Health Assessment/Th Introduction & Interviewing PDF

1- Introduction Course name: Health Assessment/ TH Course code: ADL113 Prepared by: Dr. Shereen Abd Elmoniem Associate professor of Medical-Surgical Nursing Fa...

1- Introduction Course name: Health Assessment/ TH Course code: ADL113 Prepared by: Dr. Shereen Abd Elmoniem Associate professor of Medical-Surgical Nursing Faculty of Nursing/ SCU-NMU 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 1  Outlines Introduction Definition of assessment Definition health assessment objectives of health assessment Importance of nursing health assessment 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 2  Introduction Collecting subjective data is an integral part of nursing health assessment. These types of data can be elicited and verified only by the client. Subjective data provide clues to possible physiologic, psychological, and sociologic problems. They also provide the nurse with information that reveal a client’s risk for a problem as well as areas of strengths for the client. The information is obtained through interviewing. Therefore, effective interviewing skills are vital to accurate and thorough collection of data 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 3  Assessment Is the process of collecting, validating, and clustering data. It is the first and most important step in the nursing process 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 4  Health Assessment Definition: A systematic method of collecting data about a client for the purpose of determining the client’s current and ongoing health status, predicting risks to health, and identifying health-promoting activities. Is a holistic data collection and analysis 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 5  Objectives of health assessment  Surveillance of health status  identification of occult disease  screening, and follow-up care.  Increasing client participation in health care.  Accurately define the health and risk care needs for individuals.  The client share in decision making for his own care. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 6 Importance of nursing health assessment Systematic and continuous collection of client data. It focus on client responses to health problems The nurse carefully examine the client’s body parts to determine any abnormalities. The nurse relies on data from different sources which can indicate significant clinical problems. Health assessment provides a base line used to plan the clients care Health assessment helps the nurse to diagnose client’s problem & the intervention. Complete health assessment involves a more detailed review of client’s condition. Influence the choice of therapies & client's responses. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 7  2- Interview Course name: Health Assessment/ TH Course code: ADL113 Prepared by: Dr. Shereen Abd Elmoniem Associate professor of Medical-Surgical Nursing Faculty of Nursing/ SCU-NMU 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 8  Outlines Definition of Interview Focuses of interview Phases of the Interview types of interview Communication During the Interview Factors affect the Interview Techniques enhance data collection Challenges to interview Interview techniques 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 9  DEFINITION of INTERVIEW An interview is a planned communication or a conversation with a purpose 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 10  Focuses of interview 1. Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information 2. Gathering information of the client to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nurse– client collaboration 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 11  Phases of the Interview 1- Introductory phase time (30-60 sec.) : is the time to introduce yourself to the patient explain the purpose of the interview 2- The working phase time (2- 10 min.): Time where data collection occurs. The nurse and client collaborate to identify the client’s problems and goals. 3- The termination phase. time (30-60 sec.) summarizes obtained information validates problems and goals with the client identify and discusses possible plans to resolve the problem 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 12  Types of Interviews 1. Directive interviews: – Highly structured with specific questions and controlled by the nurse. – require less time and are very effective for obtaining factual data. 2. Nondirective interviews: – controlled by the patient, although the nurse often needs to summarize and clarify the data. – require more time than directive interviews – very effective at eliciting the patient’s feelings. – help the nurse to identify what is important to the patient. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 13  Types of Interviews (cont..) 3. Focused interview: ü Collect information related to the client’s problem. ü collect missed and more in-depth information 4. Combination of directive and nondirective ü appropriate during the interview. ü The nurse begins by determining areas of concern for the client, then the health care team concern 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 14  Communication During the Interview A- Nonverbal Communication: APPEARANCE DEMEANOR :maintain a professional distance FACIAL EXPRESSION : using the right expression at the right time. ATTITUDE (nonjudgmental) SILENCE : facilitates more accurate reporting and data collection. LISTENING : is the most important skill to collect complete and valid data from the client. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 15  B- Verbal Communication Types of Questions 1. Closed questions – Used “yes” or “no” response, – takes little time and is very effective for factual data. 2. Open questions: – Elicit the patient’s perceptions, feel, insight – More time is needed. 3- Laundary List – provide the client with a choice of words to choose from in describing symptoms, conditions, or feelings. 4- REPHRASING Enables nurse and the client to reflect on what was said. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 16  Factors Affect Interview Physical setting Nurse behaviors Type of questions asked How questions are asked Personality and behavior of patients How patient is feeling at the time of interview Nature of information discussed or problem confronted 17 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed  Techniques Improve Data Collection Active listening concentrates on patient responses. Facilitation uses verbal and nonverbal phrases to encourage patients to continue talking further. Restatement is repeating what patient says in different words to confirm interpretation. Reflection is repeating what patient said and encourages elaboration or more information. Confrontation is used when inconsistencies are noted between patient report and nurse’s observations. Interpretation is used to share conclusions drawn from data. Summary :Emphasizes data related to health promotion, disease protection, and resolving health problems.  