NRS 103: Nursing Assessment and Health History

1. NRS 103: Nursing Assessment andHealth History Lecture 1 Chapters 1-3. Nancy Sanderson MSN, RN

2. Why Learn Health Assessment? AD PIE: • Every interaction is part of the nursing process • Nursing process = six steps • First step: Assessment • ANA definition (Standards of Practice) • Components of health assessment • Health history • Physical examination • Documentation of data

3. Step # 1: Assess • Full assessment • Determine what is the problem • Determine what is acceptable range, sounds, look, etc • Determine what is not within the acceptable range: crackles in lungs, abnormal heart sounds, distended abdomen, etc

4. Nursing Diagnosis (NANDA) • NOT a medical diagnosis • The nursing diagnosis helps the student critical think, determine how to plan, and to make goals NDX describes the client’s response to actual or potential problems or conditions; changes from day to day within the legal scope of independent nursing practice

5. Nursing DxVS Medical Dx • Medical Diagnosis • Made by a physician • Refers to the disease process • Somewhat uniform between clients • Remains same during disease process • Physician orders interventions • Nursing Diagnosis • Made by the nurse • Describes clients response • Responses vary between individuals • Changes as client responses change • Nurse orders interventions

6. The Nursing Process: MI • Assessment: Monitor HR/BP; Skin Color and perfusion; peripheral pulses; capillary refill • NsgDx: Risk for decreased cardiac output • Plan/goal: Cardiac pump effectiveness: VS and Fluid Balance • Intervention: Assess respiratory rate, rhythm & breath sounds; Urine output; Administer medications & IV fluids as ordered by MD • Evaluation: VS stable; UO > 30 ml/hr; meds/IV’s administered as ordered

7. Health Assessment Class • Assessment • Nursing diagnosis • Goal • Implementation • Evaluation

8. Components of Health Assessment Three primary components History (subjective data) Examination (objective data) Documentation of data Data = signs and symptoms Symptom = what client feels/communicates (subjective) Sign = clinical finding (objective)

9. A systematic method of data collection assists the nurse in identifying the client’s health characteristics Data collected focuses on client’s health compared with ideal—accounting for client’s traits • Collection and analysis of data leading to identification of problems: • Guides nurse in developing care plan • Assists client to maximize health potential • Amount of information gained during a health assessment depends on several factors including: • Context of care • Client need • Expertise of the nurse

10. Example • Subjective: “I’ve never had such bad pain in my life” • Objective: • Pt is bend over holding abdomen • Blood pressure is high • Abdomen is rigid • Bowel sounds are absent

11. Types of Health Assessment • Expertise of the nurse is gained with specialization within a given area of practice; for example: • A nurse in an adult intensive care unit has expertise assessing a client with hemodynamic instability. • A family nurse practitioner working in a women’s clinic has expertise in performing routine pelvic examinations. • Client needs vary widely. • Nurse must be prepared to conduct appropriate level of assessment. • Client’s age, general level of health, presenting problems, knowledge level, and support systems are among the variables that impact client need.

12. Data organization involves organizing or clustering data that allows problems to be clearly apparent. • Data analysis, interpretation, and clinical judgment includes: • Identification of abnormal findings • Correctly interpreting findings to select appropriate interventions • Clinical judgment to interpret or make conclusions regarding patient needs, concerns, or health problems

13. Health Promotion and Health Protection Nurses provide education and care to help meet health promotion needs. View health care as holistic: Mind Body Spirit

14. 3 Levels of Health Promotion • Primary = preventing disease from developing; promoting healthy lifestyle • Secondary = screening to find early indicators of disease • Tertiary = minimizing disability from acute/chronic illness/injury and allowing for most productive life within limitations • Immunizations, nutrition teaching, exercise • Physical examinations, teaching patient how to do a breast exam • Management of Diabetes Mellitus, Cardiac Rehab

15. Techniques for Specific Populations Cultural Diversity • Many cultures are a continuum of diversity in behaviors and beliefs. • Cultural dynamics mean change. • Culture = shared beliefs, values, and behaviors that define right, wrong, abnormal, inappropriate • Diversity can create challenges. • When cultures and languages differ • When caring for individuals by not forcing compliance, by working with beliefs and value systems

16. Ethnic and Cultural Considerations (Cont’d) • CLAS (Culturally, and Linguistically Appropriate Services) standards to ensure equitable and effective treatment. There are 14 standards. • They are organized around three themes. • Culturally-competent care • Language access services • Organizational supports for cultural competence Refer to Boxes 5-1, 5-2, & 5-3 for tools, tips and barriers of assessing spiritual & cultural needs.

