Health Assessment and Nursing Skills Module 1

The Health History & Interview

Verbal Communication Skills

• Effective Interviewing skills

  • learned w/ practice + repetition

• Speech patterns

  • moderate pace and volume

  • clear articulation (no mumbling)

• patients w/ limited english

Nonverbal communication skills

• just as, or even more, important than verbal communication

• Important components

  • Physical appearance; facial expression

  • Posture; positioning in relation to the patient

  • Gestures; eye contact

  • Voice tone; use of touch

• Communicate at patient’s eye level: SIT DOWN!!

• Touch: essential, dominant component of physical exam

  • Be careful of where you touch people (arms, shoulders, and back are the best safe places)

Techniques of Communication

• restatement

• reflection

• elaboration (facilitation)

• silence

• focusing

• clarification

• summarizing

Restatement

• relates to the content of the communication 

  • Purpose: Ask patients to elaborate especially to a “yes or no” question

Reflection

• summarizing main themes of communication

  • Validating what the patient just said to you

Elaboration (facilitation)

assists patients to more completely describe difficulties

Silence

purposefully allow patients time to gather thoughts, provide accurate answers

Focusing

redirecting patients from off-topic being discussed

Clarification

questions to ascertain patient’s meaning when word choice or ideas are unclear

Summarizing

reviewing and condensing important information into two or three most important findings

Non-therapeutic Responses:

• False reassurance

• Sympathy (taking a person’s pain for them)

• Unwanted advice

• Biased questions

• Changes of subject

• Distractions

• Technical or overwhelming language

• Interrupting

True or False:

• The therapeutic communication strategy of reflection is when the nurse restates content of the communication to the patient. Its purpose is to encourage the patient to elaborate.

• Answer: False

  • Reflection is similar to restatement; however, instead of simply restating comments, the nurse summarizes the main themes of communication

Scenario 1: telling a 60-year-old woman she needs bypass surgery

• Sit down, make eye contact

• If they ask to clarify, ask them what they know about what the procedure is first

• Let them ask questions and answer it them with their “language”

Scenario 2: telling a deaf child he must be admitted to the hospital for tests

• Find someone that knows sign language

• If the parent is there, they can communicate for their child

Scenario 3: telling a friend she needs help with an alcohol problem

• Harder to approach because you want to make sure they don’t get offended and “turn you off”

• Ask them questions so that they elaborate

Scenario 4: letting an unconscious person know you are changing the person’s IV line

You always want to warn them and let them know because they may be somewhat conscious where they can feel pain

Phases of the Interview Process:

• Preinteraction phase: compiling existing data; preparing for patient interview from existing medical records

• Beginning phase: ask for permission; introduction; state purpose for interview

• Working phase:

  • Closed-ended or direct questions: specific information

  • Open-ended questions: broad answers in patient’s own words; avoid “why” questions

Closing phase: summarizing, stating most important two to three problems or patterns

Intercultural Communication:

• Cultural differences may relate to

  • Group or ethnicity; region

  • Age; degree of acculturation into Western society

  • Combination of factors

• Communication etiquette

• Limited English skills

• Working with an interpreter

• Gender and sexual orientation issues

Primary Data Sources

Patient (subjective data)

Secondary Data Sources

• Documentation

• family members

Nurse’s role during an interview + physical assessment

• Records information

• Notes discrepancies

  • Ex: Patient says they’re allergic to penicillin, but not found in their records

• Identifies additional sources to confirm history

• Previous medical records

Components of the Health History:

• Demographic data

• Reason for seeking care

• History of present illness

  • Location; duration

  • Intensity

  • Quality/description

  • Aggravating/alleviating factors

  • Pain goal (at least to a manageable level)

  • Functional goal (being able to walk)

• Past health history

• Current medications, indications

• Review of systems

Review of systems

• General health state (general survey of a patient as soon as you walk into the room)

• Nutrition, hydration

• Skin, hair, nails (can be examined or ask the patient)

• Head and neck

  • Eyes, ears, nose, mouth, and throat

• Thorax, lungs

• Heart, neck vessels, peripheral vascular

• Breasts

• Abdominal-gastrointestinal

• Abdominal-urinary

• Musculoskeletal

• Neurological

• Genitalia

• Anus, rectum, prostate

• Endocrine, hematologic systems

Other factors/assessments done in an interview

• Social, cultural, spiritual assessment

  • May limit the assessments/treatments that you can do/provide on the patient

  • Coping/stress tolerance

• Mental health assessment

  • Mental health history; medications in use

  • Alcohol/illegal drug use

• Human violence assessment

  • Possible abuse

• Sexual history and orientation

  • Establish baseline; identify need for education

Special Situations in Interviews:

