BSN: NRS—310 Nursing Assessment

andHealth History

Nancy Sanderson MSN, RNLecture 1: Chapters 1-3, and 5

• Every interaction is part of the nursing process

• Nursing process = six steps• First step: Assessment• ANA definition (Standards of

Practice)• Components of health

assessment

▫ Health history

▫ Physical examination

▫ Documentation of data2

Why Learn Health Assessment?AD PIE:

Full assessment Determine what is the

problem Determine what is

acceptable range, sounds, look, etc

Determine what is not within the acceptable range: crackles in lungs, abnormal heart sounds, distended abdomen, etc 3

Step # 1: Assess

NOT a medical diagnosis The nursing diagnosis helps the student critical think,

determine how to plan, and to make goals

NDX describes the client’s response to actual or potential problems or conditions; changes from day to day within the legal scope of independent nursing practice

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Nursing Diagnosis (NANDA)

Nursing Diagnosis Made by the nurse Describes clients

response Responses vary

between individuals Changes as client

responses change Nurse orders

interventions

Medical Diagnosis Made by a physician Refers to the disease

process Somewhat uniform

between clients Remains same during

disease process Physician orders

interventions

Nursing Dx VS Medical Dx

Nursing Dx VS Medical DxMedical Diagnosis Nursing Diagnosis Pneumonia Dehydration Hyperkalemia ----- Myocardial infarction (heart attack)

Ineffective breathing pattern Fluid volume, risk for

deficient Electrolyte imbalance, risk

for imbalance Cardiac Output, decreased Perfusion, risk for decreased

cardiac tissue

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Assessment: Monitor HR/BP; Skin Color and perfusion; peripheral pulses; capillary refill

Nsg Dx: Risk for decreased cardiac output Plan/goal: Cardiac pump effectiveness: VS and Fluid

Balance Intervention: Assess respiratory rate, rhythm & breath

sounds; Urine output; Administer medications & IV fluids as ordered by MD

Evaluation: VS stable; UO > 30 ml/hr; meds/IV’s administered as ordered

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The Nursing Process: MI

Assessment Nursing diagnosis Goal Implementation Evaluation

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Health Assessment Class

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Components of Health Assessment

Three primary components◦ History (subjective data)◦ Examination (objective data)◦ Documentation of data

Data = signs and symptoms◦ Symptom = what client

feels/communicates (subjective)◦ Sign = clinical finding (objective)

A systematic method of data collection assists the nurse in identifying the client’s health characteristics

Data collected focuses on client’s health compared with ideal—accounting for client’s traits

Collection and analysis of data leading to identification of problems:

Guides nurse in developing care planAssists client to maximize health potential

Amount of information gained during a health assessment depends on several factors including:

Context of careClient needExpertise of the nurse

Example

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Subjective: “I’ve never had such bad pain in my life” Objective: ◦ Pt is bend over holding abdomen◦ Blood pressure is high◦ Abdomen is rigid ◦ Bowel sounds are absent

Types of Health Assessment Client needs vary widely.◦ Nurse must be prepared to conduct appropriate level of

assessment.◦ Client’s age, general level of health, presenting problems,

knowledge level, and support systems are among the variables that impact client need.

Expertise of the nurse is gained with specialization within a given area of practice; for example:• A nurse in an adult intensive care unit has expertise

assessing a client with hemodynamic instability.• A family nurse practitioner working in a women’s clinic has

expertise in performing routine pelvic examinations.

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• Data organization involves organizing or clustering data that allows problems to be clearly apparent.

• Data analysis, interpretation, and clinical judgment includesIdentification of abnormal findings: Correctly interpreting

findings to select appropriate interventions

Clinical judgment to interpret or make conclusions regarding patient needs, concerns, or health problems

Health Promotion and Health Protection

Nurses provide education and care to help meet health promotion needs.

