Methods Of Colllecting Data, Health History Flashcards
is a process of sharing information and meaning, of sending and receiving messages. The messages we communicate are both verbal and nonverbal
Communication
The ___ being sent is more accurate than the verbal one. Be conscious on your beliefs and values and do not let them influence your verbal or nonverbal communication
nonverbal message
includes vocal cues or paralinguistics, action cues or kinetics, object cues, personal space, and touch.
Nonverbal behavior
Methods of Collecting Data
Interview
Observation
Physical Assessment
Structured communication intended to obtain
subjective data
It is a planned purposeful conversation
Interview
INTERVIEW
Interpersonal skills are very important, this is
called the
therapeutic use of self
2 types of approaches of interview
Directive interview
Non-directive interview
are structured with specific questions and are controlled by the nurse. These interviews require less time and are very effective for obtaining factual data.
Directive interview
are controlled by the patient, although the nurse often needs to summarize and clarify the data.
These interviews require more time than directive interviews but are very effective at eliciting the patient’s perceptions and feelings
Non-directive interview
Types of interview questions
Closed-ended
Open-ended
Actions that convey attentive listening (LOVERS)
Lean forward
Open
Voice quality
Eye contact
Relax
Sit squarely
Phase of interview
Introductory phase
Working phase
Termination phase
is the time to introduce yourself to your patient, put him or her at ease, and explain the purpose of the interview and the time frame needed to complete it
Introductory phase
is often where data collection occurs. It is usually very structured; it is also the longest phase.
Working phase
is the end of the interview process. you need to summarize and restate your findings. This provides an opportunity to clarify the data and share your findings with the patient.
Termination phases
• Leading the patient
• Biasing yourself
• Letting family members answer for patient
• Asking more than one question at a time
• Not allowing enough response time
• Using medical jargon
• Assuming rather than clarifying and verifying
• Taking patient’s response personally
• Feeling personally uncomfortable
• Using clichés
• Offering false reassurance
• Asking persistent or probing questions
• Changing the subject
• Taking things literally
• Giving advice
• Jumping to conclusions
Common interview pitfalls
Entails deliberate use of your senses of sight,
smell, and hearing to collect data.
Look at both your patient and his or her environment to detect anything out of the ordinary.
Observation
Systematic selection, watching, or noticing and
recording patient’s characteristic, behaviors, and
events
Observation
provides the objective data base. It helps you
assess your patient’s health status and identify
actual or potential problems.
Physical Assessment
is a process which results to diagnostic statement or nursing diagnosis
Its purpose is to identify the patient’s health care
need and prepare diagnostic statement/s
It involves identifying and prioritizing actual or
potential health problems
Diagnosing
A statement of a patient’s potential or actual health problems which nurses, by virtue of their
education and experience are capable and
licensed to treat (Gordon, 1976)
Nursing Diagnosis
It is a clinical judgment about an individual,
family, or community in response to actual and
potential health problems and life process (NANDA)
Nursing Diagnosis
describes a disease or pathology of specific organs or body system which can be treated thru medical intervention
Medical Diagnosis
Describe an actual, risk, or human response to health problem that nurses are responsible for treating independently
Nursing Diagnosis
What are types of nursing diagnosis
Types:
1. Actual nursing diagnosis
2. Potential/risk nursing diagnosis
3. Possible nursing diagnosis
4. Syndrome nursing diagnosis
5. Wellness nursing diagnosis
Describes human responses to levels of wellness in an individual , family or community that have a readiness for enhancement
Wellness Nursing Diagnosis
Parts of a complete nursing diagnosis
Problem
Etiology
Signs and symptoms
Formula in stating health problem for Actual nursing diagnosis
P + E + S
Formula in stating health problem for risk nursing diagnosis
P + risk factors
Formula in stating health problem for possible nursing diagnosis
Data but inadequate and with need for further ingvestigation
Formula in stating health problem for wellness diagnosis
Healthy response, high level of wellness
Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care
Planning
It is a mental formulation of a proposed method
of doing or making something in achieving a
given end
Planning
Its purpose is to identify patient’s goals and appropriate nursing interventions
In ____, nurses should set priorities in
collaboration with patient
Goals could be long-term or short-term
Objective should be SMART
Planning
are activities that the nurse plans and must be implemented to help a patient achieve the goals
Nursing intervention
Nurses should select ____ that are
safe, specific, realistic and feasible
Nurses should understand the reason for
any _____, the expected effect, and any potential problems that may result (rationale)
Intervention
Types of nursing intervention
Development
Supplemental
Facilitative
Types of nursing intervention
Enhances patient’s capability for self-care
Developmental
Types of nursing intervention
nurse doing things for the patient because he lacks technical knowledge or has physical disability
Supplemental
Types of nursing intervention
nurse removes barriers to care
Facilitative
Types of nursing function
Facilitative Independent
Dependent
Collaborative
It involves determining the effectiveness of your
plan.