• Hearing impairment

• Low level of consciousness

• Cognitive impairment

• Mental illness

• Anxiety; crying

• Anger

• Alcohol, drug use

• Personal questions

• Sexual aggression

Interview in a nutshell:

• Prepare: read available material

• Allow time to spend with patient

• Remember communications techniques

• Review all history: past and present, including medications

• Review chief complaint (CC): what the patient is here for TODAY

• Medical diagnosis (from MD or NP, etc) comes after they do testing based on CC

Types of Assessments

• initial

• focused

• quick priority

• emergency

• time-lapsed

• triage

• patient-centered assessment method

Initial assessment

• Performed shortly after admittance to a healthcare facility

• Performed to establish a complete database for problem identification and care planning

• Performed by the nurse to collect data on all aspects of patient’s health

Focused assessment

• May be performed during initial assessment or as routine ongoing data collection

• Performed to gather data about a specific problem already identified, or to identify new or overlooked problems

• Performed by the nurse to collect data about the specific problem

• Ex: When a patient comes in with chest pain, the assessment is focused on their chest area instead of their bowel movements

Quick priority assessment

• short, focused, prioritized assessments completed to gain the most important information needed first

• Can flag existing problems and risks

• Ex: Seeing a patient on the floor

Emergency assessment

• Performed when a physiologic or psychological crisis presents

• Performed to identify life-threatening problems

• Performed by the nurse to gather data about a life-threatening problem

• Ex: Seeing the patient unconscious on the floor

  • Was the fall caused by the loss of consciousness or was the loss of consciousness caused after the fall

Time-lapsed assessment

• Performed to compare a patient’s current status to baseline data obtained earlier

• Performed to reassess health status and make necessary revisions in care plan

• Performed by the nurse to collect data about current health status of patient

Triage assessment

• A screening assessment to determine the extent and severity of patient problems and recommend appropriate follow-up

• Can be completed on the phone or in person

• Triage nurses need highly specialized nursing knowledge and clinical reasoning and judgement skills

• Estimating when the patient can be seen based on their problem (severe = immediate admission)

Patient-centered assessment method (PCAM)

• Tool used by health care practitioners to assess patient complexity using social determinants of health

• Helps ask questions to gain understanding about the patient’s health and well being, social environment, health literacy and communication skills

• A homeless patient who cannot gain support from family

Practice: Which one of the following assessments would be performed on a patient to gather data about his previously diagnosed liver cancer?

Focused assessment

Objective data

• Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them

• Ex: Elevated temperature, skin moisture, vomiting

Subjective Data

• Information perceived only by the affected person

• Ex: Pain experience, feeling dizzy, feeling anxious

Practice: A patient rates his pain as a “7” on a pain rating scale. This rating is considered objective data

False

Primary components of data collection

• Nursing history

  • Done once pt. enters nursing care and they followed by physical exam

    • identify pt. strengths and weaknesses

    • health risks

    • potential and existing health problems.

    • patient interview

  • Example: Sex, age, cultural considerations, medication, developmental history, family history, environmental history, education needs, advance directives

• Physical history

• Observation

Assessment techniques

• inspection

• palpation

• percussion

• auscultation

(usually follows this order unless assessing the abdomen)

Inspection

1. Deliberate systematic observation

2. Use your senses – sight, hearing, smell

   1. make sure you have adequate lighting/exposure

3. Begins before touching → ongoing throughout history & PE component

4. Think: What am I seeing?

   1. note both verbal statements + body language

5. This information helps focus the next steps of the assessment

Palpation

1. Cardinal rules

   1. Warm hands

   2. Use light palpation before deep palpation

      1. 1 cm: light (0.5”)

      2. 1 cm - 2cm: moderate (0.5-0.75”)

      3. 2 cm: deep (1”)

   3. Touch the area that hurts last

2. Use palmar surface and fingers for sensitivity

3. Ulnar surface for vibration

4. Dorsal surface for temperature

5. Helps you identify masses, lumps, etc.

Percussion

1. Finger functions as a hammer: needs wrist-action

   1. Exert firm pressure with finger on skin surface

   2. Separate hammer finger from other fingers

   3. Snap from wrist, not elbow or shoulder

   4. Strike with finger pad vs finger tip

2. tone is determined by the density of material as sound waves pass through.