View health care as holistic:◦Mind◦Body◦ Spirit

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3 Levels of Health Promotion◦ Primary = preventing

disease from developing; promoting healthy lifestyle

◦ Secondary = screening to find early indicators of disease

◦ Tertiary = minimizing disability from acute/chronic illness/injury and allowing for most productive life within limitations

Immunizations, nutrition teaching, exercise

Physical examinations, teaching patient how to do a breast exam

Management of Diabetes Mellitus, Cardiac Rehab

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Techniques for Specific Populations

Cultural Diversity

•Many cultures are a continuum of diversity in behaviors and beliefs.

•Cultural dynamics mean change.▫Culture = shared beliefs, values, and behaviors that

define right, wrong, abnormal, inappropriate•Diversity can create challenges.▫When cultures and languages differ▫When caring for individuals by not forcing compliance,

by working with beliefs and value systems

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Ethnic and Cultural Considerations (Cont’d) CLAS (Culturally, and Linguistically

Appropriate Services) standards to ensure equitable and effective treatment. There are 14 standards.

They are organized around three themes. ◦ Culturally-competent care◦ Language access services ◦ Organizational supports for cultural

competence

Refer to Boxes 5-1, 5-2, & 5-3 for tools, tips and barriers of assessing spiritual & cultural needs.

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Nurses and other health care teams are affected by the first standard which states “ Healthcare organizations should ensure that patients /customers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with cultural health beliefs and preferred language.”

Improving cultural awareness and meeting Standard 1 requires the nurse to take several steps:

Ethnic and Cultural Considerations (Cont’d)

Ethnic and Cultural Considerations (Cont’d)

1. Become culturally competent through sensitivity to differences between their own culture and that of the patient.

2. Avoid stereo typing and assuming the meaning of others behavior.

3. Develop a template that may be used for cultural and spiritual assessment of patient and their families.

Becoming Culturally Competent

Cultural competence is the ability to communicate among/between cultures and to demonstrate skill in interacting with and understanding people of other cultures.

A culturally-competent nurse:◦ Allows clients to explain meaning of illness◦ Respects concepts of time, space, contact◦ Respects physical/social activities◦ Respects systems of social organization/provides

environmental control

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Techniques for Specific Populations Adolescent-◦ Show respect, be totally honest, and avoid

using language that is absurd for your age or professional role.

◦Use ice breakers and keep questions short and simple.

◦Don’t assume they know anything about health interviews or physical exams.

◦Be aware of gestures and expressions.◦ If confidential material is uncovered consider

what can remain confidential and what must share.

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Techniques for Specific Populations• Under influence of Drugs/Alcohol▫Ask simple, direct questions. ▫Make manner and questions nonthreatening, and

avoid confrontation.▫Be aware of hospital security or other personnel who

could be called for assistance. • Angry/Violent▫Deal with the angry feelings first▫If sense suspicious or threatening behavior act

immediately to defuse situation.Leave the exam room door open and position self between person and door. Speak in quiet, calm voice.

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Techniques for Specific Populations Older Adult◦Always address by last name.◦Adjust pace of interview and avoid

hurrying them along. Hearing Impaired◦Ask preferred way to communicate (i.e.

signing, lip reading, or writing). Acutely Ill◦ In emergency must combine interview

and PE. Pick out points of history most important/relevant and use closed, direct question earlier.

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Patient Interview

• Orientation / Introduction Phase• Working /Discussion Phase▫Gathering data through health history▫Introduction (Indicate your role in health care team)

▫Addressing the Environment▫Establishing a therapeutic relationship

• Termination / Summary Phase▫Concluding the interview

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Introduction

Check ID band with 2 identifiers◦Name◦Identification number assigned by health

care agency◦Telephone number◦Date of birth

State your purpose & obtain consent

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Addressing the Environment Make environment comfortable and relaxed◦ Provide privacy, remove distractions◦ Appropriate lighting◦ Provide symptom management

