Course Introduction & Health History 2023 PDF

Course Introduction & Health History By, Abdelhameed Mahros Lecturer, Critical Care & Emergency Nursing 2023 Our course THEORETICAL CLINICAL Midterm 15 Application 30 Quizes 20 Final OSCE 35 Final 50...

Course Introduction & Health History By, Abdelhameed Mahros Lecturer, Critical Care & Emergency Nursing 2023 Our course THEORETICAL CLINICAL Midterm 15 Application 30 Quizes 20 Final OSCE 35 Final 50 2 TIMELINE Quiz1 Quiz2 MT Quiz3 Quiz4 Final W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W1 W1 1 2  COURSE OUTLINES Introduction to the course & Complete Health History Physical Examination Technique General survey, measurement and vital signs. content Assessment of Skin, Hair, and Nails. Assessment of Head and Neck. Assessment of Thorax, and Lungs. Assessment of Cardiovascular System. Assessment of Abdomen. Assessment of Nose, Mouth, Throat, and Ears. Assessment of Neurologic System. 4  HEALTH ASSESSMENT Gathering information about the health status of the patient A systematic, dynamic way to collect and analyse data about a client as it is the first step in delivering nursing care ◘ The most powerful tool for the nurse is to observe ◘ ◘ Patient assessment is the foundation of any plan of care. ◘ ◘ ◘ So, it should be complete & accurate Nursing Assessment During follow up Receiving Before of discharge patients Assessment In Triage hospitals, clinics, Distastes health campus Before any planned diagnostic procedure Nursing Process Stages Pre Arrival Assessment Admission Quick Check Assessment Comprehensive Admission Assessment Ongoing Assessment Types Emergency Comprehensive Focused Special Considerations o Establish a positive nurse/patient rapport to decrease the stress. o Explain the purpose for the physical assessment. o The data must be factual, not interpretive. o Obtain an informed, verbal consent for the assessment. o Ensure confidentiality of all data. o Provide privacy from unnecessary exposure. o Communicate special instructions to the patient Frameworks Functional Head to Toe Health perception, Organized, activity, Exercises, systematic, part by Nutrition, Rest and part sleep, Coping, self- concept Body system approach Allow clustering of similar data Components of Health Assessment Health History Physical examination Subjective Data Objective Data Stated by the patient Observed Health History o The history taking should lead to the following: Ø A rapport between patient and practitioner. Ø A picture of the patient as a whole “strength and weakness”. Ø A guide to which areas to examine in the physical assessment. Ø An approximate diagnosis “80% of the information needed for a diagnosis”. Ø Formulation of a plan of care for the patient Phases The The interview recording phase phase Types Health History taking Complete: Taken on initial visits to health care facilities. Interval: Collect information in visits following the initial data base is collected. Problem- focused: Collect data about a specific problem. Interview Phase Introduction: Address the patient using his or her surname. Introduce yourself and, give the reason for this interview. Facilitation: Your facilitative response encourages the patient to say more Silence. Your silence communicates that the patient has time to think and organize Reflection. A reflective response echoes the patient’s own words Empathy. An empathic response recognizes a feeling and puts it into words Clarification. Use the clarification response when the patient’s word choice is ambiguous or confusing Summary. This is a final review of what you understand the patient has said TEN TRAPS OF INTERVIEWING 1. Providing False Reassurance 2. Giving Unwanted Advice 3. Using Authority. 4. Using Avoidance Language 5. Using Professional Jargon. 6. Using Leading or Biased Questions 7. Talking Too Much. 8. Interrupting 9. Using “Why” Questions 7 components of Health History Biographical Data. Reasons for Review of Seeking System (ROS) Health Care Provider Component of Health History Life – Style & History of Health Present Practices Health Profile Concern Family Health Past Health History History Life- style 1. Activity level& Exercise 2. Nutrition & Sleep 3. Educational level, work, 4. Social Activities 5. Medication and substance abuse 6. Smoking, etc Importance: is the basis for health teaching planning Review of systems 1. General Overall Health State: 2. Integumentary (Skin, Hair and Nails): 3. Head and Neck: 4. Eye 5. Ears, Nose and Throat: 6. Thorax and Lungs: 7. Cardiovascular 8. Peripheral vascular 9. Nervous system