17. Ethnic and Cultural Considerations (Cont’d) • Nurses and other health care teams are affected by the first standard which states “ Healthcare organizations should ensure that patients /customers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with cultural health beliefs and preferred language.” • Improving cultural awareness and meeting Standard 1 requires the nurse to take several steps:

18. Ethnic and Cultural Considerations (Cont’d) • Become culturally competent through sensitivity to differences between their own culture and that of the patient. • Avoid stereo typing and assuming the meaning of others behavior. • Develop a template that may be used for cultural and spiritual assessment of patient and their families.

19. Becoming Culturally Competent • Cultural competence is the ability to communicate among/between cultures and to demonstrate skill in interacting with and understanding people of other cultures. • A culturally-competent nurse: • Allows clients to explain meaning of illness • Respects concepts of time, space, contact • Respects physical/social activities • Respects systems of social organization/provides environmental control

20. Techniques for Specific Populations • Adolescent- • Show respect, be totally honest, and avoid using language that is absurd for your age or professional role. • Use ice breakers and keep questions short and simple. • Don’t assume they know anything about health interviews or physical exams. • Be aware of gestures and expressions. • If confidential material is uncovered consider what can remain confidential and what must share.

21. Techniques for Specific Populations • Under influence of Drugs/Alcohol • Ask simple, direct questions. • Make manner and questions nonthreatening, and avoid confrontation. • Be aware of hospital security or other personnel who could be called for assistance. • Angry/Violent • Deal with the angry feelings first • If sense suspicious or threatening behavior act immediately to defuse situation.Leave the exam room door open and position self between person and door. Speak in quiet, calm voice.

22. Techniques for Specific Populations • Older Adult • Always address by last name. • Adjust pace of interview and avoid hurrying them along. • Hearing Impaired • Ask preferred way to communicate (i.e. signing, lip reading, or writing). • Acutely Ill • In emergency must combine interview and PE. Pick out points of history most important/relevant and use closed, direct question earlier.

23. Patient Interview • Orientation / Introduction Phase • Working /Discussion Phase • Gathering data through health history • Introduction(Indicate your role in health care team) • Addressing the Environment • Establishing a therapeutic relationship • Termination / Summary Phase • Concluding the interview

24. Introduction • Check ID band with 2 identifiers • Name • Identification number assigned by health care agency • Telephone number • Date of birth • State your purpose & obtain consent

25. Addressing the Environment • Make environment comfortable and relaxed • Provide privacy, remove distractions • Appropriate lighting • Provide symptom management • Privacy is essential for sensitive issues. • Openness and honesty • Health care facilities not always conducive to privacy; draw curtains when available • HIPAA- Health Insurance Portability and Accountability Act, 2003 • Physical comfort for client and nurse • Distance allows conversation, eye contact, and appropriate personal space

26. Establishing a Therapeutic Relationship • Active Listening • S- Sit facing patient • O- Observe an open posture • L- Lean towards the patient • E- Establish and maintain eye contact • R- Relax

27. Single most important factor for successful interviewing is establishing rapport to gain client’s trust. • Affected by numerous factors: physical setting, nurse behaviors, type of questions asked, how questions are asked, as well as: • The personality and behavior of clients • How client is feeling at the time of interview • Nature of information being discussed or problem being confronted • EMPATHY (Identifying with feelings) vs SYMPATHY- (feeling sorry for them) Boundaries! • Empowering vs dependency

28. Types of Data • Subjective data • What the patient tells you • Health History • Symptoms • Objective data • What examiner detects during exam • Physical Examination • Signs • Labs • Non-verbal behaviors

29. Subjective or Objective? • Patient complains of abdominal pain • Head pain is throbbing • Facial features are symmetrical • Heart rate is 80bpm • Patient feels short of breath

30. History of Present Illness Essential and relevant data about the nature and onset of symptoms for the illness that patient is requesting care for. • Using mnemonic may help to ensure obtain complete history (OLDCARTS) Onset, Location, Duration, Characteristics, Aggravating/Alleviating, Related, Treatment, Severity • O = Onset • When began? • Begin suddenly or gradually? • What was doing/mechanism? • L = Location • Where is pain/complaint located?

31. OLDCARTS • D = Duration • Symptoms always present or do they come & go? • If come & go, how long last?) • C = Characteristics • Describe pain/complaint. • Ie Sharp, dull, throbbing, aching • What is pain level at worst? What is it right now? • A = Aggravating & Alleviating Factors • What makes it worse? What makes it better? • Other symptoms that occurring at same time that could be associated/Relevant portions of the Review of Systems

32. OLDCARTS • R = Radiation • Does pain/complaint radiate? • T = Treatments tried • What have tried to treat pain/discomfort? • What was outcome? • S= Severity • How severely does this interfere with your life? • Describe how many, the size, the amount

33. Termination/Summary Phase • Give patient a clue that interview coming to end • Summarize important points and ask if summary is accurate • Address any plans for action • If you need anything else just press the call light. Otherwise I will be back in 1 hour to check on you and give you more pain medication if you need it

34. The Art of Asking Questions • Essential competency of nurses • Ask clear-spoken questions • Define words, avoid using technical/medical definitions, and use slang only if necessary for certain conditions. • Adapt questions consistent with client level of understanding and knowledge. • Encourage clients to be specific and clarify meanings. • Ask one question at a time and wait for reply. • Be attentive to client feelings that may indicate need for additional data.

