NSB103 Health Assessment PDF

NSB103 Health Assessment Lecture: Professional Communication and Health Assessment Special Acknowledgements to Dr Pauline Gillan Dr Helen Donovan  Health Assessment Interviewing Stages of the Interview Process: Stage 1: The Joining Stage The introduction to...

NSB103 Health Assessment Lecture: Professional Communication and Health Assessment Special Acknowledgements to Dr Pauline Gillan Dr Helen Donovan  Health Assessment Interviewing Stages of the Interview Process: Stage 1: The Joining Stage The introduction to the interview, during which the nurse and person establish trust and get to know each other. Introduce yourself and state your role and the purpose of the interview. Stage 2: The Working Stage Is the time when the bulk of patient data is collected. Ensure the person knows why you are collecting the data. Stage 3: The Termination Stage The last stage of the interview process; information is summarised and validated. Look at options or next things to be done. http://moziru.com/explore/Nurse%20clipart%20patient%20interview/ (Estes et al, 2020, p. 18) Effective Interviewing Be aware of your Listen and observe. own personal beliefs Focus on the Maintain eye Respond to their and how they may patient. contact. responses. affect the interview. Notice the patient’s Paraphrase and Clarify the meaning Allow for periods of speech patterns and summarise of patient responses. silence. recurring themes. responses. Remember attitudes Avoid the use of Avoid being and feelings can be Consistently monitor non-therapeutic judgmental or conveyed non- your reactions. interviewing critical. verbally. techniques.  Planning for the Patient Health Interview Gather all available patient information Seek appropriate setting for the interview (consider privacy) Set aside sufficient time for the interview (30-60mins) Ensure emotional readiness to undertake interview Begin with friendly introduction Estes et al, 2020, p. 15  General Approach to Health History Present with a professional appearance. Ensure an appropriate environment. Sit facing the patient at eye level. Ensure the patient is as comfortable as possible prior to commencing. Reserve asking intimate and personal questions for once rapport is established; remain flexible; Remind that all information is treated confidentially.  Commencing Your Patient’s Health History Date; time of health history; patient name; DOB; address; emergency contact; medicare no.; health insurance; referral from …. Seek appropriate setting for the interview (consider privacy); ensure patient comfort; set aside sufficient time for interview (30-60mins) Present with a professional appearance; begin with a friendly introduction Sit facing the patient at eye level, ensure patient comfort; SOLER model of communication Reserve asking intimate and personal questions until rapport is established Remind patient that information gained is treated confidentially  The Complete Health History Assessment Tool Source and reliability of information; patient profile Reason for seeking health care Present health and history of present illness Past health history (PHH) Family health history (FHH) Social history Health maintenance practices/health promotion activities Estes et al, 2016 p. 53  Past Health History (PHH) Medical History/Surgical History- major/minor Allergies/Medications Communicable Diseases/Injuries/accidents/Chronic illnesses/Serious episodic illness Special needs: Blood Transfusions Childhood illnesses/Immunisations  Family Health History Contains age Records the and health Ideally health status status of the grandparents, Documents of the patient patient and aunts and familial or and their the patient’s uncles should genetic immediate spouse, also be diseases. blood children, incorporated. relatives siblings and parents  Social History Explain reason for Dealing with sensitive topics: gathering social establish rapport first; eye contact; matter of fact tone; non-judgemental approach; information normalising when appropriate  Social History Drug use (prescribed; OTC; Alcohol use Tobacco use illegal/recreational) Intermittent; prolonged; quantity consumed; frequency of consumption; type; age at first consumption; length of time-consuming current amount; pattern of consumption; history of LOC/blackouts; consuming alone or with others; driving under influence; consumption during pregnancy; self-perception of drinking/drugs  Social History Includes: sexual orientation; past sexual Sexual practices practice; age of first experience; no. of partners; safe sex practices; contraception; types of intercourse; STDs (self/partner); use of medication to enhance performance etc  Social History Domestic, or intimate partner violence (IPV) Warning signs: Frequent injuries/accidents/burns Previous injuries for which the patient did not seek care Refusal to discuss injury Significant other who answers for