Health Assessment Theory Lecture 1 & 2 PDF

HEATLH – A STATE IN WHICH A PERSON IS ABLE TO LIVE TO HIS OR HER POTENTIAL. ILLNESS : THE UNIQUE RESPONSE OF A PERSON TO A DISEASE WELLNESS : AN ACTIVE STATE, ORIENTED TOWARD MAXIMIZING THE POTENTIAL OF THE INDIVIDUAL PURPOSE OF HEALTH ASSESSMNET: TO DETERMINE A PATIENT’S HEALTH STATUS, RISK FA...

HEATLH – A STATE IN WHICH A PERSON IS ABLE TO LIVE TO HIS OR HER POTENTIAL. ILLNESS : THE UNIQUE RESPONSE OF A PERSON TO A DISEASE WELLNESS : AN ACTIVE STATE, ORIENTED TOWARD MAXIMIZING THE POTENTIAL OF THE INDIVIDUAL PURPOSE OF HEALTH ASSESSMNET: TO DETERMINE A PATIENT’S HEALTH STATUS, RISK FACTOR, AND NEED FOR EDUCATION AS A BASIS FOR DEVELOPING A NURSING CARE PLAN. PROVIDE SPECIFIC CUES FOR THE HEALTH PROBLEM ROLE OF NURSE: TO COLLECT COMPREHENSIVE DATA PERTINENT TO THE PATIENT’S HEALTH OR SITUATION. HEALTH ASSESSMENT COMPREHENSIVE (ALL ASPECT)HEALTH HISTORY COMPLETE PHYSICAL EXAMINATION STEPS IN IDENTIFICATION OF PATIENT'S PROBLEM 1. HOLISTIC (WHOLE PERSON) CARE 2. ASSESSMENT ( HEALTH AND PHYSICAL) 3. OBSERVATION AND MEASUREMENT 4. PROCEDURE AND INVESTIGATION 7 FACETS / DIMENSION 1. PHYSICAL HEALTH NOTE: 2. EMOTIONAL HEALTH 1. A PERSON’S ABILITY TO ADAPT WHILE NOT 3. SOCIAL WELL BEING COMPROMISING THE FACETS IS 4. CULTURAL INFLUENCES IMPORTANT 5. SPIRITUAL INFLUENCES FOR HEALTH MAINTENANCE. 6. ENVIRONMENTAL INFLUENCES 2. HEALTH IS NOT CONSTANT AND CANNOT BE 7. DEVELOPMENTAL LEVEL TAKEN FOR GRANTED ROLE OF THE NURSE 1. THE NURSE AS CAREGIVER PERFORM HEALTH RELATED ACTIVITIES THAT A SICK PERSON CANNOT PERFORM INDEPENDENTLY. 2. THE NURSE AS EDUCATOR ONE WHO PROVIDES HEALTH TEACHING PERTINENT TO EACH CLIENT’S NEED AND KNOWLEDGE BASE. 3. THE NURSE AS COLLABORATOR ONE WHO WORKS WITH OTHERS TO ACHIEVE A COMMON GOAL 4. THE NURSE AS DELEGATOR ONE WHO ASSIGNS TASK TO SOMEONE  HEALTH HISTORY FIRST STEP OF PATIENT ASSESSMENT. COLLECTION OF SUBJECTIVE AND OBJECTIVE (PHYSICAL EXAMINATION))DATA. IDENTIFY PATIENT STRENGTHS AND AREAS OF HEALTH CARE NEEDS. PURPOSE: PROVIDES THE FOUNDATION FOR IDENTIFYING NURSING PROBLEMS AND PROVIDE A FOCUS FOR THE PHYSICAL EXAMINATION A FRAMEWORK FOR ORGANIZING PATIENT INFORMATION IN WRITTEN OR VERBAL FORM. 7 COMPONENTS OF COMPREHENSIVE HEALTH HISTORY 1. IDENTIFYING DATA AND SOURCE OF THE HISTORY 5. FAMILY HISTORY 2. CHIEF COMPLAINTS 6. REVIEW OF THE SYSTEM 3. HISTORY OF PRESENT ILLNESS ( HPI) 7. HEALTH PATTERN 4. PAST HISTORY 1. IDENTIFYING DATA ❑ AGE ❑ DATE OF BIRTH ❑ GENDER ❑ OCCUPATION ❑ MARITAL RELATIONSHIP ❑ EDUCATION LEVEL ❑ PRIMARY LANGUAGE SPOKEN AND READ SOURCE OF HISTORY ▪ PATIENT (PRIMARY) ▪ FAMILY MEMBER (SECONDARY) ▪ FRIEND (SECONDARY) ▪ LETTER OF REFERRAL(SECONDARY) ▪ MEDICAL RECORD (SECONDARY) 3. History of Present Illness. - chronological account of the patient’s chief complaint and the events