Health Care Process PDF

**CHAPTER III** **HEALTH CARE PROCESS** STEPS IN HEALTH CARE PROCESS A. Assessment B. Planning C. Implementation D. Evaluation A. **ASSESSMENT** - It is the process of collecting, organizing, validating and recording data about client's health status. It is the most important ste...

**CHAPTER III** **HEALTH CARE PROCESS** STEPS IN HEALTH CARE PROCESS A. Assessment B. Planning C. Implementation D. Evaluation A. **ASSESSMENT** - It is the process of collecting, organizing, validating and recording data about client's health status. It is the most important step of the health care process. TYPES OF ASSESSMENT a. DATA BASE ASSESSMENT - it is a comprehensive information that the midwife gathers on initial contact with the person to assess all aspects of health status, it includes the nursing health history, physical assessment, primary and provider's history and physical examination, result of laboratory and diagnostic test, and material contributed by other health personnel. b. FOCUS ASSESSMENT - this is the data the midwife gathers to determine the status of a specific condition. 1. **Data Collection** - is the process of gathering information about client's health status. It must be both systematic and continuous to prevent the omission of significant data and reflect a client's changing health status. It is achieved by performing the different methods of assessment. Types of Data a. Subjective data- referred to symptoms or also called COVERT DATA, are apparently only to the person affected and can be described or verified only by that person. Itching, pain and feeling of worry are example of subjective data. Subjective data includes the client's sensations, feelings, values, beliefs, attitude and perception of personal health status and life situation. b. Objective Data- referred to as signs or also called OVERT DATA, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt or smelled and they are obtained by observation or physical examination. For example, discoloration of skin or blood pressure reading is objective data. Source of Data - Primary Source -- Clients is the primary source of data. - Secondary Source -- it includes information provided by family members, support persons, other health professionals, records and reports laboratory and diagnostic analyses and relevant literature. Methods of Data Collection 1. REVIEW OF CLINICAL RECORD - Clinical records of the client include past medical history, results of diagnostic tests and consultation records previously collected and recorded by different health professionals who were involved in the care of the client in past and in the present. By reviewing the client's clinical record or chart before beginning assessment, especially interview, will help to avoid repeating questions that were already answered by the client, unnecessary repetition of diagnostic tests and medical procedures already conducted on the client, and helps to identify areas that needs further inquiry or clarification. 2. Interview- Is a planned conversation or a communication with a purpose Purpose of Interview: - Develop rapport with client. - Gather data about the client's health history and identify problems. - Have an opportunity to provide information to the client pertaining to his or health care. - Provide client support. KINDS OF INTERVIEW: a. Directive Interview -- it involves asking of closed ended questions to elicit specific information. The questions usually begin with when, what, who, where, do, is. The interview is controlled by the interviewer. EXAMPLE: When was your last menstrual period (LMP)? How old are you? b. Non-Directive Interview or Rapport Building Interview -- it is the type of interview that is often used for counseling, problem solving and performance appraisal. The patient controls the pace, purpose and subject matter of interview. The interviewer encourages communication by asking open ended questions, these are questions that encourage the patient to elaborate, explore and clarify their feelings and thoughts. EXAMPLE: How are you feeling lately? What would you like to talk about today? Types of Question a. Closed questions -- questions that can answered by "yes or no" and provides exact responses or factual answers. Often used in directive interview. Useful in clients who are agitated in pain, have difficulty communicating and concentrating or in a lot of stress. EXAMPLE: How old are you? Do you feel dizzy whenever you stand up from a sitting position? b. Open-ended questions -- questions that allow and encourage the client to express their feelings elaborate and explore their thoughts. Client can choose what topic to talk to. Useful at the start of an interview or to change the subject. c. Leading questions -- questions that lead client to a particular topic that the midwife needs to explore or that suggests what answer is expected. You have not eaten any fatty food in the past week, did you? The client may provide inaccurate data to please the interviewer or the midwife. Planning the Interview and Setting 1. Time - midwife needs to plan interview with clients when the client is physically comfortable and free of pain, and when interruption by friends, family, other health professionals are minimal. 