NRS 103: Nursing Assessment and Health History

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

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

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

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

Nursing Dx VS Medical Dx
Nursing Diagnosis Made by the nurse Describes clients response Responses vary between individuals Changes as client responses change Nurse orders interventions Medical Diagnosis Made by a physician Refers to the disease process Somewhat uniform between clients Remains same during disease process Physician orders interventions 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 Medical diagnosis identifies disease and organ dysfunction. Does not change as long as disease is present. Requires medical interventions

The Nursing Process: MI
Assessment: Monitor HR/BP; Skin Color and perfusion; peripheral pulses; capillary refill Nsg Dx: 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

Health Assessment Class
Nursing diagnosis Goal Implementation Evaluation

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) Systematic method of data collection to identify 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 Context of care refers to circumstance or situation related to health care delivery. The reasons different types of assessments are performed by nurses The setting or environment: physical, psychological, socioeconomic, and the expertise of nurse

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

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

Types of Health Assessment
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. 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. 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

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

Health Promotion and Health Protection
Nurses provide education and care to help meet health promotion needs. View health care as holistic: Mind Body Spirit Health promotion Behavior motivated by desire to increase well-being and actualize health potential Health protection Behavior motivated by desire to avoid illness, detect illnesses early, and maintain functioning when ill Central component of nursing Begins with health assessment—data to identify client’s health status, practices, and risk factors Interpretation of data allows nurse to target health promotion needs. Framework for health promotion Healthy People 2010: Understanding and Improving Health (DHSS) National health objectives address most significant preventable threats to health with goals to reduce threats. Two overarching goals Increase years of healthy life. Eliminate health care disparities.

3 Levels of Health Promotion
Immunizations, nutrition teaching, exercise Physical examinations, teaching patient how to do a breast exam Management of Diabetes Mellitus, Cardiac Rehab 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

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

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. Standard 1 directly affects nurses. Healthcare organizations should ensure that clients receive: Effective, understandable, and respectful care Care provided in a manner compatible with cultural health beliefs and practices and preferred language English Proficiency (LEP) must be provided an interpreter that is not family/friend. Working with an Interpreter Arrange room you and patient have eye contact. Seat interpreter next to patient. Address the patient directly. Keep sentences short and simple.

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:

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.

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

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.

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.

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.

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 Three phases Introduction: Discussion: Facilitate discussion of client’s health. Client centered—meaning clients share their concerns, beliefs, and values in their own words Summary: Review client’s main points. Emphasize data that have implications for health promotion, disease prevention, or resolving health problems. The summary allows clarification and validation for clients and shows that you have an accurate understanding of their health issues, problems, and concerns.

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

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

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 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

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

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

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

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?

OLDCARTS D = Duration C = Characteristics
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

OLDCARTS R = Radiation T = Treatments tried S= Severity
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

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

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. Some areas of questioning are sensitive, and sensitivity varies. Explain that you may have sensitive or personal questions. Use technique referred to as permission giving.

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? Close-ended questions yield more precise data. Give client options for response. Use with open-ended questions to avoid inaccuracy. Directive questions lead client to focus on one set of thoughts. Most often used in reviewing systems and evaluating functional status

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

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

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.

Challenges to the Interview
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. 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

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. Others in the room Others may disrupt and answer for client. Validate data with client. Ask to allow client to answer or ask other to allow privacy. Find activity for children who may disrupt. Language barrier Translator should be objective observer, same gender, but not a family member. Takes more time to obtain the most important data

Types of health histories Components of the health history
Personal and psychosocial history Review of systems Health history based on functional health patterns Health history is process of collecting and documenting subjective data from client through interview process. Regardless of type of history, nurses determine whether to ask or defer certain questions because situations exist when certain data are irrelevant to some individuals. Additionally, during an interview nurses may uncover important data requiring further investigation.

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

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

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

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

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

Reason for Seeking Care
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 “I’ve had pains in my stomach for the past 3 days”

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?)

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.

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.