surrounding it. ▪ Self-treatment (OTC drugs) ▪ Past occurrence of the symptoms ▪ Pertinent positive and or negative ▪ Risk factor or other pertinent information ❖ Information related to the symptoms 4. PAST HISTORY ALLERGIES - HEALTH MAINTENANCE MEDICATIONS - IMMUNIZATION NAME - SCREENING TEST DOSE/ROUTE - SAFETY MEASURES FREQUENCY OF USE - RISK FACTORS HOME REMEDIES/ NONPRESCRIPTION DRUGS TOBACCO CHILDHOOD ILLNESSES ENVIRONMENTAL HAZARD ADULT ILLNESSES SUBSTANCE ABUSE MEDICAL ALCOHOL SURGICAL ACCIDENTS PSYCHIATRIC 5. FAMILY HISTORY GENOGRAM SIBLINGS, PARENTS, GRANDPARENTS, AND CHILDREN AGE AND HEALTH CAUSE OF DEATH DOCUMENTS OF PRESENCE OR ABSENCE OF SPECIFIC ILLNESSES IN FAMILY (HYPERTENSION, CAD) 6. REVIEW OF THE SYSTEM A SERIES OF QUESTIONS ABOUT ALL BODY SYSTEM THAT HELPS TO REVEAL CONCERNS OR PROBLEMS MAY UNCOVER PROBLEMS THAT THE PATIENT HAS OVERLOOKED, PARTICULARLY IN AREAS UNRELATED TO THE PRESENT ILLNESS. NOTE: o IT IS HELPFUL TO PREPARE THE PATIENT TO QUESTIONS. o START FROM GENERAL QUESTIONS THEN SHIFT TO MORE SPECIFIC. o ADDITIONAL QUESTIONS WILL VARY DEPENDING ON AGE, COMPLAINTS, GENERAL STATE OF HEALTH, AND YOUR CLINICAL JUDGEMENT REVIEW OF THE SYSTEM / SAMPLE QUESTIONS  7. HEALTH PATTERN GATHER PERSONAL/ SOCIAL HISTORY FROM THE PATIENT DAILY LIVING ROUTINES THAT MAY INFLUENCE HEALTH AND ILLNESS PHYSICAL EXAMINATION A PROCESS TO OBTAIN OBJECTIVE DATA FROM THE PATIENT. PURPOSE: TO DETERMINE CHANGES IN A PATIENT’S HEALTH STATUS AND HOW TO RESPOND TO A PROBLEM AS WELL AS PROMOTE HEALTHY LIFESTYLE AND WELLBEING  FOUR BASIC TYPES OF ASSESSMENT 1. COMPREHENSIVE HEALTH 2. FOCUSED OR PROBLEM ORIENTED ASSESSMENT ASSESSMENT. - CONDUCTED TO ADDRESS A SPECIFIC PROBLEM / CURRENT HEALTH PROBLEM - INVOLVES A COMPLETE HEALTH HISTORY AND PHYSICAL EXAMINATION. 3. FOLLOW UP HISTORY - PROVIDES THE NURSE WITH A FULL - A FORM OF FOCUSED ASSESSMENT PICTURE OF THE PATIENT’S HEALTH - PATIENT PROBLEM IS EVALUATED AFTER STATUS, AS WELL AS HEALTH PROMOTION TREATMENT, OR A SECOND SHIFT NURSE MAY AND RISK REDUCTION NEEDS. FOLLOW UP A PROBLEM IDENTIFIED BY A NURSE ON EARLIER SHIFT.  FOUR BASIC TYPES OF HEALTH ASSESSMENT 4. EMERGENCY ASSESSMENT - RAPID, FOCUSED ASSESSMENT CONDUCTED WHEN ADDRESSING A LIFE-THREATENING OR UNSTABLE CONDITION - SYSTEMIC PRIORITIZATION EX: ASSESSMENT OF CIRCULATION, AIRWAY, AND BREATHING  TYPES OF PATIENT DATA 1. SUBJECTIVE INFORMATION / SUBJECTIVE DATA 2. OBJECTIVE INFORMATION / OBJECTIVE DATA NOTE: WHEN STUDENTS ARE COLLECTING THE INFORMATION AND SHARING IT WITH INSTRUCTORS, ADDRESSES AND PHONE NUMBERS SHOULD BE DELETED, AND INITIALS (NOT NAMES) SHOULD BE USED TO PROTECT THE CLIENT’S PRIVACY. MEASUREMENT O – ONSET VITAL SIGNS L – LOCATION 1. TEMPERATURE 2. CARDIAC RATE/ PULSE RATE D – DURATION 3. RESPIRATORY RATE C – CHARACTERISTIC SYMPTOMS 4. BLOOD PRESSURE 5. PAIN (5TH VITAL SIGNS) A – ASSOCIATED MANIFESTATION O–L–D–C–A–R–T–S R- RELIEVING FACTORS T- TREATMENT 4. PROCEDURES AND INVESTIGATION LABORATORY – PHYSIOLOGICAL FUNCTION OF AN ORGAN DIAGNOSTIC PROCEDURE – ANATOMICAL STRUCTURE OF AN ORGAN COMMUNICATION ▪ AN EXCHANGE OF INFORMATION ▪ INVOLVES SENDING AND RECEIVING MESSAGES BETWEEN TWO OR MORE PEOPLE INTERVIEW PROCESS (HEALTH INTERVIEW) ▪ A PURPOSEFUL, TIME LIMITED VERBAL INTERACTION BETWEEN NURSE AND CLIENT ▪ TO ESTABLISHED TRUST AND RAPPORT ▪ TO COLLECT SPECIFIC INFORMATION ▪ TO VALIDATE APPROPRIATE HEALTH AND ILLNESS INFORMATION ▪ TO IDENTIFY PATIENT’S KNOWLEDGE OF PERSONAL HEALTH AND ILLNESS STATUS Note: Since the nurse is the first to interact with the patient, the first impression of the individual is important for effective interviewing. PHASES OF INTERVIEW 1. PRE – INTERVIEW : SET THE STAGE FOR A SMOOTH INTERVIEW SELF –REFLECTION REVIEW PATIENT RECORD SET INTERVIEW GOALS REVIEW OWN CLINICAL BEHAVIOR AND APPEARANCE 2. INTRODUCTION : PUT THE PATIENT AT EASE AND ESTABLISHED TRUST GREET PATIENT AND ESTABLISH RAPPORT ESTABLISH THE AGENDA FOR THE INTERVIEW CONFIDENTIALITY RESPECT 3. Working : obtain patient information Invite the patient ‘s story Identify and respond to emotional cues Expand and clarify the patient’s story Generate and test diagnostic hypothesis Negotiate a plan, including further evaluation, treatment, education, and self-management support prevention 4. Termination : Summarize important points Discuss plan of care / Future interviews Perfect time to inform patient about laboratory and diagnostic procedure. THERAPEUTIC COMMUNICATION TECHNIQUE DESCRIBE THE SKILLS THAT FORM THE BASIC TOOLS OF INTERVIEWING 1. ACTIVE LISTENING ACTIVE LISTENING IS THE PROCESS OF CLOSELY ATTENDING TO WHAT THE PATIENT IS COMMUNICATING 2. GUIDED QUESTIONING OPTIONS TO EXPAND AND CLARIFY THE PATIENT’S STORY. 3. MOVING FROM OPEN-ENDED TO FOCUSED QUESTIONS. YOUR QUESTIONING SHOULD PROCEED FROM GENERAL TO SPECIFIC. 4. NONVERBAL COMMUNICATION COMMUNICATION THAT DOES NOT INVOLVE SPEECH OCCURS CONTINUOUSLY AND PROVIDES IMPORTANT CLUES TO FEELINGS AND EMOTIONS. 5. EMPATHIC RESPONSES CONVEYING EMPATHY GREATLY STRENGTHENS PATIENT RAPPORT. 6. Validation Validate or acknowledge the legitimacy of the emotional experience. 7. Reassurance The action of removing someone's doubts or fears 8. Summarization Giving a capsule summary of the patient’s story during the course of the interview It identifies what you know and what you do not know 9. Transitions Tell them when you are changing directions during the interview. 