Challenges to the Interview overly talkative patients:Redirect conversation with closed-ended questions that may help reduce distractions. Others in the room:Do not assume relationships; it is best to clarify. Language barriers: Interpreter should be objective observer, of same gender, but not a family member. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 19  Question During an initial interview, the client makes this statement: “I don’t understand why I have to have surgery, I’m really not that sick or in pain right now.” What is the nurse’s best response? 1. “It’s OK to be worried. Surgery is a big step.” 2. “What kind of questions do you have about your surgery?” 3. “I think these are things you should be asking your doctor.” 4. “Have you had surgery before?” 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 20  3- THE HEALTH HISTORY Course name: Health Assessment/ TH Course code: ADL113 Prepared by: Dr. Shereen Abd Elmoniem Associate professor of Medical-Surgical Nursing Faculty of Nursing/ SCU 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 21  Learning Objectives Definition of health history The importance of health history The components of a health history. Therapeutic communication Document the health history 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 22  Definition Systematic collection of subjective data which stated by the client, and/or his family, and objective data which observed by the nurse. The health history is typically done on admission to hospital, but may be taken whenever additional subjective information needed. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 23  Importance of the history It identifies: what has happened the personality of the patient how the illness has affected him and his family any specific anxieties the physical and social environment It establishes the nurse–patient relationship. It often gives the diagnosis. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 24  Types of Nursing Health History Complete health history: taken on initial visits to health care facilities. Interval health history: collect information in visits following the initial data base is collected. Problem- focused health history: collect data about a specific problem Emergency health history: Nurses collect the most important information and defer obtaining details until patients are stable. They elicit the reason for seeking care along with current health problems, medications, and allergies. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 25  Types of health histories (cont..) vComprehensive health history: establishes complete database. vEpisodic or follow-up: assessment focuses on specific problems for which patient is already receiving treatment. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 26  The Health History Sequence  Biographical data  Reason for seeking care (chief complaints)  Present health or history of present illness  Past health  Family history  Functional assessment including activities of daily living (ADLs)  Environmental  Cultural assessment  Review of Systems (ROS) Dr.Shereen Abd El-Moneam Ahmed 10/11/2024 27  Ending the History When you have completed the history, it is often helpful to say, – “Is there anything else you would like to tell me?” or – “What additional concerns do you have?” – This allows the patient to end the history by saying what is on his or her mind and what concerns the patient most. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 28  Documenting Your Findings The approach to documentation is usually source-oriented or problem-oriented. A- Source-oriented documentation is done by department, so each healthcare group has a section to document findings. This method easily identifies each discipline, but it tends to fragment the data, making it difficult to follow the sequencing of events. B- problem-oriented medical records (POMR), everyone involved in the care of the patient charts on the same form. This allows for better communication of data to resolve the patient’s problems collaboratively. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 29  Purposes of documentation Provides a chronological source of client assessment data. Ensures that information about the client and family is easily accessible to the health care team. Method of communication prevents fragmentation, repetition, and delays in carrying out the plan of care. Establishes a basis for screening or validation proposed diagnoses. Acts as a source of information to help diagnose new problems. 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 30  Purposes of documentation determine the educational needs of the client, family, and significant others. support financial reimbursement for transitional or skilled care needed by the client. Constitutes a permanent legal record of the care that was or was not given to the client. Provides access to significant epidemiologic data for future investigations and research 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 31  Guidelines for documentation Document legibly or print neatly in un-erasable ink Use correct grammar and spelling Use phrases instead of sentences to record data Record data findings, not how they were obtained Write entries objectively without making premature judgments or diagnosis Record the client’s understanding and perception of problems 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 32  Guidelines for documentation Avoid recording the word “normal” for normal findings Record complete information and details for all client symptoms or experiences Include additional assessment content when applicable Support objective data with specific observations obtained during the physical examination 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 33  Documentation Methods SOAPIE Method Subjective data From the patient Objective data: observed or assessed data Assessment/clinical judgment Plan Interventions Evaluation 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 34 DAR Method Data Action Response PIE Method Problem Interventions Evaluation 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 35  THANK YOU 10/11/2024 Dr.Shereen Abd El-Moneam Ahmed 36