Past Health History Childhood Illnesses Accidents / injuries
Chronic illness Medications Previous Medical Conditions/Problems Previous Hospitalizations /Surgeries Include type, year, and residual problems for all above Immunizations Include dates and reactions

Family History (Cont’d)
Narrative form or illustrated Genogram to document presence of condition Tool consisting of a family tree diagram depicting members within a family over several generations Useful in tracing diseases with genetic links Symbols are used to indicate men and women and those who are alive and deceased. Include current ages of those who are alive, and cause of and age at death of those who are deceased. Refer to genogram figure in text book pg. 16 Fig. 2-3

Family History Blood relatives: biologic parents, aunts, uncles, siblings, children, and including spouse Identify genetic, familial, environmental factors that might affect current or future health status. Trace back two generations to parents and grandparents.

Personal & Psychosocial History
Mental Health Mental illnesses (anxiety, depression, etc.) Stressful events Describe stresses in life now What methods do you use to relieve stress and are they effective? Personal coping strategies Do you have a social support network (family, friends, coworker, church? Personal Habits Tobacco (packs/day, how long?) Alcohol (drinks/day, how long?) Illicit Drugs (name of drug, how often, how long?)

This information may help identify unique patient needs, areas for patient education, and the need for non-nursing type interventions Family/Social Relationship Role in the family How getting along? Domestic Violence Diet and Nutrition Record 24 hour diet recall Who buys and prepares food for patient? Functional Ability Ability to perform self-care activities Personal status: general statement of feelings about self Family and social relationships Diet and nutrition Functional ability Mental health Personal habits: tobacco, alcohol, illicit drugs Health promotion activities Environment

Mental Health Mental illnesses (anxiety, depression, etc.) Stressful events Describe stresses in life now What methods do you use to relieve stress and are they effective? Personal coping strategies Do you have a social support network (family, friends, coworker, church? Personal Habits Tobacco (packs/day, how long?) Alcohol (drinks/day, how long?) Illicit Drugs (name of drug, how often, how long?)

Sleep patterns Short-term sleep deprivation associated with Delay of wound healing Decreased performance and alertness Memory and cognitive impairment Stressed relationships Decreased quality of life Occupational and automotive injury Long-term Increased BP, heart attack, heart failure, stroke, obesity, diabetes mellitus, psychiatric problems, ADD, mental impairment Note: Alcohol, nicotine & caffeine are stimulants and should be avoided 4-6 hours before bed

Health Promotion Exercise Type & frequency Self-examination Oral hygiene practices Frequency of brushing/ flossing Date of last screening examination i.e. BP, breast, prostate, glucose, colon Immunizations

Environment (living & work environment) Housing & Neighborhood Type of structure, live alone, safety Hazards at workplace or home? Use of seat belt? Use of sun block? Cigarette smoke? How are medications stored in the house? Own a gun? If yes, how stored?

Review of Systems Purpose is to:
Evaluate past and present health states for each body system Double check that no data were omitted in the present illness section Evaluate health promotion practices

Review of Systems Past and present health of each body system
Conduct symptom analysis when clients indicate presence of symptoms. Medical terms Define for client understanding. Use for documentation and communication with health team. Avoid repeating review of systems if present health status section data is sufficient.

Review of Systems (Cont’d)
General symptoms Integumentary Head and neck Breasts Respiratory Cardiovascular Gastrointestinal Urinary system Reproductive Musculoskeletal Neurologic system

Review of Systems (Cont’d)
Additional health promotion data may be collected during review of systems. In a comprehensive health assessment, you ask most of the questions. In a focused health assessment, you ask questions about systems related to reasons for seeking care.

Summary Collecting a thorough history accomplishes several goals.
Establishes a therapeutic relationship with the client Provides a snapshot of client and identifies problems mentioned by client that can be confirmed or refuted during exam Data must be organized, synthesized, and documented. Organized collection of data makes documentation easier.

NRS 103: Nursing Assessment and Health History

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NRS 103: Nursing Assessment and Health History

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