Module 2: Health History Flashcards
Phases of the Nursing Process
- Assessment - the most critical phase
- nursing diagnosis
- planning
- implementation
- evaluation
- revision of care
What is a health history?
- the FIRST interaction with the client or family
-its the gathering of subjective data through interview
-sets the foundation of the nurse-client relationship
Things to keep in mind about approach and communication in a health history?
- ensure privacy
-refuse interruptions
-be observant
-be reflective and avoid own biases and judgment
4 Phases of the Health History Interview
- Pre Introductory
- Introductory
- Working
- Summary and Closing
Pre-Introductory Phase
- the nurse reviews medical record prior to meeting with the patient
-knowing information beforehand aids the interview
-can also obtain data from watching the patient (pain?, Limp?, etc)
Introductory Phase
-phase 2 of health history
- establishing rapport phase
-always explain why you are asking questions and taking notes
-keep the physical environment in mind and protect HIPAA
- ensure privacy and assure comfort
At what level should the introductory phase and health history interview be conducted at?
eye level (to establish comfort and rapport)
Working Phase
- Identify the reason for seeking care/admission
- obtain current health status and symptom analysis
- Past medical history and family history show patient risk factors
- Review of Systems occur
- free flowing or structured
take a psychosocial profile and keep developmental and ethnic considerations in mind
What things does the working phase allow the nurse to identify?
- Actual or potential health problems
-strengths of the patient
-supports for the patient
-teaching needs
-discharge needs
-referral needs
Summary/Closing Phase
Summarizes info gleaned from the working phase:
- Summary
-Reflection
-Clarification
-ID any further concerns
-Closing the loop
Non-Verbal Communication Considerations
-Appearance (professional)
-Demeanor (professional - neutral but friendly)
-Facial expression (neutral but friendly)
-Attitude (non-judgmental)
-Silence (facilitates accurate data collection and sorting of thoughts)
-Listening (be effective)
Strategies to be an effective interviewer?
-Open Ended Questions
-Facilitate
-Reflection
-Empathy
-Get Clarification
-Summarize what the patient says!
Common Pitfalls of Interviewing?
-Omitting data
-misinterpreting the data
-interrupting
-including irrelevant data
-Failure to follow up (VERY IMPORTANT)
-poor communication
-giving bad cues (i.e. shaking head)
Special Considerations during interviews?
- Gerontologic Variations
2.Cultural Variations - Emotional Variations
Gerontologic Variations
- age related changes/differences among people
-use straightforward language, do not talk down to (ageism)
-establish and maintain trust, privacy and partnership
Cultural Variations
ethnic and cultural variations in communication and self disclosure styles may significantly affect information obtained
Emotional Variations
clients may be scared, anxious, or have difficulty expressing certain concerns
Types of Health Assessments
- Comprehensive Health History
- Ongoing Health History
- Focused Health History
Comprehensive Health History
-Gathers: biographical and demographic information, partnership status, religion, level of education, occupation, health insurance, SS number, advance directives
-Assess the reliability and source of information
-very important at first admission
Ongoing Health History
occurs after the comprehensive database is established in subsequent visits
Focused Health History
ALL components of the complete health history with a FOCUS on the SPECIFIC REASON the client is seeking care
-includes emergencies / emergency health history
Components of Health History Assessment?
1.Subjective data
2.Pain Scale
3.Learning Style of Client
4.Chief Complaint
5. Current Health Status
6. Symptom Analysis
7. Past Health History
8. Immunization Record
9. Allergies
10. Medications (including herbals, OTC-over counter)
11. Recent Travel
12. Household Pets
13. Military Service
14. Response to health Problems
15. Family History / Genogram
What should the nurse do with a chief complaint?
quote it
COLDSPA
- Symptom Analysis
C = Character
O = Onset
L = Location
D = Duration
S = Severity
P = Pattern
A = Associated Factors
Genogram
Family history diagram
Review of Systems (ROS)
-Part of Working Phase
- occurs after the rest of the health assessment
- involves Asking the patient (subjective data) questions about various body systems
- organized and efficient
Approach for asking ROS questions?
Cephalocaudal approach (head to toe) to asking questions
What is a massive benefit to the ROS stage?
its a great time to teach HEALTH PROMOTION (teaching moment for self exams)
Why are developmental stages important to keep in mind during health history assessments?
- have to know your audience
- stress, illness, disease, natural events, and unnatural events can make developmental travel go forward or backward
How do health practices and beliefs influence the health history assessment?
- You do not want to be preachy/judgmental - just guide
- need/want to know their nutritional preferences, activity, sleep patterns, personal habits, coping mechanisms, supports, sexuality, religion , etc
- You need to be able to explain why you are asking
Nursing Physical Exam
purpose is to address the patients response to medical illness. To promote general health and well being
different from medical examination
Medical Examination
Purpose is to diagnose and treat medical illness or injuries
What is the purpose of the physical assessment?
