Week 1 Lecture - Legalities, Confidentiality, Health History PDF

NRSG 301 – Health Assessment z Confidentiality, Legalities, Interview and Health History Taking z Welcome to NRSG 301-3 § Instructor: Gwen Keeler MScN, NP(F) § NRSG 301-3: 90 minutes classroom instruction and 90 minu...

NRSG 301 – Health Assessment z Confidentiality, Legalities, Interview and Health History Taking z Welcome to NRSG 301-3 § Instructor: Gwen Keeler MScN, NP(F) § NRSG 301-3: 90 minutes classroom instruction and 90 minutes laboratory practice per week. z Providing Privacy and Protecting Dignity What do nurses need to do to protect a patient’s privacy and ensuring dignity is preserved z Confidentiality § “Nurses have ethical and legal responsibilities to protect clients’ privacy and the confidentiality personal and health information” (BCCNM Practice Standard – Privacy and Confidentiality) § What does this look like in your practice z Legalities § Nurses are a self regulated profession that is overseen by the BCCNM, NNPBC and the BCNU § Each of these organizations has a responsibility to protect nurses and or the public to ensure safety § There are also many pieces of legislation that help guide nurses’ decision-making processes z Examples of Important Legislation § Provincial Legislation § Health Professions and Occupations Act (2022) § Federal Legislation § Assisted Human Reproduction Act (2004) § Controlled Drugs and Substances Act (1996) § Food and Drugs Act (1985) z The Nursing Process § The purpose of the nursing assessment is to identify actual or potential health problems or needs, establish a plan of care, provide appropriate intervention and evaluate the impact of those interventions z The Interview and Health History Taking § Preparation § Setting the Stage § Establishing Rapport Image from Pixta z Appropriate use of Language § Avoid use of jargon § Person first language – so § Use clear, simple language important and assess for § People are not their understanding regularly problems. § You can use teach back § Avoid value laden language methods for this – don’t overuse z Gathering Information § Active or attentive listening § Guided questioning § Summarization § Transition § Empathetic responses § Empowering the Patient § Verbal and non-verbal communication § Validation § Reassurance § z 20 Questions § Let’s Play 20 Questions § Partners please! § One partner picks an item and the other partner asks questions to guess what it is. § The interviewer must ask questions that DO NOT result in a yes or no answer § The interviewee must answer the question without using the function of the item. § If you DO as a yes or no question, you lose 1 question! You only have 20!!! z Comprehensive Health History § Initial information § Age and gender § Presenting Concern § Why they came to hospital § History of Presenting concern § The story of what happened to bring them to hospital, what they experienced – Chronology of events z Health History Continued § Medical History § Previous Diagnoses § Previous surgeries § Previous serious illness § Medications § What medications do they take at home § Substance use z Health History Continued § Allergies § To medication/contrast dye § Environmental § Food allergies § Pertinent Family History § Make sure this is pertinent to your assessment – if they have chest pain – familial cardiac history etc. z Social History § What do they do, have they § Occupation done in the past – looking for potential exposures § Living situation § Who do they live with, where do they live, are they safe at home. § Tobacco use/Alcohol use § How often and for how long? Amount at each intake. § If pertinent to assessment § Sexuality § Hours of sleep, are they § Sleep rested, do they snore/nap z Social History Continued § Dietary § Any dietary considerations § Recent Travel § When and where to § Immunizations § Which one’s, when and are they up to date based on age and stage.  z Three Tiers of Health Promotion Primary Secondary Tertiary Prevention Prevention Prevention Preventing people and Detection of disease before The prevention of symptoms emerge complications when a populations from becoming condition or disease is ill, sick or injured in the first present or has progressed Screening programs place Must be tailored to peoples/communities’ needs and social contexts z Health Promotion is based on § Social Determinants of Health § Income and social status Population Health Promotion Model § Employment and working conditions § Education and literacy § Childhood experiences § Physical environments § Social Supports and coping § Healthy behaviours § Accessto health care services § Biology and genetic endowment § Gender § Culture § Race/racism