1Health Assessment Lecture 1ish

 What is health?

Health is not merely the absence of disease or illness. It involves complete physical, emotional, and mental well-being.

What are Social Determinants of Health (SDOH)?

They include conditions where people:

• are born

• live

• learn

• work

• play

• worship

• age

What is a health assessment?

The systematic collection of data used to determine a person's health status.

It has two major components:

1. Health history

2. Physical examination

 What are the five steps of the nursing process?

Think ADPIE:

• Assess → gather information

• Diagnose → identify patient problems

• Plan → set goals

• Implement → perform nursing actions

• Evaluate → determine whether goals/outcomes were met

What is the nurse's role during assessment?

The nurse:

• collects data

• analyzes results

• prioritizes concerns

• reports important findings

• identifies knowledge gaps

• educates the patient

• reassesses for changes

• documents findings

What 4 principles should guide a health assessment?

Remember:

• Trust

• Privacy

• Confidentiality

• Patient is fully informed

• Consent

• Introduction of name/role/purpose

• Correct patient identification

Identification can include full name, DOB, MRN, preferred name, and pronouns.

What systems are included in a head-to-toe assessment?

The slides use a system-by-system approach:

• Neurological

• HEENT

• Respiratory

• Cardiac/peripheral vascular

• GI

• GU

• Musculoskeletal

• Integumentary

What is the difference between subjective and objective data?

Subjective = symptom

• What the patient reports

• Feelings/experiences

• Collected mainly through the interview

Objective = sign

• Something observable or measurable

• Detected by the healthcare provider

• Collected through physical examination/tests

Think:

Subjective = Said by patient
Objective = Observed

 Why should subjective and objective information be combined?

Data should be triangulated so the nurse can understand the bigger picture.

Incomplete or inaccurate information can result in an incorrect nursing plan or intervention.

What can make assessment data inaccurate?

Objective-data problems:

• equipment calibration

• poor maintenance

• user error

• malfunction

Subjective-data problems:

• mistrust

• lack of privacy

• culture

• memory

• health literacy

• difficulty explaining symptoms

• time limitations

What is the primary goal of the nurse-patient interview?

A purposeful conversation designed to improve the patient's well-being.

It has three purposes:

1. Establish trust/support

2. Gather information

3. Offer information

 What makes a nurse-patient interview successful?

It should:

• gather complete and accurate data

• develop rapport and trust

• allow the patient to share relevant information

• begin teaching for health promotion/disease prevention

What are the four phases of interviewing?

Pre-interview:
Review chart, set goals, prepare environment/privacy.

Introduction:
Establish trust and rapport.

Working:
Gather information, form hypotheses, take notes/document.

Termination:
Summarize and discuss the plan.

Open-ended vs. closed-ended questions?

Open-ended:
Requires more than one-word answers.

Example:
"Tell me more about your leg pain."

Closed/focused:
Usually answered with yes/no or a short answer.

Example:
"Did you take medication for the pain?"

During an interview, should you start with open or focused questions?

Start open-ended, then move toward focused questions as you need specific information.

 What are examples of verbal therapeutic communication?

• Active listening

• Open → focused questioning

• Empathy

• Validation

• Reassurance

• Summarizing

• Empowering the patient

What is motivational interviewing?

An evidence-based therapeutic communication method used to bring out the patient's own motivation for behavior change.

The slides emphasize:

• Open-ended questions

• Affirmation

• Reflective listening

• Summarizing

 What nonverbal behaviors affect therapeutic communication?

• Appearance

• Posture

• Sitting with patient

• Gestures

• Facial expressions

• Eye contact

• Voice/tone

• Touch

What communication behaviors should nurses avoid?

Avoid:

• leading/biased questions

• dominating conversation

• false reassurance

• withholding information

• failing to validate

• unwanted advice

• using authority

• professional jargon

• colloquial/slang speech

How should the nurse adapt interviews for different patients? Like silent, altered capacity, talkative, crying, language barrier

Silent: silence may be okay; assess comfort/culture.

Altered capacity: If the patient can’t reliably answer or make decisions, get information/help from an appropriate surrogate,

Talkative: set limits redirect them back to the important questions

Crying: pause and offer empathy.

Language barrier: use a medically trained interpreter and translate written information too.

How should the nurse respond to an angry/disruptive patient?

• Validate feelings

• Allow the patient to be heard

• De-escalate if safety becomes a concern

• Ask for help/reinforcement when needed

• Be aware of personal bias

How should the nurse communicate with a dying patient?

Avoid false reassurance and understand end-of-life decisions such as DNR status.

DNR = Do Not Resuscitate. It means if the patient’s heart stops or they stop breathing, they have chosen not to have CPR/resuscitation performed.