• Did you meet your goals and outcomes?
• Need for patient reassessment
Evaluation
Every assessment that follows also needs to be
documented. To ensure continuity of care, your
patient’s assessment needs to be communicated
to all members of the healthcare team involved
in her or his care.
___ is one way of communicating patient assessment and intervention
Documentation
Documentation Methods
- Source-oriented or problem-oriented
documentation
a. SOAPIE
b. PIE
c. DAR (FDAR) - Charting by exemption (CBE) - is a shorthand
documentation method frequently used to save
time. - Narrative method
Provides the subjective database for your
assessment.
The purpose of it is to identify not only actual or potential health problems but also your patient’s
strengths.
As well as identify supports, identify teaching
needs, identify discharge needs, identify referral
needs.
Health History
Reason for seeking care
Chief complaint
Types of health history
Complete health history
Focused health history
includes biographical data, reason for seeking care, current health status, past health status, family history, a detailed review of systems, and a psychosocial profile
Complete health history
focuses on an acute problem, so all of your questions will relate to that problem.
Focused health history
Provide you with direct information related to a
current health problem, alert you to risk factors
for health problems, and point out the need for
referrals.
____ include the patient’s name, address, phone number, contact person, age/birth date, place of birth, gender, race, religion, marital status, educational level, occupation, and social security number/ health insurance.
Biographical data
Level of preventive healthcare
Primary
Secondary
Tertiary
• Usual state of health.
• Any major health problems.
• Usual patterns of healthcare.
• Any health concerns.
Current health status
assesses childhood illnesses, hospitalizations, surgeries, serious injuries, adult medical problems (including serious or chronic illnesses), immunizations, allergies, medications, recent travel, and military service.
The purpose is to identify any health factors from the past that may have a direct relationship to your patient’s current health status.
Past health history
Provides clues to genetically linked or familial
diseases that may be risk factors for your
patient.
Family history
Is a litany of questions specific to each body
system. The questions are usually about the most frequently occurring symptoms related to a specific system
Review of systems
Developmental assessments are often performed on ___ because the developmental changes that occur at this age are very observable and measurable.
children
Illness and hospitalization can have a major
impact on a child’s growth and development, by
either halting its progression or regressing it to
an earlier stage.
Developmental consideration
Focuses on health promotion, protective patterns, and roles and relationships.
It includes questions about healthcare practices and beliefs, a description of a typical day, a nutritional assessment, activity and exercise patterns, recreational activities, sleep/rest patterns, personal habits, occupational risks,
environmental risks, family roles and
relationships
Psychosocial profile
Is a process during which you use your senses to
collect objective data.
Most patient view PE with at least some anxiety
Physical Examination
• Goal is to identify variations from
normal.
• Explain procedure first
• Head to Toe
• Unaffected areas before affected
Physical Examination (PE)
Skills required by the nurse
Communication skills
Observation skills
Assessment techniques
Assessment techniques
Inspection
Palpation
Percussion
Auscultation
___ is the most frequently used assessment technique, but its value is often overlooked
The visual examination (using naked eye) of the
patient for detection of significant physical
features
Inspection
You are using your sense of touch to collect data.
