Assessment of the Whole Person PDF

Assessment of the Whole Person Helen P. Neil, Ph. D. (c), RN, MSN-HCSM, CLNC, FCN Health Assessment Theory 2416 Leaders Defining the Art & Science of Nursing Welcome to the most honored profession! Leaders Defining the Art & Science of Nursing  What to Stu...

Assessment of the Whole Person Helen P. Neil, Ph. D. (c), RN, MSN-HCSM, CLNC, FCN Health Assessment Theory 2416 Leaders Defining the Art & Science of Nursing Welcome to the most honored profession! Leaders Defining the Art & Science of Nursing  What to Study Lecture Objectives in Syllabus – Page 6-7 Unit 1 – Assessment of the Whole Person – Chapter 1 – Evidence-based practice – Chapter 2 – Cultural Assessment – Chapter 3 – The Interview – Chapter 4 – The Complete Health History Leaders Defining the Art & Science of Nursing  Lecture Objectives - 1 Understand the concept of health. Identify the components of EBP. Describe the components of assessment & diagnostic reasoning. Leaders Defining the Art & Science of Nursing  Lecture Objectives - 2 Recognize the phases of the nursing process. Discuss the components of culturally competent care. Explain the components, equipment, and techniques of an interview when performing a complete health assessment. Leaders Defining the Art & Science of Nursing  Medical Terminology Assessment Environment Biomedical model Holistic Health Critical thinking Acculturation Diagnostic reasoning Cultural and linguistic Evidence-based practice competence. Nursing Process Ethnicity Subjective Data Ethnocentrism Objective Data Spirituality Prevention Values Leaders Defining the Art & Science of Nursing  Concept of Health Holistic health – Mind, body, spirit Wellness vs Health – The frequency interval of assessment varies with the person's illness and wellness needs. https://www.youtube.com/watch? v=5syJjBQ_k6o Leaders Defining the Art & Science of Nursing Include Body, Mind, & Spirit to Promote Health https://www.physio-pedia.com/ What_is_Health%3F Leaders Defining the Art & Science of Nursing  HEALTH PROMOTION Health Promotion and disease prevention – Why and how do we do this? – What types of health promotion and disease prevention can you participate in? Leaders Defining the Art & Science of Nursing  Evidence-Based Practice Skin Breakdown Evidence-based practice is a systematic approach emphasizing the best research available. Leaders Defining the Art & Science of Nursing  Nursing Process Assessment Diagnosis Planning Implementation Evaluation Leaders Defining the Art & Science of Nursing  THE NURSING PROCESS Leaders Defining the Art & Science of Nursing  How to perform a NURSING ASSESSMENT | ADPIE Nursing https://www.youtube.c om/watch?v=ReVtLRu RZTA Leaders Defining the Art & Science of Nursing  Remember the Steps Assessment Diagnosis Planning Implementation Evaluation Leaders Defining the Art & Science of Nursing  ASSESSMENT SUBJECTIVE OBJECTIVE – What the patient says – What the HCP sees, – What the family says hears, feels, smells, or tastes! – What the caregiver Walks with a shuffle says Heart murmur Pain Skin is warm to touch Medical history Foul odor of wound Family history CF test Leaders Defining the Art & Science of Nursing  Assessment Leaders Defining the Art & Science of Nursing  Assessment Subjective Data – what the patient or caregiver “says’ Objective – See – Hear – Smell – Feel – Taste Leaders Defining the Art & Science of Nursing  Assessment Creating a database leads to clinical judgement Assessment is the collection of data about the individual's health state. – subjective data – objective data Leaders Defining the Art & Science of Nursing  Assessment – Priorities Priority Setting – First-level Emergent – Second-level Requires your prompt attention – Third level Important, but not urgent Leaders Defining the Art & Science of Nursing  Remember the Steps Assessment Diagnosis Planning Implementation Evaluation Leaders Defining the Art & Science of Nursing  Diagnostic Reasoning Gather data – what is important? Analyze the data to identify diagnoses – Identify available cues (lab tests, chief complaint, symptoms, x-rays, etc) – Formulate diagnostic hypotheses – Gather data relative to the tentative hypotheses – Evaluate each hypothesis with the data – Arrive at a final diagnosis Leaders Defining the Art & Science of Nursing  Diagnosis – Step 2 NANDA – we must follow these guidelines Diagnostic Reasoning – Analyzing health data and drawing conclusions to identify a diagnosis – Receiving cues, formulating hypothesis, gathering data relevant to the hypothesis, evaluation of hypothesis with new data to arrive at final diagnosis – Validate data and look for gaps Leaders Defining