- Collect Objective Data
- Validate the ROS subjective findings (ex: says they had surgery, you will see a scar)
- ID actual OR potential health issues
Complete Physical Asessment
- Initial exam, baseline data
- General survey, vital signs, all body systems
- Class focuses on this type, but this does not mean every area is focused - they are at least addressed
Focused Physical Examination
- Acute problem exam
-general review of ASSOCIATED body systems
Examples of Physical Assessment Instruments and Tools
Thermometer
Stethoscope
Sphygomomanometer
Pen Light
Ophthalmoscope
Otoscope
Tuning Fork
Height and Weight Scale
Tape Measure
Tongue Blade
Cotton Balls
Cup of Water
Paper Clip
Q tip
Gloves
Reflex Hammer
4 Physical Assessment Techniques
- Inspection (direct and indirect)
- Palpation (light and deep)
- Percussion (direct and indirect)
- Auscultation (direct and indirect)
Inspection
View the client/surrounding areas
Direct = eyes
Indirect - X ray
Palpation
Touch - light and deep
Percussion
- tapping/percussing to elicit sounds
-direct - tapping directly on area
-Indirect - utilizing one finger and tapping with the other finger
Auscultation
-listening
-direct - putting ear up to patient
-indirect - stethoscope
In physical assessments we use …
our senses!!!
-look, listen, smell, feel
Before the physical assessment, what should be done?
- Assess own feelings of anxiety
- Achieve self confidence through practice
- Know prevention of transmission of infectious agent precautions
CDC Prevention of Transmission of Infectious Agents Standard Precautions?
-hand hygiene
-PPE use (gloves, gowns, mouth/nose/eye protection)
-proper respiratory hygiene and cough etiquette
-patient placement
-patient care equipment and instruments/devices
-environmental care
-textile and laundry precaution
-safe injection practices
-infection control practices
-worker safety
Important of the Inspection technique?
recognizing what you can see
During the physical assessment do not be afraid to …
use your hands
Crepitus
can feel air trapped in the skin ; may indicate broken bone
Percussion Sound (IPDQS): Resonance
Intensity - Moderate to Loud
Pitch - Low
Duration - Long
Quality - Hollow
Source - Normal Lung
Percussion Sound (IPDQS): Tympany
Intensity - Loud
Pitch - High (musical)
Duration - Moderate
Quality - Drum Like
Source - Gastric air bubble; Intestinal air
Percussion Sound (IPDQS): Dullness
Intensity - Soft to moderate
Pitch - Medium
Duration - Moderate
Quality - Thud like
Source - Liver; full bladder; pregnant uterus
Percussion Sound (IPDQS): Hyperresonance
Intensity - Very Loud
Pitch - Very Low
Duration - Very Long
Quality - Booming
Source - Hyperinflated lung (Emphysema)
Percussion Source (IPDQS): Flatness
Intensity - Soft
Pitch - High
Duration - Short
Quality - Flat
Source - Muscle
Where to stand when ausculatating?
on the right hand side of the patient so we can stretch the stethoscope and hear the heart
Stethoscope Diaphragm
-large part
-high pitch sounds
-place firmly on patients
Stethoscope Bell
- small part
-low pitch sounds
-place lightly on patients
-goes over arteries
Tips to help hear better with Stethoscope?
-wet hair to minimize sound
-close eyes to focus
-practice, practice, practice
Important Variations in Physical Assessment Approach
-Age / developmental stage
ex: infant, child, adolescent, adult, elder
9 Positions for Physical Exam
Supine
Sitting
Dorsal Recumbent (catheterization)
Sims
Prone
Left Lateral Recumbent
Knee Chest (spinal tap/epidural)
Standing
Lithotomy (good for pelvic exam)
General Survey of the Physical Assessment
- doorway assessment of the client
- look for things like facial characteristics, posture and gait, speech, dress/grooming/hygiene, mental status, culture, developmental stage
What to refer to for mental status in physical assessment?
- Appearance
- Behavior
- Cognitive Function
- Thoughts
- consider on a case by case business
-Individuals may not have things appear overtly
Vital Sign aspects of the Physical Assessment
- hemodynamic change - the most important things to assess
1. tempearture
2. pulse
3. respiration
4. blood pressure
5. pulse oximetry
6. height and weight
7. pain (should not be here though since its subjective_
Head to Toe Assessment
- assess HEENOT (head, ears, eyes, nose, oral, and throat areas) and work down to skin, circulatory, respiratory, breast, abdomen, musculoskeletal, neurological
-note pertinent NEGATIVE findings
Rebound Tenderness
pushing on the abdomen and then releasing it, if there is pain then its a positive finding
Integumentary
Skin
The physical assessment is ___
objective
The health history assessment is ____
subjective
The physical assessment _____ the health history
verifies
To be proficient in physical assessment one must ___
practice
Start the physical assessment with a …
general survey
Physical assessments identify …
health risks and problems
Physical exam requires what of the nurse?