10. Empowering the Patient. Patients who are self-confident and understand the recommendations are most likely to adopt offered advice, make lifestyle changes, or take medications as prescribed. PREPARING FOR THE PHYSICAL EXAMINATION 1. REFLECT YOUR APPROACH TO THE PATIENT 2. ADJUST THE LIGHTING AND ENVIRONMENT 3. CHECK THAT THE EQUIPMENT IS AVAILABLE AND IN WORKING ORDER 4. MAKE THE PATIENT COMFORTABLE 5. CHOOSE THE SEQUENCE OF EXAMINATION Preparing for the physical examination 1. REFLECT YOUR APPROACH TO THE PATIENT - MANY PATIENTS VIEW THE PHYSICAL EXAMINATION WITH ANXIETY. - AVOID INTERPRETING YOUR FINDINGS. - AVOID SHOWING DISTASTE, ALARM, OR OTHER NEGATIVE REACTIONS. 2. ADJUST THE LIGHTING AND THE ENVIRONMENT - SOME ENVIRONMENTAL FACTORS AFFECT THE CALIBER OF THE EXAMINATION. - TANGENTIAL LIGHTING IS OPTIMAL FOR INSPECTING STRUCTURES 3. CHECK YOUR EQUIPMENT - COLLECT ALL NECESSARY EQUIPMENT AND SUPPLIES AND CHECK ALL ARE IN WORKING ORDER. 4. MAKE THE PATIENT COMFORTABLE - PATIENT PRIVACY AND COMFORT - DRAPING THE PATIENT - COURTEOUS CLEAR INSTRUCTIONS - KEEPING THE PATIENT INFORMED 5. CHOOSE THE SEQUENCE OF EXAMINATION - ORGANIZED YOUR COMPREHENSIVE OR FOCUSED EXAMINATION AROUND FOUR GOALS: 1. MAXIMIZE PATIENT’S COMFORT 2. MAINTAIN PATIENT SAFETY 3. AVOID UNNECESSARY CHANGES IN POSITION 4. ENHANCE CLINICAL ACCURACY AND EFFICIENCY Note: Hand hygiene practices reduce the transmission of multidrug resistant organism THE CARDINAL TECHNIQUES OF EXAMINATION  INSPECTION CLOSE OBSERVATION OF THE DETAILS OF THE PATIENT’S APPEARANCE - HEIGHT BEHAVIOR - JUGULAR VENOUS PULSATION MOVEMENT - ABDOMINAL CONTOUR FACIAL EXPRESSION - LOWER EXTREMITY EDEMA MOOD - GAIT BODY BUILD SKIN CONDITIONS EYE MOVEMENTS PHARYNGEAL COLOR SYMMETRY OF THORAX  PALPATION TACTILE PRESSURE FROM THE PALMAR FINGERS OR FINGER PADS TO ASSESS AREAS OF SKIN ELEVATION AND DEPRESSION WARMTH OR TENDERNESS LYMPH NODES AND PULSES CONTOURS AND SIZES OF ORGANS AND MASSES CREPITUS IN THE JOINTS NOTE: METACARPAL/ PHALANGEAL JOINT OR ULNAR SURFACE OF THE HAND IS USED TO DETECT VIBRATION.  PERCUSSION USE OF THE STRIKING OR PLEXOR FINGER, USUALLY THE THIRD, TO DELIVER A RAPID TAP OR BLOW AGAINST THE DISTAL PLEXIMETER FINGER. THE DISTAL THIRD FINGER OF THE LEFT HAND LAID AGAINST THE SURFACE OF THE CHEST OR ABDOMEN, TO EVOKE A SOUND WAVE SUCH AS RESONANCE OR DULLNESS FROM THE UNDERLYING TISSUE OR ORGANS. THIS SOUND WAVE ALSO GENERATES A TACTILE VIBRATION AGAINST THE PLEXIMETER FINGER.  AUSCULTATION USE OF THE DIAPHRAGM AND BELL OF THE STETHOSCOPE TO DETECT THE CHARACTERISTICS OF: HEART LUNG BOWEL SOUNDS LOCATION, TIMING, DURATION, PITCH, AND INTENSITY NOTE: FOR THE HEART THIS INVOLVES SOUNDS FROM CLOSING OF THE FOUR VALVES AND FLOW INTO THE VENTRICLES AS WELL AS MURMURS. AUSCULTATION ALSO PERMITS DETECTION OF BRUITS These four techniques—inspection, palpation, percussion, and, finally, auscultation will always be utilized in order in all systems with the exception of the abdomen. ▪ I–P–P–A ▪ I – A – P - P – for abdomen ( to avoid altering the bowel sounds)