2. Place- a well lighted, well ventilated room that relatively free of noise, movements, and distractions encourages communication. In addition, a place where others cannot overhear or see the client is desirable. 3. Seating Arrangement- standing and looking down at a client who is in bed or in chair, the midwife risk intimidating the client. When the client is in bed, the midwife can seat at 45 degree angle to the bed. 4. Distance- the distance between the interviewer and the interviewee should neither too small nor too great because people feel uncomfortable when talking to someone who is too closed or too far. Most people feel comfortable maintaining a distance of two to three feet during interview. 5. Language- use simple words and avoid using of medical words as much as possible. If giving a written documents to clients, the midwife must determine whether the client is able to read or no. For clarification always ask questions or let your client repeat all your instructions. Stages of Interview: a. The opening - the purpose of the opening is to establish rapport and orient the interviewee. Establish rapport is a process of creating goodwill and trust. It can begin in greeting or a self-introduction accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner. b. The body - this is the question-and-answer portion where the interviewer obtains the needed information from the interviewee. c. The Closing - the interviewer usually terminates the interview when the needed information is obtained. The client terminates it when the client decides not to give any more questions for some reasons. EXAMPLE: Well, that's all I need to know for now. Do you have any question before we end this interview? The closing is important for maintaining the rapport and for facilitating future interactions. **2.HISTORY TAKING** - The history taking is the primary source of information about the patient. It can be obtained from the patient himself, relatives or existing old health records. Often, it is the combination of all these that helps in making the health history of the patient. CONTENTS OF HISTORY TAKING: a. Demographic data - Includes information such as name, address, telephone number, sex, age, civil status, religion and race. b. Chief complaint (CC) - The CC is the main reason for seeing health care or consultation to the clinic. The CC is recorded in the patient's own words. EXAMPLE: "I have menstruating nonstop for more than two weeks already." Or "Palagi akong nahihilo." c. History of present illness -- which should contain the "Eight areas of Investigation" which are: \* Sequence and chronology \* Intensity or severity \* Frequency \* Setting \* Location and radiation \* Associated manifestations \* Character complaint \* Aggravating or alleviating factors d. Past History - includes childhood diseases, immunizations, allergies, past hospitalizations and diseases, accidents, injuries past and current medications, prenatal, labor, delivery, neonatal history. e. Family History - includes the risk factors for certain disease, the ages of siblings, parents and grand parents and their current state of health or if they are deceased, the caused of death - are obtained. Particular attention should be given to disorders such as heart disease, cancer, diabetes, hypertension, obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism and any mental health disorder. f. Review of systems - Rundown from head to toe of the patient's present health status. Contains only subjective data given by the patient. It does not include information taken from physical examination. \* General -- height, weight \* Hair \* Fever, chills \* Eyes \* Skin \* Nails \* Head 3. **Physical Assessment -** A complete physical health assessment is a systematic data collection method or manner (head to toe assessment) that uses observational skills to detect health problems. These specific assessments are made in relation to chief complain, the midwife own observation of problems, the client's current problem, nursing interventions provided and medical therapies. Purpose of Physical Examination: a. b. c. d. e. f. g. h. PREPARATION: a. Environment - - - - b. Equipment - - - c. Client 1. - - - 2. - 3. Client Position and Body Area Assessed: Several positions are frequently required during the physical assessment. The client's physical condition, energy level and age should also be taken into consideration. ------------------ --------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------- **Position** **Description** **Areas Assessed** **Cautions** Dorsal Recumbent Back lying w/ knee and hips externally rotated; small pillow under the head; soles on the surface Head and neck, axilla, thorax, lungs, breast, heart, extremities, peripheral pulse, V/S, vagina Maybe contraindicated for client's who have cardio pulmonary problems. Not used for abdominal assessment because tension on the abdominal muscles. Supine Back lying position w/ legs extended w/ or w/o pillow under the head Head, neck, axilla, anterior thorax, lungs, breast ,heart ,abdomen, extremities, peripheral pulse Tolerated poorly by patient with cardio-vascular and respiratory problems Sitting A seated position, back unsupported and legs hanging freely Head, neck, posterior and anterior thorax, lungs, breast, axilla, heart, vital signs, upper and lower extremities, reflexes Elderly and weak clients may require support. Lithotomy Back lying position with foot support in strirrups; the leg with edge Female genitals, rectum and female reproductive tract Maybe uncomfortable and tiring for elderly people and often embarrassing Sims Side lying position with lowermost arm behind the body, upper most leg flexed at hip and knee, upper arm flexed at shoulder and elbow Rectum, vagina Difficult for the elderly and people with limited joint movement. Prone Lie on abdomen with head turned to side with or w/o small pillow Posterior thorax, hip joint movement Often not tolerated by the elderly and people with cardiovascular and respiratory problems. ------------------ --------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------- ###### PATIENT'S POSITIONING GUIDE & CHEAT SHEET **PRONE *-*** Face lying position. Surgery of Spine, Examination of the back and Hip movement.  **SUPINE -**Back lying position with legs extended and arms at the side of the body. The best position for examination of the abdomen. To inspect for lumps and breast masses- LYING SUPINE with pillow under the shoulder. **SIMS-** Side-lying position with lowermost arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow. It permits free drainage of mucus secretions especially among patients who are unconscious and unable to swallow. Examination of vagina, rectum, ENEMA, insertion of SUPPOSITORY. **LATERAL (SIDE-LYING POSITION)** - In lateral or side-lying position, the patient lies on one side of the body with the top leg in front of the bottom leg and the hip and knee flexed. An increase in flexion of the top hip and knee provides greater stability and balance. This flexion reduces lordosis and Promotes good back alignment. Relieves pressure on the sacrum and heels. **SEMI FOWLERS-** Head of bed is raised between 15° and 45°, typically at 30°. Relief from lying position to promote lung expansion. Fowler's position is named after George Ryerson Fowler, who saw it as a way to decrease the mortality of peritonitis.  **TRENDELENBURG**- Head of bed is lowered, and the foot raised in a straight incline. To promote venous circulation in certain clients to provide postural drainage of basal lung lobes. To encourage drainage of secretions from the lungs of the normal newborn. SHOCK, prolapsed umbilical cord, POST PARTUM HEMORRHAGE. **DORSAL RECUMBENT-** If the patient is in a supine position with the knee flexed, this often used to comfort the patient with back strain. The best position for examination of the abdomen.  **LITHOTOMY-** Best position for rectal or vaginal examination. Most used position for delivery. Place the legs on the stirrups simultaneously avoiding any pressure in nerves. **KNEE- CHEST**- Kneeling position with face flat on bed. Best measure for severe abdominal pain, DYSMENORRHEA, SEVERE ABDOMINAL PAIN, RECTAL EXAM, COLIC, ABDOMINAL DISCOMFORT. **Reverse Trendelenburg's** - A patient position wherein the head of the bed is elevated with the foot of the bed down. It is the opposite of Trendelenburg's position. Best measure for Gastrointestinal problems and prevent esophageal reflux. **Draping-** are made up of paper, cloth or bed linen. Drapes should be arranged so that the area to be assessed is exposed & other body areas are covered. Draping the Patient - Protect the patient's privacy - Provide warmth - Drape must not interfere with exam - Sterile drapes are used during surgical procedures **Instrumentation-** all