Cognitive Skills
Psychomotor Skills
Interpersonal Skills
Affective Skills
Ethical Skills
Nursing Process
- Assessment (subjective and objective)
- Nursing Diagnosis (approved NANDA)
- Planning (STG and LTG for family and patient)
- Implementation (Interventions with rationale)
- Evaluation (goals met? interventions done?)
- Revision of Care
ADL
activities of daily living
2 Major Models for Nursing to Analyze Health and Disease promotion and prevention?
- Health belief model
- Health promotion model
3 concepts of Health Belief Model
- Existence of sufficient motivation
- Belief that one is susceptible or vulnerable to a serious problem
- Belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost
3 Focuses of the Health Promotion Model
- Individual characteristics and experiences
- Behavior specific cognition and affect
- Behavioral outcomes
4 Basic Types of Assessment
- Initial and Periodic Comprehensive Assessment
- Ongoing or Partial Assessment
- Focused or Problem Oriented Assessment
- Emergency Assessment
4 Steps of the Nursing Processes Assessment Phase
- Subjective Data collection (health history)
- Objective Data collection (physical exam)
- Validation of Data
- Documentation of Data
-no rigid order, can be simultaneous and overlapping
Nursing Diagnosis Definition
a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community. A nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable
Analyzing the assessment data reveals one of three things, what are they?
- A nursing diagnosis
- collaborative problem/concern
- need for a referral
8 Sections of a Complete Health History?
- Biographical Data
- Reasons for Seeking Healthcare
- History of Present Health Concern (COLDSPAR)
- Personal health history
- Family Health History
- ROS
- Lifestyle and Health Practices profile
- Developmental Level
4 Types of Palpation
- Light
- Moderate
- Deep
- bimanual
Fingertips are sensitive to …
fine discrimination
Ulnar/Palmar surfaces are sensitive to …
vibrations, thrills, fremitus
Dorsal Hand Surfaces are sensitive to …
temperature/gross discrimination
3 Types of Percussion
- Direct
- Blunt (strike hand with other fist; detect organ tenderness)
- Indirect/Mediate (most common)
Sitting Position
- sit upright at edge of bed/chair
-allows full expansion of the lungs and asymmetry assessment
Supine Position
- laying down with legs together
-peripheral pulse sights, abdominal muscle relaxation
-good for extremity assessment
Dorsal Recumbent Position
- lie down on the bed with knees bent and legs separate, feet flat, arms in u shape near head
-better than supine for back pain
-abdomen not assessed here since the muscles are contracted
Sims Position
- lay on side with lower arm placed behind body and upper arm flexed at the shoulder and the elbow. Lower leg is slightly flexed at the knee while upper leg is flexed at a sharper angle and pulled forward
-assess rectal/vaginal areas
-hard for elderly due to joint problems
Standing Position
-normal, resting posture
-assess posture, balance, gait, male genitalia
Knee Chest Position
- kneel on table with body weight supported by the chest and knees, 90 degree angle between body and hips. arms above head with head turned to one side
-assess rectum
-may be uncomfortable/embarassing
-elderly and resp/cardiac problems unable to tolerate
Prone Position
-lie down on abdomen with head to side
-assess hip joint and back
-bad for cardiac and respiratory problems
Lithotomy Position
-stirrups on back
-assess female genitalia, repro tacts, and rectum
-be quick as its embarassing
Adventitious Breathing Sounds
abnormal breath sounds over the lungs
BMI
Body mass index (height:weight ratio)
Bronchial breath Sounds
-heard over larynx/trachea, and are high pitched harsh blowing sounds
-expiration sound is longer than inspiration
Bronchovesicular Breath Sounds
-normal breath sounds heard over mainstem bronchus
-moderate blowing sounds with inspiration equal to expiration
Cyanosis
bluish coloring of the skin and mucous membranes
Diaphoresis
excessive perspiration
Ecchymosis
collection of blood in subcutaneous tissues that cause purplish discoloration
Edema
accumulation of fluid in extracellular spaces
Erythema
redness of skin
IADLS
activities of daily living needed for independent living
Jaundice
yellow appearance of skin
Pallor
paleness of the skin
Petechiae
small, purplish hemorrhagic spots on the skin that do not blanch when applied with pressure
Precordium
anterior surface of the chest wall overlying the heart and its related structures
Turgor
tension of the skin determined by its hydration
Vesicular Breath Sounds
normal sound of respiration heard on auscultation over peripheral lung areas