35. Health History Questions • Begin health history with open ended questions • Ask for narrative information • What brings you to the hospital today? • How can I/we help you today? • What concerns do you have today? • Continue with closed or direct questioning • Ask for specific information that elicits a 1 or 2 word response • Are you having any pain? • How would you describe your pain?

36. Techniques That Enhance Data Collection • Active listening concentrates on client responses and subtleties. • Avoid formulating next question during responses. • Avoid making assumptions about client responses. • Facilitation uses phrases to encourage clients to continue talking further. • Verbal: “What do you mean?”, “Go on,” “Uh-huh,” “Then…?” • Nonverbal: head nodding or shifting forward to listen more intently

37. Techniques That Enhance Data Collection (Cont’d) • Interpretation is used to share conclusions drawn from data. • Client may then confirm, deny, or revise. • Summary condenses and orders data to clarify sequence of events for client’s clarity. • Emphasizes data related to health promotion, disease protection, and resolving health problems

38. Managing Awkward Moments • Displays of emotion • Crying is natural and should be expected. • It may indicate need for follow-up. • A compassionate response enhances relationship. • Anger is uncomfortable for client and nurse. • Deal with it directly. • Identify source of anger: you or another person. • Discuss approaches and acknowledge feelings. • If client unable to continue, honor request to work with another nurse.

39. Challenges to the Interview • Silence • Necessary for clients to reflect and gather courage to address painful topics or issues • Feedback that client is not ready to discuss topic or that the approach needs to be evaluated • Become comfortable with silence • Managing overly talkative clients • Overly detailed problems may become distraction. • Re-focus interview on events relative to present. • Re-direct conversation with close-ended questions that may help reduce distractions.

40. Challenges to the Interview (Cont’d) • Others in the room • Don’t assume relationships, best to clarify. • Parent or guardian may answer for child. • Interview adolescents directly. • For adults unable to answer, another person may assist. • Client should be involved to the extent of capabilities. • When able to answer, direct questions to client. • If others in room, obtain client’s permission.

41. The Health History Types of health histories Components of the health history Personal and psychosocial history Review of systems Health history based on functional health patterns

42. Types of Health Histories (Cont’d) • Comprehensive health history • History for problem-based or focused health assessment • Episodic or follow-up assessment • Focuses on specific problems for which client is already receiving treatment • Assesses for changes since last visit

43. Components of the Complete Health History • Biographical Information • Reason for Seeking Care • Client expectations • History of Present Illness/Present Health Status • Past Health History • Family History • Environmental History • Personal & Psychosocial History (Spiritual) • Review of Systems

44. Types of Health Histories • Complete • Generalized • Comprehensive • Focused • Problem oriented • On-going

45. Health History Based on Functional Health Patterns (Cont’d) Health perception–health management Nutrition-metabolism,nutrition-metabolic Elimination Activity-exercise Cognitive-perception Sleep-rest Self-perception– self-concept Role-relationship Sexuality-reproduction Coping-stress tolerance Values-belief

46. Biographical Information • Factual demographic data about the patient • Name • Age • Marital Status • Address • Occupation • Primary Care Provider • Primary Language Spoken

47. Reason for Seeking Care “I’ve had pains in my stomach for the past 3 days” • Chief complaint or presenting problem • Brief statement regarding purpose for visit • Recorded in direct quotes from client • Multiple reasons: list and prioritize • Client may not give reasons until comfortable • Client condition determines next step • Urgencies requires expediency • Bibliographic data delayed • Data analysis to determine cause and develop plan

48. Present Health Status • Focus on client conditions. • Health conditions, acute and chronic • Duration and impact on daily lives • For example, diabetes, hypertension, heart disease, sickle cell anemia, cancer, seizures, pulmonary disease, arthritis, mental illness • Medications and reasons for taking each • Prescriptions • Over-the-counter • Herbal preparations • Allergies (true reaction or sensitivity?)

49. Present Health Status (Cont’d) • Allergies • Foods • Medications • Environmental factors • Contact substances • Specifically ask about substances client could be exposed to in health care setting, such as latex and iodine. • Clarify and distinguish between side-effect and allergy.

50. History of Present Illness • Nurse documents present illness or problem. • Further investigation of presenting problem • Symptom analysis is a systematic collection of data about history of symptom status. • Various formats include onset, location, duration, characteristics, severity, associated symptoms, alleviating and aggravating factors, and any self-treatments. • If general visit and no presenting problem, focus interview on current state of health.