Health History Taking, General Survey, and Mental Health Status Assessment Flashcards

1
Q

Biomedical approach to health

A
  • Dominated most of the 20th century
  • Emphasized health as the absence of disease
  • No health promotion/health prevention strategy
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2
Q

Behavioural approach to health

A
  • Emerged in the 1970s
  • Lalonde Report (1974)
  • First modern government in the Western world that acknowledged the missing parts in the biomedical approach
  • Wanted to decrease behavioural factors that compromised health
  • Social campaigning about health and lifestyle
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3
Q

Socio-environmental approach to health

A
  • Mid 1980s
  • Realization that these “healthy lifestyle changes” were only being made by those in upper brackets
  • Concept that there are socioeconomic factors that influence health and decisions regarding health
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4
Q

Ottawa Charter

A
  • Recognized health as a fundamental human right
  • Identified 9 pre-requisites for health
  • peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice, equity
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5
Q

WHO definition of health

A
  • Health seen as a resource for everyday life
  • Not he objective of living
  • Positive concept emphasizing social and personal resources as well as physical capabilities
  • Not just the absence of disease
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6
Q

What is health assessment

A

“Assessment is the collection of data about an individual’s health status”

  • Involves both subjective (symptoms) and objective data (signs)
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7
Q

Types of assessment

A

1) Complete health assessment
- Complete head to toes exam
- Also includes full health history; physical exam; family history

2) Episodic or Problem based assessment (Focused assessment)
- For a limited or short term problem, usually directed at one issue at a time

3) Follow up assessment
- Already an identified issue and following or re-evaluating how the patient is doing

4) Emergency assessment
- Very rapid collection of assessment data usually done to ensure live saving measures

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8
Q

Why is health assessment important

A
  • Collecting all the pieces to make the big picture
  • The hallmark of what nurses do
  • It’s from gathering the data that we can make our judgements
  • Other healthcare professionals will be making judgements based off our data
  • Always assessing, always investigating
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9
Q

Nursing Process

A

Assess
- Gather information about the client’s condition

Diagnose
- Identify the client’s problem

Plan
- Set goals of care and desired outcomes and identify appropriate nursing actions

Implement
- Perform the nursing actions identified in planning

Evaluate
- Determine if goals met and outcomes achieved

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10
Q

The complete health history: Subjective assessment

A
  • Biographical data
  • Source of history
  • Reason for seeking health care
  • History of current illness (PRQRTU-AAA)
  • Past health
  • Family history
  • Review of systems
  • Functional assessment (ADLs)
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11
Q

PQRSTU-AAA

A
P - provokes
Q - quality and/or quantity
R - region and/or radiation
S - severity 
T - timing
U - understanding the patient's perspective
A - associated factors
A - alleviating factors
A - aggravating factors
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12
Q

Past health

A
  • Childhood illnesses
  • Accidents/injuries
  • Serous/chronic illness
  • Hospitalizations
  • Operations
  • Obstetrical history
  • Immunizations
  • Last exam date
  • Allergies
  • Current medications
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13
Q

Review of systems

A
  • General overall health
  • Skin, hair
  • Eyes, ears, nose, mouth and throat
  • Neck
  • Breasts
  • Axilla
  • Respiratory system
  • Cardiovascular system
  • Peripheral vascular system
  • GI systen
  • Urinary system
  • Genital system
  • Sexual health
  • Musculoskeletal system
  • Neurological system
  • Hematological system
  • Endocrine system
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14
Q

Functional Assessment (ADLs)

A
  • Self esteem/self concept
  • Financial resources
  • Activity/mobility
  • Sleep/rest
  • Nutrition and elimination
  • Relationships/support systems
  • Spiritual resources
  • Coping and stress management
  • Alcohol, tobacco, substance use
  • Environmental hazards
  • Violence in the home
  • Occupational health
  • Perception of health
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15
Q

The physical assessment: objective data

A
  • Vital signs
  • Measurements
  • IPPA
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16
Q

IPPA

A

I - inspection
P - palpation
P - percussion
A - auscultation

17
Q

Insepection

A
  • “Concentrated watching”
  • Compare side to side
  • Expected vs unexpected findings
18
Q

Palpation

A
  • Using your sense of touch to assess the client
  • Texture, temperature, moisture, organ location and size, vibrations, pulsations
  • Systematic, calm and gentle
  • Palpate tender areas last
  • Start with light palpation and move to deep palpation
  • Fingers palpation to discriminate fine things, swelling or pulses
  • Back of hand good for assessing temperature
  • Ulnar surface of hand good for vibrations
19
Q

Percussion

A
  • A method of tapping on a surface to determine the density of the underlying structure
used to:
- Map out the location/size of an organ
- Provide information regarding the density of a structure
▪Detecting a mass
▪Elicit pain
▪Elicit deep tendon reflexes

Common Percussion Notes:
▪Resonant- hollow, air-filled
▪ Dullness- muffled thud (not air-filled, could be filled with something else like fluid, a mass, etc.)