equipment for health assessment should be clean, in good working order and readily accessible. Equipment is frequently set up on trays, ready for use. ###### EXAMINATION EQUIPMENT TO PERFORM PHYSICAL EXAMINATION - Stethoscope -- to listen the body sound - Otoscope -- to examine the ear - Ophthalmoscope- to examine the inner part of the eyeball - Penlight- to visualize any part  - - Sphygmomanometer --to measure BP - Foetoscope- to listen the F.H.S - Thermometer- to measure the temperature  - Tongue depressor -- to examine the mouth and throat - Laryngoscope- to examine the larynx - TPR Tray- to assess the vital signs - Pharyngeal Retractor- to examine the pharynx - Weighting Machine- to check the weight - Tuning Fork- to test the hearing - Nasal Speculum -- to examine the nostril - Percussion Hammer- to test reflexes - Vaginal speculum- to examine the genitals in women - Proctoscope- to examine the rectum Stainless Steel Proctoscope, For Diagnostic Surgery, Material Grade: Ss 304 at Rs 100/piece in New Delhi - Gloves- to examine the pelvis internally  - Sterile specimen bottles- to collect specimen of necessary METHODS OF EXAMINATION a. INSPECTION/OBSERVATION - - - - - b. PALPATION - - - TYPES OF PALPATION - - c. PERCUSSION - - d. AUSCULTATION - TYPES OF AUSCULTATION - - COMMONLY USED ASSESSMENT INSTRUMENTS 1. 2. 3. 4. 5. 6. 4. ### The Different Laboratories - CBC - Urinalysis - Blood Typing - Fasting Blood Sugar - HIV 1 and 2 - HBsAg - VDRL/RPR The different laboratory test: - Sputum Examination - Stool Examination / Fecalysis ### Fasting Blood Sugar Test (FBS) - A fasting blood sugar test measures sugar (glucose) in your blood. It\'s a simple, safe and common way to diagnose pre-diabetes, diabetes or gestational diabetes. A healthcare provider will prick your finger or use a needle to draw blood from a vein in your arm. What should be the FBS result for pregnancy? When to do fasting blood sugar test during pregnancy? How many times should I check my blood sugar during pregnancy? ### **HIV (human immunodeficiency virus ) Elisa Test** - HIV is caused by a virus. It can spread through sexual contact, illicit injection drug use or sharing needles, contact with infected blood, or from mother to child during pregnancy, childbirth or breastfeeding. HIV destroys CD4 T cells --- white blood cells that play a large role in helping your body fight disease. ###### WHY SHOULD I HAVE AN HIV TEST DURING PREGNANCY? - What is the purpose of the HIV test? - HIV testing determines if a person is infected with HIV. The human immunodeficiency virus (HIV) is the virus that causes acquired immunodeficiency syndrome (AIDS). AIDS is the most advanced stage of HIV infection. Why Should Pregnant Women Be Tested for HIV? HIV testing is done by ### **VDRL (Venereal disease research laboratory test)- Syphilis/ RPR** - This test is used to screen for syphilis. The bacteria that cause syphilis is called Treponema pallidum. Your health care provider may order this test if you have signs and symptoms of a sexually transmitted illness (STI). Syphilis screening is a routine part of prenatal care during pregnancy. Why the Test is Performed Normal Results What Abnormal Results Mean What does FTA-ABS test for? ▶ **Fluorescent treponemal antibody absorption test** What is the confirmatory test for syphilis in pregnancy? - ###### HIV/AIDS - **Lyme disease** - **Certain types of pneumonia** - **Malaria** - **Systemic lupus erythematous** Potential Risks: - Excessive bleeding - Fainting or feeling lightheaded - Multiple punctures to locate veins - Hematoma (blood accumulating under the skin) - Infection (a slight risk any time the skin is broken) ### Hepatitis B surface antigen (HBsAg) - This test looks for hepatitis B surface antigens in your blood. The test is used to find out whether you have a recent or long-standing infection from the hepatitis B virus (HBV). HBV has proteins called antigens on its surface that cause your immune system to make antibodies. What is the purpose of the Hep B test? ### Urinalysis (test of urine) - A urinalysis is a test of your urine. It\'s used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes. A urinalysis involves checking the appearance, concentration and content of urine. Urine Specimen Collection: 1. 2. 3. 4. 5. 6. When is the best time to collect urine for urinalysis? ### 6.Ultrasound (Sonogram) - An [ultrasound] is an imaging exam that uses sound waves to create detailed pictures of organs inside your body. The pictures are called sonograms. An ultrasound is a safe, fairly quick procedure that's available at most imaging centers and some doctors' offices. {#ultrasound-sonogram---an-ultrasound-is-an-imaging-exam-that-uses-sound-waves-to-create-detailed-pictures-of-organs-inside-your-body.