the Art & Science of Nursing  Critical Thinking – Step 2 Critical Thinking – Intuition/recognition of patterns – Learn to assess and modify before acting – Learn to sort through dynamic, unpredictable situations – Think outside the box – Avoid assumptions There will not be any one protocol you can memorize that will apply to every situation. Leaders Defining the Art & Science of Nursing  Critical Thinking Leaders Defining the Art & Science of Nursing  Examples of Nursing Dx NANDA DX – Ineffective airway clearance – Risk for unstable blood pressure – Sedentary lifestyle – Impaired swallowing – Impaired urinary incontinence – Activity intolerance Leaders Defining the Art & Science of Nursing Leaders Defining the Art & Science of Nursing  Remember the Steps Assessment Diagnosis Planning Implementation Evaluation Leaders Defining the Art & Science of Nursing  Planning = Care Plan Leaders Defining the Art & Science of Nursing  Planning – Step 4 Establish priorities Develop outcomes Set timelines for outcomes Identify interventions Integrate evidence-based trends and research Document the plan of care Leaders Defining the Art & Science of Nursing  Remember the Steps Assessment Diagnosis Planning Implementation Evaluation Leaders Defining the Art & Science of Nursing  Examples Outcomes OBJECTIVES/OUTCOMES/GOALS – The patient will return demonstrate how use incentive spirometry with zero coaching by the end of the shift. – The patient’s systolic blood pressure will remain < 138 after walking 100 ft. – The patient will walk once around the block 5 times a week for two weeks following discharge. – The patient will walk to the nurses’ station from his room and back with zero complaints of dyspnea. – The patient will weigh self daily and notify MD of 3 pounds weight gain within 48 hours. Leaders Defining the Art & Science of Nursing  Outcomes/Goals Leaders Defining the Art & Science of Nursing  Implementation – Step 5 Implement in a safe and timely manner Use evidence-based interventions Collaborate with colleagues Use community resources Coordinate care delivery Provide health teaching and health promotion Document implementation and any modification Leaders Defining the Art & Science of Nursing  Remember the Steps Assessment Diagnosis Outcomes/Goals Planning Implementation Evaluation Leaders Defining the Art & Science of Nursing  Evaluation – Step 6 Progress toward outcomes Conduct systematic, ongoing, criterion-based evaluation Include patient and significant others Use ongoing assessment to revise diagnosis, outcomes, plan Disseminate results to patient and family Leaders Defining the Art & Science of Nursing  Objectives for Chapter 1 Explain the concept of health Use the components of EBP Describe the components of an assessment & diagnostic reasoning Use the five phases of nursing process Leaders Defining the Art & Science of Nursing  Let’s Practice https://forms.office.com/r/pSeipyLGUn Leaders Defining the Art & Science of Nursing Chapter 2 Cultural Assessment Leaders Defining the Art & Science of Nursing  Chapter 2 Objectives Discuss the components of culturally competent care. – SDOH – Linguistic Competence – Socialization and enculturation – Four Characteristics of culture – Ethnicity – Acculturation – Religion and Spirituality – Beliefs about causes of illness – Cultural Self-Assessment – Spiritual assessment Leaders Defining the Art & Science of Nursing  Social Determinants of Health Leaders Defining the Art & Science of Nursing  Know the Factors! Social Determinants of Health (SDOH) – Factors that influence a person’s health status Leaders Defining the Art & Science of Nursing  Health Disparities – Vulnerable Groups Women Children LGBGQ Aged Mentally Ill Sensory perception Language Barriers Religions Leaders Defining the Art & Science of Nursing  Linguistic Competence Leaders Defining the Art & Science of Nursing  Socialization and Enculturation Socialization or enculturation is the process of being raised within a culture and acquiring the norms, values, and behaviors of that group. Examples – Dress codes – Watching parents buy groceries – Slang – Religious practices Leaders Defining the Art & Science of Nursing  Four Characteristics of Culture Culture has four basic characteristics: 1. Learned from birth through language acquisition and socialization 2. Shared by all members of the same cultural group 3. Adapted to specific conditions related to environmental and technical factors and the availability of natural resources 4. Dynamic and ever changing Leaders Defining the Art & Science of Nursing  Cultural Assessment Terms! Religion and Spirituality – Religion refers to an organized system of belief – Spirituality is a broader connection with a belief Ethnicity – Shared traits such as geography, language, or religion Acculturation – Adopting the culture of the majority culture Leaders Defining the Art & Science of Nursing  **Dimensions of Acculturative Stress** INSTRUMENTAL/ SOCIAL/ SOCIETAL ENVIRONMENTAL INTERPERSONAL Financial Loss of social networks Discrimination/stigma Language barriers Loss of social status Level of acculturation Lack of access to health Family conflict Political/historical forces care Family separation Legal status Unemployment Intergenerational conflict Lack of education Changing gender roles Leaders Defining the Art & Science of Nursing  Cultural Beliefs Beliefs about causes of illness Biomedical/Scientific Naturalistic Magicoreligious Assumes cause and Most frequently found in Supernatural forces effect American Indians, Asians dominate and others Germ theory Human life is only one Fate of the world aspect of nature depends on the actions of supernatural forces for good or evil Embraced by healthcare Forces of nature must be Voodoo or witchcraft educational programs kept in natural balance Yin/yang theory Hot/Cold theory Leaders Defining the Art & Science of Nursing  Cultural Competence Goals – Cultural sensitivity, cultural appropriateness, cultural competence Cultural Self Assessment Cultural Assessment – Heritage, health practices, communication, family roles, nutrition, childbirth, spirituality, death, health providers Spiritual Assessment – FICA Spiritual History Tool (faith, importance/influence, community, and address/action) – https://www.youtube.com/watch?v=9-1PhLXcMSg Leaders Defining the Art & Science of Nursing  The Cultural Interview Usually the first point of contact and the most important part of data collection – Gather complete and accurate data – Establish trust – Educate the patient about their health state – Build therapeutic relationship – Health promotion and disease prevention Leaders Defining the Art & Science of Nursing  Let’s Practice https:// forms.office.com/r/ G2BbSwSJ0B Leaders Defining the Art & Science of Nursing Leaders Defining the Art & Science of Nursing  Chapter 3 – The Interview Leaders Defining the Art & Science of Nursing  Chapter 3 Objectives Identify the components/techniques of an interview and the complete health assessment. Go to pages 6-7 in our syllabus Leaders Defining the Art & Science of Nursing  Communicating during the Interview Communication – Sending/Receiving – Internal Factors Liking others, empathy, ability to listen, self- awareness – External Factors Privacy, interruptions, physical environment, dress, note-taking Leaders Defining the Art & Science of Nursing  Physical Environment Room temperature Sufficient lighting Quiet environment with no interruptions Remove distractions Explain the equipment according to development Arrange equal–status seating Leaders Defining the Art & Science of Nursing  Patient Communication https://www.youtube.com/watch?v=zSSoYmQS6Ng Leaders Defining the Art & Science of Nursing  The Documentation of the Interview Note-Taking – Disadvantages of excessive note-taking The Electronic Health Record (EHR) – Mandated by the federal government – Improves documentation – Failure to capture psychosocial and emotional info – Do not let the computer become a barrier – Explain charting and position the monitor where the patient can see it Leaders Defining the Art & Science of Nursing  The Interview – Making it Easy Communication Techniques – Introducing the interview – Open-ended questions – Closed/direct questions – Verbal response/assisting the narrative Leaders Defining the Art & Science of Nursing  Interview Traps – AVOID! Ten Traps 1. False assurance 2. Unwanted advice 3. Using authority 4. Avoidance language 5. Distancing 6. Professional jargon 7. Biased questioning 8. Talking too much 9. Interrupting 10. Using “why” questions Leaders Defining the Art & Science of Nursing  The interview – Non-verbal Communication Non-verbal skills – Physical appearance – Posture – Gestures – Facial expression – Eye contact – Voice – Touch Leaders Defining the Art & Science of Nursing  The interview – Wrap it up! Closing the Interview Interviewing the parent or caregiver Communicating with different ages Interviewing people with special needs Cultural considerations on gender Cultural considerations on sexual orientation Leaders Defining the Art & Science of Nursing  The interview Working with and without an interpreter – Consider verbal and nonverbal communication – Bi-lingual interpreter required for non-English speaking persons – Refrain from using a family member or friend – Bilingual team member, trained