Importance of Health Assessment and the Interview

Exam 1 Content (ch. 1 & 2)

Assessment

collect data and information pertinent to the client and/or situation

Diagnosis

analyze the data to determine what the problem is

Outcome Identification

what is the goal now?

Planning

how will you attain the outcome? what will you do?

Implementation

coordinate care and implement the plan

Evaluation

reassess and collect data - was the goal met?

Nursing Process

Assessment

Diagnosis

Outcome Identification

Planning

Implementation

Evaluation

Components of Health Assessment

health history, physical examination, reviewing data from the health record (if there is any), and documenting the findings/data

Levels of Health Promotion

primary, secondary, and tertiary

Primary

(everyone)

preventing problems

ex. immunizations, healthy diet, working out, good hygiene, mental health

Secondary

(at-risk people before symptoms occur)

early detection before a possible/expected problem occurs

ex. breast cancer screening

Tertiary

(people diagnosed w/ disease)

treating and/or preventing complications from disease

ex. maintaining insulin and diet for diabetes management

A mother of three is being seen for a screening assessment (secondary prevention). While planning the initial part of the visit with this patient, the nurse needs to ensure that:

Information about the patient’s lifestyle habits is gathered.

A nurse is assessing a female teenager. The nurse asks the young woman to bend over and touch her toes. The nurse assesses the curvature of the spine as a means of detecting scoliosis. Assessing the curvature of the spine is an example of:

Secondary prevention

Comprehensive Health History

detailed history at onset of care in primary care setting

typically used at admission to a hospital (for newly admitted patients) or a long-term care facility

includes review of systems and collects subjective data

Subjective Data

symptoms

perceived and reported by the patient

ex. pain, itching, nausea, numbness

Objective Data

signs

observed (inspection), felt (palpation), heard (auscultation), percussed, and measured

ex. vital signs, rash, enlarged lymph node, swelling of an extremity, slurred speech, fever, hairless

Problem-based/Focused Assessment

history and exam are limited to specific problem

chief complaint/symptom

commonly used in walk-in clinics or the emergency room

Chief Complaint/Presenting Problem

the reason for seeking health care

record in quotes: “here for a routine exam,” “I have had a fever for a week,” limit to 1-2 sentence(s)

urgency dictates expediency - delay biographic data in emergent situations

Shift Assessment

head-to-toe assessment at routine times during a shift or based on changes

when a nurse changes shifts, this is when you would perform it

Screening Assessment

short, focused on a specific potential problem

ex. drug screening, alcohol use

Episodic/Follow-up

follow up for previously identified problem

ex. pneumonia follow up, diabetes

Physical Exam

once you are done with the health history, then you would perform this exam

collects objective data

Biographic Data

collected at the 1st visit

help form a complete picture of patient as unique individual

emphasizes not making assumptions of people based on appearance

History of Present Illness

conduct a symptom analysis using OLDCARTS

O: onset

L: location

D: duration (intermittent/constant)

C: characteristics

A: aggravating factors

R: related symptoms

T: treatment

S: severity (0-10)

Present Health Status

includes health conditions, current health problems, medications, and allergies (includes rash or difficulty breathing, adverse effects, and ALWAYS ask what the reaction is !!)

Past Health History

includes childhood illness, surgeries, hospitalizations, accidents or injuries, immunizations, last examination(s), and obstetric history

Family History

patient’s blood relative - biological parents and siblings, aunts, uncles and grandparents; used to identify potential genetic illness

spouse - helps identify potential environmental factors of illness

conditions to ask about - hypertension, stroke, seizure, mental illness, substance abuse, endocrine diseases and kidney disease

- record three generations

Genogram

useful for pediatric patients, but don’t use it on older adults

Personal Status

cultural/religious affiliation, educational preparation, occupational history, hobbies

ex. coal miner, Christianity, dancing

Family and Social Relationships

is client satisfied with interpersonal relationships

is client involved with social organizations/groups

- be alert to issues of domestic violence

Diet/Nutrition

have client describe typical daily dietary intake

use of supplements/appetite supplements

Functional Ability

is client able to complete self-care activities?

is client able to complete activities of daily living (ADLs)?

- more so for older adults

Mental Health

ask client about personal stressors

what type of coping skills are utilized?

ex. tobacco, alcohol, illicit drug use - document tobacco use in pack years

Health Promotion Activities

self-exams (testicular and breast) - secondary

seat belt use, exercise sleep habits - primary

Environment

consider potential hazards in the home

ex. lack of fire detectors, poor lighting, stairs, inadequate pest control

consider potential hazards in the community

ex. heavy traffic, violence, firearms

consider potential hazards in the workplace

ex. inhalants, noise, heavy lifting, stress

consider potential hazards associated with travel

- when? where? length of stay?

Review of Systems

subjective data collected directly from the patient regarding his/her perception of the following body systems

includes integumentary, head and neck, breasts, respiratory, cardiovascular, gastrointestinal, urinary, reproductive, musculoskeletal, and neurologic systems

Active Listening

listening with a purpose

verbal and non-verbal messages

focus on patient’s response

eye contact is also important!

Facilitation

use phrases to encourage patient to continue

ex. “go on,” “uh-huh,” “then?”

nonverbal facilitation - nodding, shifting forward in seat

Clarification

used to obtain more information about conflicting or vague statements

ex. “what do you mean by ‘almost lost it?’”

repeat back what they said and ask what they meant

Restatement

repeat patient statement to confirm interpretation

ex. “let me make sure I understand what you said”

Reflection

asks patient question to clarify phrase or sentence (“you just didn’t feel right?”)

encourages elaboration (similar to clarification but rephrases a patient statement as a question)

Confrontation

used when inconsistencies are noted between reports and observations

ex. patient stays on diet, but weight has increased. say “I’m confused…” the nurse’s tone is important

avoid “why’s”

Interpretation

opportunity to share conclusions drawn from data they have given

ex. “I wonder if your home environment is contributing to your anxiety…”

allows patient to confirm, deny or revise information

Summary

condenses data from interview to help clarify a sequence of events

Techniques that Diminish Data Collection

- using medical terminology

- expressing value judgements (cannot have biases, previous opinions, etc.

- interrupting the patient

- being authoritarian or paternalistic (remember unspoken power dynamic)

- using “why” questions

Managing Awkward Moments

- answering personal questions

• provide brief direct answers

- silence

• allows client time to reflect or gather courage - can be brief pauses

- displays of emotion

• ex. crying

• avoid “don’t cry” response; allow patient time to recover, provide compassion, and postpone further questions until client has recovered

- anger

• acknowledge anger

• apologize if warranted and honor request for a different nurse

• ex. “this topic prompted an emotional response, tell me more about how you’re feeling…”

Challenges to the Interview

- talkative patient

• redirect using closed-ended questions

- others in the room

• don’t assume relationships exist

• interview adolescent patients in private

• can request others to leave until end of interview

• find age-appropriate activity for young children

• if patient has questions answered for them, ask to have patient answer for themselves *

- language barrier

• acquire interpreter, don’t use family members, and focus on collecting most important data

- cultural differences

• each individual is unique, so avoid stereotyping