-the-pictures-are-called-sonograms.-an-ultrasound-is-a-safe-fairly-quick-procedure-thats-available-at-most-imaging-centers-and-some-doctors-offices..ListParagraph} Why is it important to have an ultrasound? How an UTZ is performed? Kind of Ultrasounds: - **Transvaginal ultrasound,** which examines the reproductive organs from inside the vagina. - **Pelvic Ultrasound ,**this method brings the probe closer to the uterus. This provides a clearer view of a fetus during a mother\'s first trimester. **A pelvic ultrasound**allows quick visualization of the female pelvic organs and structures including the uterus, cervix, vagina, fallopian tubes and ovaries. Ultrasound uses a transducer that sends out ultrasound waves at a frequency too high to be heard. This kind of ultrasound is used in early pregnancy to determine how far along a mother is and a due date. This method brings the probe closer to the uterus. This provides a clearer view of a fetus during a mother\'s first trimester. - **Abdominal ultrasound,** which examines organs from outside the belly. In an abdominal ultrasound, gel is applied to the abdomen and the ultrasound transducer glides over the gel on the abdomen to create the image. A woman may need to have a full bladder for abdominal ultrasounds in early pregnancy. Providers use abdominal ultrasounds after about 12 weeks of pregnancy. Traditional ultrasounds are 2D. More advanced technologies like 3D or 4D ultrasound can create better images. This is helpful when your provider needs to see your baby\'s face or organs in greater detail. Providers use abdominal ultrasounds after about 12 weeks of pregnancy. Traditional ultrasounds are 2D. More advanced technologies like 3D or 4D ultrasound can create better images. This is helpful when your provider needs to see your baby\'s face or organs in greater detail. In an **abdominal ultrasound**, gel is applied to the abdomen and the ultrasound transducer glides over the gel on the abdomen to create the image. A woman may need to have a full bladder for abdominal ultrasounds in early pregnancy. ### Sputum Examination How do you prepare for a sputum test? How long does sputum test take? What is the best time to collect sputum? Instruct Patient to do the ff: 1. Cough hard from deep inside the chest three times to bring sputum up from your lungs. 2. 3. 4. 5. ### Complete blood count (CBC) ▶ What is a normal CBC level for a pregnant woman? ▶ Why CBC is needed? ### Blood typing test ▶ Why is blood typing important in pregnancy? ##### Different blood types - **Type AB** - **Type B** - **Type A** - **Type O** 10.FECALYSIS/ STOOL EXAMINATION {#fecalysis-stool-examination.ListParagraph} ------------------------------- ▶ What are the methods of stool examination? ▶ What are the 2 types of stool tests? ▶ How do I prepare for a stool test? ▶ How should I collect and store a FECAL (stool) sample? - collect your fecal (stool) sample in the sterile container given to you by your doctor - store the container in a fridge in a sealed plastic bag if you can\'t hand it in straight away ▶ Collecting a stool sample - A GP or another healthcare professional, such as a nurse, should explain how to collect the sample. - The doctor or a member of staff at the hospital will give you a plastic (specimen) container. - Try not to collect pee (urine) with the fecal , but don\'t worry if you do. If you need to pee, do this first before collecting the fecal. To collect the sample: - - place something in the toilet to catch the poo, such as a potty or an empty plastic food container, or spread clean newspaper or plastic wrap over the rim of the toilet - - use the spoon or spatula that comes with the container to put the required amount of poo into the container, then screw the lid shut - - tip the remaining poo into the toilet, put anything you used to collect it in a plastic bag, tie it up and put it in the bin - wash your hands thoroughly with soap and warm running water - Follow any other instructions your doctor has given you. COMMON MEDICAL ABBREVIATIONS USED: ---------------------------------- - RPR - (Rapid Plasma Reagen) - AOG - (Age of Gestation) - EDC - (Estimated Date of Confinement) - EDD - (Estimated Date of Delivery) - NPO -- (Nothing Per Orem) - Rx -- Treatment - Hx- History - Dx- Diagnosis - Q- every - Qd- everyday - Qod- every other day - Qh- every hour - S- without - SS- on e half - C- with - SOS- if needed - AC- before meals - PC- after meals - BID- twice a day - TID- thrice a day - QID- four times a day - OD- once a day - DR- Delivery Room - ER- Emergency Room - PO- per Orem/per mouth - KVO- keep vein open - UTZ- Ultrasound