interpreter, telephone translation services – What to do when language interpreter is unavailable? Tools for determining literacy – Tools, what can you do? Leaders Defining the Art & Science of Nursing  Stages of Cognitive Development Table 3.4 Developmental Competence – Parent and caregiver – greet both by name – Infant to 12 months – make direct contact, calm voice – Toddler – simple direct questions – Preschooler – then operate in the present, egocentric – School age – pose the questions at the child, they can add to the history of the illness – Adolescent – don’t want to be different, rationales – Older Adults – may be HOH, may have visual problems, may move slow, may respond slowly, be patient. Leaders Defining the Art & Science of Nursing  Age - Appropriate Interviews Infant & Child –Greet child, questions will be focused to the caregiver > 12 years of age – Formal Operations – ask them questions – let caregiver verify Adolescent – may need to ask caregiver to leave assess for S/S of abuse, encourage + behaviors Older Adult – assess for S/S of abuse, hopelessness, avoid elderspeak, address the patient, touch, HOH, Visually impaired, etc Leaders Defining the Art & Science of Nursing  PRACTICE CHAPTER 3 https:// forms.office.com/r/ E07AmWvrZ6 Leaders Defining the Art & Science of Nursing Leaders Defining the Art & Science of Nursing Chapter 4 – The Complete Health History Leaders Defining the Art & Science of Nursing  Chapter 4 Objectives Identify the components/techniques of an interview and the complete health assessment. Go to pages 6-7 in our syllabus Leaders Defining the Art & Science of Nursing  The Complete Health History Biographic Data Source of History Reason for Seeking Care – Sign vs. Symptom History of Present Illness (HPI) – Pain (PQRST) Past Health Family History Review of Systems Functional Assessment Perception of Health Leaders Defining the Art & Science of Nursing  The Complete Health History Children – Includes: age and developmental stage, mother’s health during pregnancy, labor and delivery, nutrition Adolescent – Includes a psychosocial review to improve communication with the youth Leaders Defining the Art & Science of Nursing  History of Present Illness The reason for seeking care – subjective data – Location – Character or Quality – Quantity or severity – Timing (onset, duration, frequency) – Setting – Aggravating or relieving factors – Associated factors – Patient’s perception Leaders Defining the Art & Science of Nursing  Health History Past Health - events are important because they may have residual effects on the current health state. Family History - an accurate family history highlights diseases and conditions for which a particular patient may be at increased risk. Review of Systems - The order of the examination of body systems is roughly head to toe. Functional Assessment – an assessment of the activities of daily living. Leaders Defining the Art & Science of Nursing  Pain Assessment PQRSTU – P: Provocative or Palliative. – Q: Quality or Quantity. – R: Region or Radiation. – S: Severity Scale – T: Timing – U: Understand - Patient's Perception of the Problem. Leaders Defining the Art & Science of Nursing  Past Health History Childhood Illnesses. Last Examination Date. Accidents or Injuries. Allergies. Serious or Chronic Current Medications. Illnesses. Family History. Hospitalizations. Culture and Genetics Operations. Biographic data Obstetric History. Spiritual Immunizations. resources/religion Nutritional support Leaders Defining the Art & Science of Nursing  Review of Systems General Overall Health Peripheral Vascular. State. Gastrointestinal. Skin, Hair, and Nails. Urinary System. HEENT Genital System Neck Musculoskeletal System. Beast Neurologic System. Axilla Hematologic System. Respiratory System. Endocrine System. Cardiovascular. Leaders Defining the Art & Science of Nursing  Functional Assessment Activities of Daily Living (ADLs) Self-Esteem, Self-Concept. Activity/Exercise. Sleep/Rest. Nutrition/Elimination. Interpersonal Relationships/Resources. Spiritual Resources. Coping and Stress Management. Personal Habits. Leaders Defining the Art & Science of Nursing  SBAR Situation Background Assessment Recommendation Leaders Defining the Art & Science of Nursing  Standardized Communication Leaders Defining the Art & Science of Nursing  Practice Chapter 4 https:// forms.office.com/r/ e43db7bue7 Leaders Defining the Art & Science of Nursing  What to Study? Chapter Objectives Medical Terms See syllabus Lab book Practice questions – Each chapter don’t forget the rationales Leaders Defining the Art & Science of Nursing Leaders Defining the Art & Science of Nursing