Transcript Chapter 1,2,3, and 5 NRS 310 Lecture 1

BSN: NRS—310
Nursing Assessment
and
Health History
Nancy Sanderson MSN, RN
Lecture 1: Chapters 1-3, and 5
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
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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
3
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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
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Nursing Diagnosis
Made by the nurse
Describes clients
response
Responses vary
between individuals
Changes as client
responses change
Nurse orders
interventions
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Medical Diagnosis
Made by a physician
Refers to the disease
process
Somewhat uniform
between clients
Remains same during
disease process
Physician orders
interventions
Medical Diagnosis
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Pneumonia
Dehydration
Hyperkalemia
----Myocardial infarction (heart
attack)
Nursing Diagnosis
 Ineffective breathing
pattern
 Fluid volume, risk for
deficient
 Electrolyte imbalance, risk
for imbalance
 Cardiac Output, decreased
 Perfusion, risk for
decreased cardiac tissue
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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
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Assessment
Nursing diagnosis
Goal
Implementation
Evaluation
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Three primary components
◦ History (subjective data)
◦ Examination (objective data)
◦ Documentation of data
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Data = signs and symptoms
◦ Symptom = what client
feels/communicates (subjective)
◦ Sign = clinical finding (objective)
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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
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Subjective: “I’ve never had such bad pain in my life”
Objective:
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Pt is bend over holding abdomen
Blood pressure is high
Abdomen is rigid
Bowel sounds are absent
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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.
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• 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
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Nurses provide education and care to help
meet health promotion needs.
View health care as holistic:
◦ Mind
◦ Body
◦ Spirit
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◦ 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
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Immunizations,
nutrition teaching,
exercise
Physical examinations,
teaching patient how to
do a breast exam
Management of
Diabetes Mellitus,
Cardiac Rehab
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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
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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.
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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:
1.
2.
3.
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.
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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:
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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
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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.
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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.
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Older Adult
◦ Always address by last name.
◦ Adjust pace of interview and avoid
hurrying them along.
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Hearing Impaired
◦ Ask preferred way to communicate (i.e.
signing, lip reading, or writing).
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Acutely Ill
◦ In emergency must combine interview
and PE. Pick out points of history most
important/relevant and use closed,
direct question earlier.
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Orientation / Introduction Phase
• Working /Discussion Phase
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▫ 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
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 Check
ID band with 2 identifiers
◦ Name
◦ Identification number assigned by health
care agency
◦ Telephone number
◦ Date of birth
 State
your purpose &
obtain consent
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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
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Professional Image
▫ Clean, neat, well groomed, & conservatively
dressed
▫ Odor free
▫ Tattoos covered & piercings removed
▫ Speak in clear, well-modulated voice with good
grammar
▫ Listens to others and communicates effectively
▫ Helps and supports colleagues
▫ Begins shift on time
▫ Is organized, well prepared, and equipped for the
responsibilities of the nursing role
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•
Active Listening
▫ S- Sit facing patient
▫ O- Observe an open
posture
▫ L- Lean towards the
patient
▫ E- Establish and
maintain eye
contact
▫ R- Relax
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• 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
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Subjective data
 What the patient tells you
 Health History
 Symptoms
•
Objective data
 What examiner detects during exam
 Physical Examination
 Signs
 Labs
 Non-verbal behaviors
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Patient complains of abdominal pain
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Head pain is throbbing
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Facial features are symmetrical
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Heart rate is 80bpm
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Patient feels short of breath
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Essential and relevant data about the nature and onset of symptoms for the illness that
patient is requesting care for.
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Using mnemonic may help to ensure obtain complete
history (OLDCARTS)
Onset, Location, Duration, Characteristics, Aggravating/Alleviating,
Related, Treatment, Severity
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O = Onset
◦ When began?
◦ Begin suddenly or gradually?
◦ What was doing/mechanism?
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L = Location
◦ Where is pain/complaint located?
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D = Duration
◦ Symptoms always present or do they come & go?
 If come & go, how long last?)
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C = Characteristics
◦ Describe pain/complaint.
 I.e.: Sharp, dull, throbbing, aching
◦ What is pain level at worst? What is it right now?
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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
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R = Radiation
◦ Does pain/complaint radiate?
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T = Treatments tried
◦ What have tried to treat pain/discomfort?
◦ What was outcome?
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S= Severity
◦ How severely does this interfere with your life?
◦ Describe how many, the size, the amount
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Give patient a clue that interview is
coming to an end
 Summarize important points and ask if
summary is accurate
 Address any plans for action
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◦ 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
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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.
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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?
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Active listening concentrates on client
responses and subtleties.
▫ Avoid formulating next question during
responses.
▫ Avoid making assumptions about client
responses.
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Facilitation uses phrases to encourage
clients to continue talking further.
▫ Verbal: “What do you mean?”, “Go on,” “Uhhuh,” “Then…?”
