Health Assessment / Theory PDF

Health Assessment / Theory Dr. Ala Ashour 1  Health Assessment Lecture 1 Introduction The Interview The complete Health History, Dr. Ala Ashour 2  Definition: The collection of data about an individual’s health state to re...

Health Assessment / Theory Dr. Ala Ashour 1  Health Assessment Lecture 1 Introduction The Interview The complete Health History, Dr. Ala Ashour 2  Definition: The collection of data about an individual’s health state to reveal health problem. ◦ Subjective data (i.e., what the person says about himself or herself during history taking) ◦ Objective data (i.e., what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination).  Together with patient’s record & laboratory studies, these elements form the Data Base 3 1. Complete (Total Health) Database ◦ Complete health history (Hx) and full physical examination. 2. Focused or Problem-Centered Database ◦ Collect “mini” data base related to system that has the problem 3. Follow-Up Database ◦ Evaluation of the status of individual’s health 4. Emergency Database ◦ Rapid collection of the data in emergency situations. 4 1. Developmental stage ◦ Physical, Psychosocial, Cognitive, Behavioral. 2. Cultural & Family Values. ◦ Linguistic Competence 3. Religious Beliefs. 4. Mental Status. 5  Is a structured interaction between health care provider & the patient.  The first point of contact with a client & the most important part of data collection.  During the interview you collect subjective data (i.e., what the person says about himself or herself) ❑ Characteristics of a Successful Interview:  Ends with a complete & accurate health history.  Discuss health promotion & disease prevention  Initiates teaching.  Establish a trust & therapeutic relationship with the patient. 6  Is based on communication; sending & receiving messages.  Communication: is exchanging information so each person clearly understand the other.  Communication is based on behavior, conscious and unconscious, verbal and nonverbal.  Much more than talking & hearing is necessary 7 1. Sending: Verbal and Nonverbal communication  Verbal Communication:  The words you speak, vocalizations, the tone of voice.  Nonverbal communication:  This is your body language—posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair. 2. Receiving messages: ◦ Your words & gestures must be interpreted in a specific context to have meaning. ▪ The receiver puts his or her own interpretation on your words. ▪ The receiver attaches meaning determined by (based on) his or her past experiences, culture, and self concept, as well as current physical & emotional state. 8 3. Interview Affected by : A. Internal Factors: (specific to the examiner) a. Liking others b. Empathy (recognizing & accepting the other persons feeling without criticism). c. Ability to listen d. Self-Awareness B. External Factors: a. Privacy b. Interruptions c. Physical environment: Room Temp, light, noise 9  Composed of three phases 1. Introduction phase: short & direct -Address the person, using his or her name & shake hands.  Introduce your self & state your role in the agency (if you are a student, say so). - Give the reason for the interview 2. Working phase: data collection phase  Open-ended questions: for narrative information  Closed questions: for specific information 3. Closing phase The session should end gracefully 10  Verbal responses to gather more data ◦ Facilitation ◦ Silence ◦ Reflection ◦ Empathy ◦ Clarification ◦ Confrontation ◦ Interpretation ◦ Explanation ◦ Summary 11 12 13  Traps of interviewing:  Providing false assurance or reassurance  Giving unwanted advice  Using authority  Using avoidance language  Engaging in distancing (impersonal speech)  Using professional jargon  Using leading/biased questions: “You don’t smoke, do you?” Better questions are: “Do you smoke?”  Talking too much: A good rule for every interviewer is to listen more than you talk.  Interrupting  Using “why” questions 14  Nonverbal Communication: (Your body language) ◦ Physical appearance ◦ Posture: the position in which someone holds their body when standing or sitting. ◦ Gestures: a movement of part of the body, especially a hand or the head, to express an idea or meaning. ◦ Facial expression ◦ Eye contact ◦ Voice ◦ Touch 15 16  Nonverbal Communication: (Your body language) 17 Examples of inappropriate communication by nurse with young woman with a disability in a wheelchair. The nurse stands instead of sitting at the patient’s eye level (A) and talks to the patient’s mother rather than directly to the patient (B). 18  Purpose is to collect subjective data (patient’s story)  History is combined with the objective data from physical examination & laboratory studies to form the data base.  Health history provides a complete picture of the persons past & present health.  It describes the individual as a whole & how the person interacts with the environment.  Is a screening tool for abnormal symptoms, health problems, concerns, & it records ways of responding to the health problems.  For the ill person, the health history includes a detailed and chronologic record of the health problem. 19  Components of health history: 1. Biographical data 2. Reason for seeking care (chief complain) 3. History of present illness 4. Past health history 5. Family history 6. Review of system 7. Functional assessment or activity of daily living (ADLs) 8. Perception of health 20 1. Biographical data: (name, age, gender, birth place, marital status, race, religion, occupation, and address). 2. Reason for seeking care (Chief complain) o A brief spontaneous statement in the person own words that describes the reason for seeking care. o Title of the story to follow = one or two sign or symptoms (the most important) plus their duration o Framed by patient’s own words (not translated) o E.g: “Chest pain” for 2 hours. 21 3. History of present illness: details (PQRSTU) of the reason for seeking care from time symptom first started until now. o P : Provocative (aggravating) or Palliative (relieving) o Q: Quality (burning, sharp) or Quantity (terrible pain) o R: Region or Radiation o S: Severity scale o T: Timing (onset, duration, frequency) o U: Understand patient's perception. E.g; (what do you think it means?) 22 4. Past health history o Childhood illness (Measles, Mumps) o Accidents or injuries (fractures, head injury, burns) o Chronic illnesses (DM, HTN) o Hospitalization (cause, hospital name, how long) o Operations (type of surgery, date) o Obstetric history (number of pregnancies, abortions) o Immunization o Last examination date (physical, dental, vision, ECG) o Allergies (allergen & reaction) o Current medications 23 5. Family history (genogram) o Age and cause of death of blood relatives (parents, grandparents, siblings) o Ask about spouse & children o Ask about any family history of heart disease, high blood pressure (HTN), stroke, diabetes (DM), blood disorder, cancer, arthritis, allergies, obesity, mental illness, kidney disease & tuberculosis (TB). o Construct accurate family tree or genogram 24 Genogram: used to record history of family members, including their age and cause of death or, if living, their current health status 25 6. Review of Systems (ROS): ▪ Purposes: To evaluate the past & present health state of each body system To double-check in case significant data were missing from the present health history To evaluate health promotion practices ▪ Order of examination: head to toe Exclude symptoms covered in the present health history Only the most common symptoms are listed Medical terms are listed, but they need to be translated to patient. You need to record the presence or absence of all symptoms 26 27 7. Functional Assessment Measures a persons self care ability ▪ Self-esteem, Self-concept: including education, income, & religious practices ▪ Activity/ Exercise: including activity of daily living (ADLs): bathing, dressing, toileting, eating, walking. ▪ Sleep / Rest: sleep patterns, daytime naps, any sleep aids used ▪ Nutrition / Elimination: record the diet taken over the last 24 hours, eating habits, current appetite. Usual patterns of bowel elimination & urinating. 28 ◦ Interpersonal relationship (social roles) ◦ Spiritual resources ◦ Coping & stress management ◦ Personal habits (Tobacco) ◦ Alcohol ◦ Illicit or street drugs ◦ Environment/hazards ◦ Intimate partner violence ◦ Occupational health- hazard (asbestos, inhalants, chemicals) 29 8. Perception of health ❑ How the patient defines health? ❑ How the patient views his/her current health status? ❑ What the patient expects from health care providers? ❑ What are your concerns? 30