• "With whom do you socialize most frequently?"

• "Are you involved in any community activities?"

• "How do you feel about your community?"

• "Do you think that you have enough time to socialize?" • "What do you see as your contribution to society?"

Relationships

Ask clients to describe the composition of the family into which they were born and about past and current relationships with these family members. In this way, you can assess problems and potential support from the client's family of origin. In addition, similar information should be sought about the client's current family (Fig. 3-3). If the client does not have any family by blood or marriage, then information should be gathered about any significant others (including pets) that may constitute the client's

Relationships sample questions:

• "Who is (are) the most important person(s) in your life? Describe your relationship with that person."

• "What was it like growing up in your family?"

• "What is your relationship like with your spouse?"

• "What is your relationship like with your children?"

• "Describe any relationships you have with significant others."

• "Do you get along with your in-laws?"

• "Are you close to your extended family?"

• "Do you have any pets?"

Values and Belief System

*Assess the client values. In addition, discuss the clients' philosophical, religious, and spiritual beliefs. Some clients may not be comfortable discussing values or beliefs. Their feelings should be respected. However, the data can help to identify important problems or strengths

values and belief system sample questions:

• "What is most important to you in life?"

• "What do you hope to accomplish in your life?"

• "Do you have a religious affiliation? Is this important to you?"

• "Is a relationship with God (or another higher power) an important part of your life?"

• "What gives you strength and hope?"

Education and Work:

Questions about education and work help to identify areas of stress and satisfaction in the client's life. If the client does not perceive that he has enough education or his work is not what he enjoys, he may need assistance or support to make changes. Sometimes discussing this area will help the client feel good about what he has accomplished and promote his sense of life satisfaction. Questions should bring out data about the kind and amount of education the client has, whether the client enjoyed school, whether he perceives his education as satisfactory or whether there were problems, and what plans the client may have for further education, either formal or informal. Similar questions should be asked about work history

education and work sample questions:

• "Tell me about your experiences in school or about your education."

• "Are you satisfied with the level of education you have? Do you have future educational plans?"

• "What can you tell me about your work? What are your responsibilities at work?"

• "Do you enjoy your work?"

• "How do you feel about your coworkers?"

• "What kind of stress do you have that is work related? Any major problems?"

• "Who is the main provider of financial support in your family?"

• "Does your current income meet your needs?"

Stress Levels and Coping Styles:

To investigate the amount of stress clients perceive they are under and how they cope with it, ask questions that number of dichotomous concepts to describe growth from birth to death (Table 3-1). Although there are implied age ranges attached to these stages and it is hoped that a person might move through them in an orderly fashion, this does not always occur. Thus it is important to look at the client's behavior rather than age to identify the stage of development currently in progress.