Nursing Assessment: Subjective vs Objective Information

Understanding Subjective and Objective Information

• Subjective information includes the client's point of view, feelings, perceptions, and concerns obtained through interviews
• Chief complaint: the reason the patient is seeking assistance, written in quotes
• HPI (History of Present Illness): a detailed description of the primary problem using symptom analysis
• PQRST: Past medical history, including immunizations, allergies, and responses

Components of a Full and Focused Exam

• Comprehensive Assessment:
  • Identifying data and source of the history
  • Reliability
  • CC (Chief Complaint)
  • HPI (History of Present Illness)
  • PQRST
  • Past medical history, including immunizations, allergies, and responses
  • Family history
  • Personal and social history
  • Review of systems (head to toe subjective data)
• Focused Assessment:
  • Identifying data
  • CC
  • HPI
  • Data from PMH, FH, SH that pertains to the complaint
  • ROS (Review of Systems) that pertains to the complaint

Approaches to Discussing Sensitive Topics

• Be aware of self and how personal judgments affect thinking
• Confidentiality is of high importance
• Patient's autonomy cannot be ignored
• Be direct and firm
• Do not apologize for questions
• Do not preach
• Do not push too hard
• Be ready to explain why you need to ask
• Explore patient's feelings
• Offer patient opportunity to ask questions
• Use gender-neutral language

Cultural Competence

• Assess patient's personal beliefs about health
• What religious influences may affect care?
• What language is primary?
• What are the roles in the family?
• Are there special dietary practices that may influence compliance or recovery?
• Recognize diversity
• Demonstrate respect for the unfamiliar
• Identify own cultural beliefs
• Don't stereotype
• Learn the facts
• Develop a plan with culture in mind

Assessment Tools

• 2-question depression screening:
  • In the last month, have you been bothered by little interest or pleasure in doing things?
  • Feeling down, depressed, or hopeless?
• MMSE (Mini-Mental State Exam):
  • Standardized screening tool for mental status
  • Max score: 30
  • Depressed clients w/o dementia score 24-30
  • Score of 20 or less is found with dementia, delirium, schizophrenia, or an affective disorder
• MOCA (Montreal Cognitive Assessment):
  • Brief (10-minute) screening tool for mild cognitive impairment
  • More sensitive for early or mild impairment, a risk factor for dementia
  • Normal score: 26-30
  • Lower score requires more in-depth assessment
• Beck's Depression Scale:
  • Assesses severity of depression in adults and adolescents (13 and up) without a diagnosis of a psychiatric illness
  • Not a sole diagnostic measure
  • Highly reliable
  • Score of < 15: mild depression
  • Score 15-30: moderate depression
  • Score > 30: severe depression
• PHQ-9:
  • Rates the frequency of symptoms to score severity
  • Can be utilized multiple times to show trends
  • Question 9 asks about suicide ideation
  • Score 5-9: minimal symptoms
  • Score 10-14: mild depression
  • Score 15-19: major depression, moderately severe
  • Score > 20: major depression, severe
• Duke Activity Index:
  • Self-administered questionnaire that measures a patient's functional capacity
  • Can be used to get a rough estimate of a patient's peak oxygen uptake
  • Assesses the functional capacity of patients with cardiovascular disease
  • Final score ranges between zero and 58.2 points
  • The higher the score, the better the functional capacity

HPI Components

• Complete, clear, and chronologic description of the problems prompting the patient's visit
• Symptom Analysis:
  • P: precipitating/palliative/provocative
  • Q: Quantity or Quality
  • R: Region/Radiation
  • S: Severity
  • T: Timing
  • Most important: HAVE YOU EVER HAD THIS BEFORE?

Health Promotion and Counseling

• Optimal weight, nutrition, and diet
• BMI > 25: risk for heart disease, HTN, high LDL, low HDL, high triglycerides, hyperglycemia
• Blood pressure and dietary sodium
• A difference of 5g of salt intake a day is linked to a 23% difference in the rate of stroke and a 17% difference in the rate of total cardiovascular disease
• Daily dietary intake of 2300 mg is tolerable
• Exercise
• Tobacco cessation

Billing Types and Time

• Problem-focused: CC, brief HPI
• Expanded problem-focused: CC, limited exam of affected body area or organ system and other symptomatic or related organ system
• Detailed: CC, extended HPI, problem pertinent ROS and other additional pertinent PMH, SH &/or FH related to problem
• Comprehensive: CC, extended HPI, full ROS, complete past, family, and social history

Complexity of Medical Decision Making

• Straightforward
• Low complexity
• Moderate complexity
• High complexity

Type/Definition of Each of the 5 Billing Levels

• Levels of Evaluation and Management:
  • Level 1: straightforward
  • Level 2: low complexity
  • Level 3: moderate complexity
  • Level 4: high complexity
  • Level 5: high complexity with multiple conditions