How should communication be adapted for hearing or visual impairment?

Hearing impairment:

• hearing devices

• sign-language interpreter when appropriate

• speak clearly

• do not yell

Visual impairment:

• assistive devices

• read material aloud

• large-print materials

 How should the nurse respond to sexual advances, children, and older adults?

Sexual advances: calmly and firmly establish professional boundaries.

Children: parents can help provide history.

Older adults: use their proper name — NOT "honey" or "sweetie." Speak slowly and use family for history if necessary.

 What is a health history?

A structured framework for organizing subjective patient information and communicating it to other healthcare providers.

Comprehensive vs. focused health history?

This card is comparing two different types of health histories a nurse might take.

Comprehensive health history = the FULL picture. You usually do this with a new patient because you do not know much about them yet. You ask about things like past illnesses, surgeries, medications, allergies, family history, lifestyle, and current health.

Example: a patient comes to a new primary care office for the first time. The nurse asks about their whole medical background to create a baseline.

Focused/problem-oriented health history = only the CURRENT problem. You usually do this when the patient is already known or when they come in with one specific complaint.

Example: a patient you already know comes in saying, “My right knee has been hurting for 3 days.” You mainly ask questions about the knee pain: when it started, where it hurts, what makes it better/worse, whether there was an injury, etc.

The easiest way to remember it is:

Comprehensive = Everything

Focused = One problem

What are the major parts of a comprehensive adult health history?

• Identifying data/source

• Chief complaint

• History of present illness (HPI)

• Past medical/surgical history

• Family history

• Review of systems

• Health patterns

What is the primary source vs. secondary source of health history?

Primary source: the patient.

Secondary sources:

• family

• friend

• provider

• medical record

The nurse should also consider the source's reliability.

What is the chief complaint?

The patient's reported reason for seeking care.

Whenever possible, document it in the patient's own words.

Example:

"I've had a terrible cough for 3 weeks."

What is the History of Present Illness (HPI)?

A clear and comprehensive description of:

• onset of the problem

• symptoms/manifestations

• treatments

• outcomes

The slides recommend using OLDCART(S) to organize the HPI.

• O — Onset: When did it start?

• L — Location: Where is it?

• D — Duration: How long has it been happening?

• C — Characteristics: What does it feel like?

• A — Aggravating factors: What makes it worse?

• R — Relieving factors: What makes it better?

• T — Timing: When does it happen? Constant or comes and goes?

• S — Severity: How bad is it, usually on a 0–10 scale?

What information is included in past history?

Allergies

• medication

• food

• insects

• environment

• document the specific reaction

Medications

• prescriptions

• OTC

• vitamins

• herbal supplements

Diseases/history

• medical

• surgical

• psychiatric

• accidents

Health maintenance

• immunizations

• screenings

• social history/substance use/violence

Why do nurses obtain family history?

To identify inheritable diseases and genetic predispositions.

A genogram may be used.

What is the Review of Systems (ROS)?

A system-by-system review of symptoms experienced by the patient to ensure important information isn't missed.

Symptoms may be related or unrelated to the chief complaint.

Start open-ended and become more specific.

What body systems may be included in ROS?

Examples from the slides:

• General

• HEENT

• Neck

• Respiratory

• Cardiovascular

• GI

• Peripheral vascular

• Urinary

• Reproductive

• Musculoskeletal

• Skin

• Psychiatric

• Neurologic

• Hematologic

• Endocrine

What health patterns should nurses assess?

External factors such as:

• values/beliefs

• activity/exercise

• sleep/rest

• nutrition/elimination

• interpersonal relationships/resources

• spirituality

• coping/stress management

What is the most important rule when discussing sensitive topics?

Be nonjudgmental.

Also:

• explain why you're asking

• normalize the questions

• acknowledge your own discomfort/bias

• don't avoid necessary topics just because they're uncomfortable

What should you know about asking about sexual history?

Ask when the information is pertinent to care, such as urinary/genital concerns, and consider appropriate LGBTQIA+ care considerations.

What should the nurse consider during mental health and violence assessment?

Mental health:

• trauma-informed approach

• cultural considerations

• mood changes/depression symptoms

• ask about suicidal thoughts

Violence/abuse:

• if abuse suspected, spend part of encounter alone with patient

• do not force the situation

• watch nonverbal communication

How should subjective information be documented?

Use the patient's direct words whenever possible.

Examples:

Patient reports...
Patient denies...

Quotes can be used for the patient's exact statement.

What does SOAP stand for?

S — Subjective
What the patient reports.

O — Objective
Observable/factual information collected by the nurse.

A — Assessment
Professional interpretation of the subjective + objective information.

P — Plan
Next steps, goals, and interventions.