patient Significant other with history of violence or substance abuse  Holistic Health Assessment Social Implications Always be aware of how social situations impact on a persons life, lifestyle and the support systems that are Psychological Implications available to them. A person’s level of fear, sadness, anxiety, distress etc. has the potential to impact negatively on a person’s health and how they present. Conversely a person’s level of happiness, positivity, feelings of acceptance etc can have the reverse presentation. Cultural Implications It is important to understand the dynamics and respond to the challenges inherent in: Bilingualism Multiculturalism Cultural identity Spiritual Implications A person’s spiritual beliefs can affect health behaviours Culturally Safe Assessments Culture Subculture Ethnic identity Minority groups: Health Maintenance/Promotion Activities Diet Sleep Health maintenance/ promotion activities Exercise are practices a person uses to Use of safety promote health living: devices Stress management Health check-ups  Concluding the Health History (Terminating Phase) Ask the Explain the patient Include the next step in about use of Thank the the additional assistive patient. assessment information devices. and when to discuss. to expect it.  General Survey Objective Data; what you assess. Head-to-toe (cephalocaudal) approach  Physical Presence  Psychological Presence Types of  Distress and Pain questions:  Vital Signs (body temperature, Sign and symptom- heart rate, respiration rate, blood related questions Disease-related pressure, and oxygen saturation) Document positive questions and pertinent negative findings. Interviewing the Patient with Diverse or Special Needs The person The person who is culturally with vision, or linguistically hearing or diverse; low speech literacy levels impairments The person under the influence of alcohol or drugs The person who is emotional  Interviewing with a Health Care Interpreter Use trained healthcare interpreter where possible Allow time for patient and interpreter before interview Use brief questions Maintain eye contact with patient, watch non- verbal communication Be patient and allow extra time Provide pre-printed questions or instructions in patient’s native language https://aiic.net/page/6612/the-death-of-healthcare-interpreting-in-the-netherlands/lang/1  Documentation Legal record of patient encounter May be used by many professionals, and is a mechanism of communication Document in a professional and legally acceptable manner Follow institution’s documentation system Electronic medical records (EMRs) are a paperless system of documentation Admission Assessment Form  Assessment - Specific Documentation Guidelines  Record all data that contribute directly to the assessment  Use specific measurements  Refer to findings using anatomical landmarks  Avoid judgmental language  Avoid evaluative statements  Document any changes in the patient’s condition https://study.com/academy/lesson/examples-of-soap-notes-in-nursing.html  References Australian College of Nursing (2018). AcN Professional Portfolio. Retrieved from https://www.acn.edu.au/membership/acn-professional-portfolio Australian Nursing and Midwifery Federation NT, (2015). Nursing Portfolio. Retrieved from www.anmfnt.org.au/system/files/resources/files/anmfnt_portfolio_oct_14.pdf?...1 Clinical Excellence Commission (n.d). In Safe Hands, Clinical Handover Overview. Retrieved from http://www.cec.health.nsw.gov.au/quality- improvement/team-effectiveness/insafehands/clinical-handover Estes, M., Calleja, P., Theobald, K., & Harvey, T. (2016). Health Assessment and Physical Examination. Australian and New Zealand (2nd Ed). Cengage. South Melbourne. Hockenberry, M. & Wilson, D. (2015). Wong’s. Nursing care of Infants and Children. (10th Ed). Elsevier. Mosby. Hunter New England Health (2009). ISBAR revisited: Identifying and Solving Barriers to effective clinical handover, Project toolkit, Newcastle. Retrieved from https://www.safetyandquality.gov.au/implementation-toolkit-resource-portal/resources/organisational-leadership ISBAR%20revisited%20Identifying%20and%20solving%20barriers%20to%20effective%20handover%20in%20inter-hospital%20transfer%20- %20Project%20Toolkit.pdf Lewis, P., & Foley, D. (2011). Weber & Kelly’s Health Assessment in Nursing. First Australian and New Zealand Edition. Sydney AUS: Wolters Kluwer: Lippincott Williams & Wilkins. O'Toole, G. (2016). Communication: Core Interpersonal Skills for Health Professionals. United States: Elsevier. Stein-Parbury, J. (2021). Placing communication at the heart of person-centred care.. In J. Crisp, C. Douglas, G. Rebeiro & D. Waters (eds). Potter & Perry's Fundamentals of Nursing (5th Ed.) Sydney, Mosby Elsevier Victoria Department of Health (2014). Clinical Handover,Standard 6. Retrieved from www.grhc.org.au/document-library/doc.../916-clinical- handover-v1-ms-word