   1. the denser the medium, the quieter the tone

3. Detects tissue density

4. Notes arise from structures 4-6 cm deep in the body

5. Noises:

   1. loud over air

   2. moderately loud over fluid

   3. soft over solid

6. Ranges from (hyper)resonance to dullness

7. Types of percussion:

   1. Direct

   2. Blunt

   3. Indirect: helps when eyes are closed

Types of sounds during percussion

1. Flatness: bone or muscle

2. Dullness: heart, liver, spleen

3. Resonance: air filled lungs (hollow)

4. Hyperresonance: emphysematous lung (hyperinflated)

5. Tympany: air-filled stomach (drumlike)

Auscultation

1. Requires a stethoscope:

   1. Angle the ear pieces toward the nose to project to the tympanic membrane

   2. Hold end piece between pointer and middle finger

2. Diaphragm: 

   1. Best for HIGH pitched sounds

      1. Breath sounds, bowel sounds, normal heart sounds

   2. Press firmly on skin

3. Bell

   1. Best for LOW pitched sounds

      1. Murmurs, bruits

   2. Press lightly on skin

4. Tubing

   1. Thick, stiff, heavy

   2. 12-18 inches to minimize distortion

5. Tips:

   1. Warm your stethoscope

   2. Examine from the right side

   3. Close eyes to focus attention

   4. Auscultate on BARE skin

Quality of sounds during auscultation

1. Quality of Sounds:

   1. Pitch

      1. High to low

   2. Loudness

      1. Soft to loud

   3. Duration

      1. Short, medium, long

      2. Respiration should be longer than inspiration

   4. Quality

      1. Description

General Survey

• Provides clues to overall health

• Begins the moment of contact

• First impressions → cues to what follow up is needed during exam

• Challengers your observational skills

• Usually includes vital signs, height, and weight

What to observe for when conduction a health assessment

• signs of distress

• stature & build

• dressing & grooming

• posture, gait, coordination

• eye contact

• level of consciousness

• affect

• speech patterns

• vision or hearing problems

• nutritional state

• significant others accompanying patient

What are the risk factors that must be identified in a Neuro Assessment?

• History of numbness, tingling, seizures, trembling

• Headaches or dizziness

• Trauma to head or spine

• History of HTN (hypertension) or stroke

• Changes in vision, hearing, taste, or smell

• History of diabetes or cardiovascular disease

• Alcohol and medications

When a risk factor is identified, what does the nurse do?

nurses think of the worst case scenario and rule it out from there

What are the steps to a neuro assessment?

• identify risk factors

• Health history interview

  • Possibility that a patient already has a neurological disorder or in a possibility to have dementia

• Mental status

  • The patient can know their name, location, time, but be abnormal in terms of behavior

• Memory

  • Especially for a dementia patient

  • Short-term: remember a word from the beginning of the appointment until the end

  • Long-term: “when did you get married?”

• Emotional status

  • A neurological disorder can lead to an impact on the emotional status

• Cognitive abilities and behavior

  • Tested by reading or doing a math problem

• Cerebellar function: 

  • Motor skills, coordination, and balance

• Cranial nerve function:

  • There are 12 cranial nerves with different functions mostly in the head and neck area

• Motor and sensory function:

  • Reflexes

Assessing Mental Status

• Level of consciousness: awake and alert, lethargic, stuporous, comatose

  • Glasgow Coma Scale (GCS): for patients with a cognitive impairment

• Level of awareness: time, place, person

• Memory

• Language

Glasgow Coma Scale (GCS)

• Eye Opening Response

  • 4: Spontaneous

  • 3: To speech

  • 2: To pain

  • 1: No response

• Verbal Response:

  • 5: Oriented to time, place, and person

  • 4: Confused

  • 3: Inappropriate words

  • 2: Incomprehensible sounds

  • 1: No response

• Motor Response:

  • 6: Obeys commands

  • 5: Moves to localized pain

  • 4: Flexion withdrawal from pain

  • 3: Abnormal flexion (decorticate)

  • 2: Abnormal extension (decerebrate)

  • 1: No response

Response Scores for A Glasgow Coma Scale

• Best response: 15

• Comatose client: 8 or less

• Totally unresponsive: 3