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Health Assessment

Health Assessment. Patrick Heyman, PhD, ARNP. Patrick Heyman, PhD, ARNP. B.S. from Palm Beach Atlantic BSN, MSN, PhD from University of Florida Board Certified Nurse Practitioner Worked in both hospital and outpatient settings Also teach Ballroom and Latin dancing

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Health Assessment

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  1. Health Assessment Patrick Heyman, PhD, ARNP

  2. Patrick Heyman, PhD, ARNP • B.S. from Palm Beach Atlantic • BSN, MSN, PhD from University of Florida • Board Certified Nurse Practitioner • Worked in both hospital and outpatient settings • Also teach Ballroom and Latin dancing • Missionary kid, grew up in Liberia, Costa Rica, and Uruguay

  3. Wholistic Assessment and Documentation

  4. Health Assessment • What is Health? • Medical Model • Functional Model • Wellness Model • System Stability • Homeostasis – dynamic balancing • Allostasis

  5. Assessment • Nursing Process • Assessment • Diagnosis • Planning • Implementation • Evaluation

  6. Neuman Systems Model • Person Variables • Physiological • Psychological • Socio-cultural • Developmental • Spiritual

  7. Wholistic Assessment • Humanistic • Reductionistic vs. Wholistic • Five Person Variables • Perception of Nurse and Patient

  8. Documentation • Legal record • If you don’t document it, you didn’t do it • HIPPA • When turning in assignments regarding real patients, use patient’s initials only. • If making a copy of part of a chart for reference for an assignment, obscure identifiers.

  9. Kinds of Data • Datum – piece of information • Database – Collection of all data concerning a patient • Subjective data • Symptoms • Objective data • Signs

  10. Documentation Considerations • Narrative vs. Charting by exception • Appropriate use of abbreviations • Appropriate use of medical terminology • Models • H&P • SOAP: subjective, objective, assessment, plan • DAR: data, action, response • DARP: data action, response, plan

  11. Talking to the Patient

  12. Basic Interviewing Technique • Building Rapport • Be yourself, but not too much of yourself • Use discretion • Present • Interest • Competence • Confidence • Do not present • Apathy • Diffidence • Arrogance

  13. Basic Interviewing Techniques • Dress • Professional • Not imposing • Patient Centric Interview • Open ended questions • Empathy – Not Sympathy • Provider centric

  14. Basic Interviewing Techniques • Interviewer centric • Use of silence • Time • Attention • Schedule

  15. Interviewing Stages • Introduction • Establish who you are • Establish agenda • Working Phase • Patient centric • Provider Centric • Conclusion • Provide closure • Establish a plan

  16. Introductory Script • Hello, Mr. Smith? • My name is ________. • I am a ________. • I am here to __________. • I just need to verify your id bracelet. • Do you have any questions for me before we begin.

  17. Cultural Considerations • Culture - A complex pattern of shared meanings, behaviors, and beliefs, that are learned and acquired by a group of people. • Characteristics • Learned from birth through socialization and language • Adapted to specific conditions • Dynamic • Shared by in common

  18. Related words • Subculture • Ethnocentrism • Prejudice • Stereotype • Discrimination

  19. Cultural Values • Dominant Value Orientation • Innate Human Nature • Relationship to nature • Time Dimension • Purpose of Existence • Family • View of Health and Illness • Family relationships • Communication patterns

  20. View of Health and Illness • Freedom from disease • Able to go to work • Feel good • Pathogenesis • Biomedical • “Naturalistic” • Magico-Religious

  21. Family relationships • Who makes decisions • Who counts as family • Loyalty to the family

  22. Communication patterns • Language • Dialects, slang, and vague language • Conversational style • Silence

  23. Communication Patterns • Nonverbal • Eye contact • Posture • Personal space • Response to touch • Orientation to time • Expression of symptoms • Stoic • Expressive

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