▫ Nonverbal: head nodding or shifting forward to
listen more intently
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Clarification is used to gather more information.
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Restatement is repeating in different words what
client says to confirm interpretation.
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Reflection is repeating what client said and
encourages elaboration or more information.
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Confrontation is used when inconsistencies are noted
between client report and nurse’s observations.
◦ Use tone of voice to convey confusion or possible
misunderstanding.
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Interpretation is used to share conclusions
drawn from data.
◦ Client may then confirm, deny, or revise.
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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
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Using medical terminology confusing to client
◦ May not understand question or be embarrassed to
request clarification, and therefore give inaccurate
data
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Expressing value judgments
Giving false reassurance
Interrupting while clients are talking
Having an authoritarian or paternalistic
demeanor
Asking “Why” questions that may threaten
clients and make them defensive
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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.
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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.
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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
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Others in the room
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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.
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1.
2.
3.
4.
5.
Types of health histories
Components of the health history
Personal and psychosocial history
Review of systems
Health history based on functional
health patterns
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Comprehensive health history
 History for problem-based or
focused health assessment
 Episodic or follow-up
assessment
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◦ Focuses on specific problems for
which client is already receiving
treatment
◦ Assesses for changes since last
visit
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•
History for problem-based or focused health
assessment
▫ Data that are limited in scope to specific problem
▫ Detailed enough that nurse may be aware of other
health-related data affecting the current problem
▫ Focused interview also used when client seeks to
address urgent problems such as relief from asthma
attacks or chest pain
 Further data may be collected once client is stabilized.
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 Biographical Information
 Past Health History
 Reason for Seeking Care
 Family History
 Client expectations
 History of Present Illness/Present
Health Status
 Environmental History
 Personal & Psychosocial
History (Spiritual)
 Review of Systems
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 Complete
◦ Generalized
◦ Comprehensive
 Focused
◦ Problem oriented
 On-going
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 Complete
◦ Generalized
◦ Comprehensive
 Focused
◦ Problem oriented
 On-going
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Not all histories are organized by body
systems.
Nurses may use a common interview
format based on functional health
patterns.
◦ Database for organizing client information
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Functional health patterns collects and
organizes data in 11 areas.
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Health perception–
health management
Nutrition-metabolism,
nutrition-metabolic
Elimination
Activity-exercise
Cognitive-perception
Sleep-rest
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Self-perception–
self-concept
Role-relationship
Sexualityreproduction
Coping-stress
tolerance
Values-belief
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 Factual
demographic data about the
patient
◦ Name
◦ Age
◦ Marital Status
◦ Address
◦ Occupation
◦ Primary Care Provider
◦ Primary Language Spoken
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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
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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?)
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Allergies
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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.
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Nurse documents present illness or problem.
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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 selftreatments.

If general visit and no presenting problem,
focus interview on current state of health.
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Childhood Illnesses
 Accidents / injuries
 Chronic illness
 Medications
 Previous Medical Conditions/Problems
 Previous Hospitalizations /Surgeries
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◦ Include type, year, and residual problems for all
above
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Immunizations
◦ Include dates and reactions
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Women Only
◦ Last menstrual period
(LMP)
◦ Last pregnancy
 Gravida
 Para
 Abortion/miscarriage
◦ Last pap smear
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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.
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Ask about specific diseases.
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Alzheimer’s disease
Cancer (all types)
Diabetes mellitus: (specify type 1 or type 2)
Coronary artery disease including myocardial infarction
Hypertension
Stroke
Seizure disorders
Mental illness, including depression, bipolar disorder, schizophrenia
Alcoholism and/or drug abuse
Endocrine diseases
Kidney disease
Genogram a tool useful in tracing diseases with genetic tendencies
refer to Fig. 2-3 (pg16).
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•
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?)
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Have you ever felt the need to Cut down on drinking?
Have you ever felt Annoyed by criticism of your
drinking?
Have you ever felt Guilty about drinking?
Have you ever taken a drink first thing in the morning
(Eye-opener) to steady your nerves or get rid of a
hangover?
◦ Two or more + answers suggest alcohol misuse
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This information may help identify unique patient needs,
areas for patient education, and the need for non-nursing
type interventions
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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?
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Functional Ability
Ability to perform self-care activities
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•
Sleep patterns
▫ Short-term sleep deprivation associated with
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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
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Health Promotion
◦ Exercise
 Type & frequency
◦ Self-examination
 Type & frequency
◦ Oral hygiene practices
 Frequency of brushing/ flossing
◦ Date of last screening examination
 i.e. BP, breast, prostate, glucose, colon
Immunizations
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
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?
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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
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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.
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General symptoms
Integumentary
Head and neck
Breasts
Respiratory
Cardiovascular
Gastrointestinal
Urinary system
Reproductive
Musculoskeletal
Neurologic system
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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.
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
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.
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