____ is used to assess every system. It usually follows inspection, but both techniques are often performed simultaneously.
___ allows you to assess surface characteristics, such as texture, consistency, and temperature, and allows you to assess for masses, organs, pulsations, muscle rigidity, and chest excursion
Palpation
Types of palpation
Light palpation
Deep palpation
May obtain data such as
• presence of mass
• Organ enlargement
• Tenderness
• Swelling
• Moisture
• Temperature
• texture
PALPATION
For fine tactile discriminations, such as texture
of skin and size of lymph nodes, use ___
because they are most sensitive areas
fingers
For temparature use ___ of the
hands/fingers
dorsa
____ aspect of the hands are more sensitive
to vibration
Palmar
For position and consistency, use
grasping action of the fingers
Use ____ to determine tenderness
ballottement
When palpating abdomen, particularly during
deep palpation, use ___ technique
bimanual
____ is used to assess density of underlying structures
It entails striking a body surface with quick, light
blows and eliciting vibrations and sounds.
The sound determines the density of the underlying tissue and whether it is solid tissue or filled with air or fluid.
Percussion
Types of percussion
Direct/immediate percussion
Indirect or mediate
Fist or blunt
is directly tapping your hand or fingertip over a
body surface to elicit a sound or to assess area
of tenderness
Direct immediate percussion
place your non- dominant hand over a body surface, pressing firmly with your middle finger
Indirect or mediate
to assess tenderness of an organ
Fist or blunt percussion
Mapping out location and size of an organ
Determining density (air, fluid, solid) of a structure
Detecting superficial mass (up to 5 cm deep)
Eliciting pain if underlying structure is inflamed
Eliciting a DTR using a percussion hammer
Uses for percussion
What are percussion sounds
Resonance
Tympany
Dullness
Hyperresonance
Flatness
Intensity: Moderate to loud
Pitch: Low
Duration: Long
Quality: Hollow
Source: Normal Lung
Resonance
Intensity: Loud
Pitch: High
Duration: Moderate
Quality: Drumlike
Source: Gastric air bubble; intestinal air
Tympany
Intensity: Soft to moderate
Pitch: Medium
Duration: Moderate
Quality: Thudlike
Source: Liver; full bladder; pregnant uterus
Dullness
Intensity: Very loud
Pitch: Very low
Duration: Very long
Quality: Booming
Source: Hyper inflated lung (as in emphysema)
Hyperresonance
Intensity: Soft
Pitch: High
Duration: Short
Quality: Flat
Source: Muscle
Flatness
involves using your sense of hearing to collect data
You will listen to sounds produced by the body,
such as heart sounds, lung sounds, bowel
sounds, and vascular sounds.
Auscultation
Types of auscultation
Direct auscultation
Indirect auscultation
Usually last technique during PE
(exception – abdomen, it’s the 2nd technique
after inspection)
ABDOMEN = IAPP
Use stethoscope to block sounds not magnify
• Diaphragm-firmly against skin
• Bell- lightly against skin
Auscultation
Frequency of sound vibrations, high or low.
Pitch
loudness of sound: loud or soft (amplitude)
Intensity
length of sound: short, long
Duration
subjective terms- harsh, tinkling, etc
Quality
• Study of the whole individual
• Overall impression
• Begins at the first encounter with a person
• Introduction to the physical assessment
• Composed of 4 parts: physical appearance, body structure, mobility & behavior
General survey
Age
Sex
LOC
Skin color
Facial features
Physical appearance
Stature
Nutrition
Symmetry
Posture
Position
Body contour
Body structure
Gait
Range of motion
Mobility
Behavior
Facial expression
Mood
Speech
Dress/hygiene
• S- Severity
• L- Location
• I- Influencing factors
• D- Duration
• A- Associated Symptoms
Assessing Distress/Pain