20
Q

Ascultation

A

▪ Listening to sounds produced by the body
▪ Important to have a good quality stethoscope
▪ Diaphragm – bigger, flatter side; used to hear high-pitched sounds
▪ Bell – smaller, concave piece; best for low-pitched sounds

Common issues when auscultating:
▪ Extra room noise
▪ Shivering – can sound like an unexpected sound
▪ Hair – makes sound similar to fluid in lungs
▪ Listening over clothes/gowns
▪ Tubing rubbing against objects (or itself)
▪ Poorly fitting earpieces
▪ Incorrect placement of earpiece
▪ Poor quality stethoscope

21
Q

Social and cultural considerations in health assessment

A

Consider the following:
▪Social determinants of health
▪Dangers of “culturalism”
- Assuming a person has a certain set of beliefs because they belong to a certain cultural and look/claim to be a part of a certain culture
▪ We all have a cultural orientation
- Family background, socioeconomic status, spiritual orientation, etc. affects how we view the world

In your practice:
▪ Approach from a position of curiosity, reflexivity and empathy
▪With all clients it is important to:
▪ Build trust – genuine trust
▪ Listen – actively listen
▪ Convey respect – even when people are making choices and decisions that you wouldn’t make or contradicts their health
▪ Promote client comfort, dignity and safety

22
Q

The general survey

A

▪ Is a survey of the overall impression or appearance of the client
▪ Should occur each time you meet the client

Consists of 4 areas:
▪ Physical Appearance
▪ Body Structure
▪ Mobility
▪ Behaviour
23
Q

General survey: Physical appearance

A

▪ Level of consciousness (LOC)
▪ Skin condition
▪ Facial features
▪ Acute signs of distress

24
Q

General survey: Body structure

A

▪ Symmetry
▪ Posture
▪ Position

25
Q

General survey: Mobility

A

▪ Gait
- Noticing anything different than normal
▪ Range of Motion (ROM)
- Mobility in joints? Is movement coordinated?

26
Q

General survey: Behaviour

A

▪ Facial expressions
- Appropriate for situation? Maintaining eye contact?
▪ Mood/Affect
▪ Speech
- Clear, understandable? Something changed?
▪ Dress
▪ Personal Hygiene

27
Q

Mental Health vs Mental Illness

A

▪ Mental Health = a person’s emotional and cognitive well-being, everyone has mental health, one’s level of mental health will fluctuate.
- Everyone has mental health

▪ Mental Illness = Can take many forms, just like a physical illness. A mental illness or disorder affects a person’s mood, thinking and behaviour, can cause significant distress, and impair one’s ability to function in their everyday life.

28
Q

Mental Health Assessment: ABCT

A
  • Appearance
  • Behaviour
  • Cognition
  • Thinking
29
Q

ABCT: Appearance

A

General presentation

  • Posture
  • Body movement
  • Dress
  • Hygiene
30
Q

ABCT: Behaviour

A

▪ Speech
▪ Mood/affect
- Differences or variations from the last time you saw them
- Checking in with them about their mood, asking them if it is different

31
Q

ABCT: Cognition

A

▪ LOC (alert, awake)
▪ Orientation (to person, place, and time)
▪ Attention and concentration (able to attend to you and follow conversation, distracted)
▪ Memory (able to recall what happens in the day)
▪ Comprehension and reasoning (following what you’re saying, making reasoning that is seemingly making sense, degree of insight)

32
Q

ABCT: Thinking

A

▪ Process (are they making sense, can I follow them)
▪ Content (logical)
▪ Insight and Judgment (into illness or what’s happening, following a thought process)
▪ Perception (about themselves and the world around them)
- Looking for changes or differences for previous experiences
- Quick screen as part of everyday assessment