• Privacy is essential for sensitive issues.▫Openness and honesty ▫Health care facilities not always conducive to

privacy; draw curtains when available▫HIPAA- Health Insurance Portability and

Accountability Act, 2003▫Physical comfort for client and nurse▫Distance allows conversation, eye contact, and

appropriate personal space26

Establishing a Therapeutic Relationship

• Professional Image▫Clean, neat, well groomed, & conservatively dressed▫Odor free▫Tattoos covered & piercings removed▫Speak in clear, well-modulated voice with good

grammar▫Listens to others and communicates effectively▫Helps and supports colleagues▫Begins shift on time▫ Is organized, well prepared, and equipped for the

responsibilities of the nursing role

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Establishing a Therapeutic Relationship

• Active Listening▫S- Sit facing patient▫O- Observe an open

posture▫L- Lean towards the

patient▫E- Establish and

maintain eye contact▫R- Relax

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• Single most important factor for successful interviewing is establishing rapport to gain client’s trust.

Affected by numerous factors: physical setting, nurse behaviors, type of questions asked, how questions are asked, as well as:

The personality and behavior of clientsHow client is feeling at the time of interviewNature of information being discussed or problem being confronted

EMPATHY (Identifying with feelings) vs SYMPATHY- (feeling sorry for them) Boundaries!

Empowering vs dependency

Types of Data• Subjective data

What the patient tells you Health History Symptoms

• Objective data What examiner detects during exam

Physical Examination Signs Labs Non-verbal behaviors

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Subjective or Objective?• Patient complains of abdominal pain

• Head pain is throbbing

• Facial features are symmetrical

• Heart rate is 80bpm

• Patient feels short of breath

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History of Present IllnessEssential and relevant data about the nature and onset of symptoms for the illness that

patient is requesting care for. Using mnemonic may help to ensure obtain complete

history (OLDCARTS)Onset, Location, Duration, Characteristics, Aggravating/Alleviating,

Related, Treatment, Severity O = Onset ◦When began? ◦ Begin suddenly or gradually? ◦What was doing/mechanism?

L = Location ◦Where is pain/complaint located?

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OLDCARTS D = Duration ◦ Symptoms always present or do they come & go?

If come & go, how long last?) C = Characteristics ◦ Describe pain/complaint.

I.e.: Sharp, dull, throbbing, aching◦What is pain level at worst? What is it right now?

A = Aggravating & Alleviating Factors ◦What makes it worse? What makes it better? ◦Other symptoms that occurring at same time that could be

associated/Relevant portions of the Review of Systems

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OLDCARTS R = Radiation ◦ Does pain/complaint radiate?

T = Treatments tried ◦What have tried to treat pain/discomfort? ◦What was outcome?

S= Severity ◦ How severely does this interfere with your life?◦ Describe how many, the size, the amount

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Termination/Summary Phase Give patient a clue that interview is

coming to an end Summarize important points and ask if

summary is accurate Address any plans for action◦ If you need anything else just press the call light.

Otherwise I will be back in 1 hour to check on you and give you more pain medication if you need it

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The Art of Asking Questions

• Essential competency of nurses▫Ask clear-spoken questions▫Define words, avoid using technical/medical

definitions, and use slang only if necessary for certain conditions. Adapt questions consistent with client level of

understanding and knowledge.▫ Encourage clients to be specific and clarify meanings.▫Ask one question at a time and wait for reply.▫ Be attentive to client feelings that may indicate need

for additional data.

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Health History Questions• Begin health history with open ended questions▫Ask for narrative information• What brings you to the hospital today?• How can I/we help you today?• What concerns do you have today?

• Continue with closed or direct questioning▫Ask for specific information that elicits a 1 or 2 word response• Are you having any pain?• How would you describe your pain?

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Techniques That Enhance Data Collection• Active listening concentrates on client

responses and subtleties.▫Avoid formulating next question during

responses.▫Avoid making assumptions about client

responses.• Facilitation uses phrases to encourage

clients to continue talking further.▫Verbal: “What do you mean?”, “Go on,” “Uh-

huh,” “Then…?”▫Nonverbal: head nodding or shifting forward to

listen more intently

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Techniques That Enhance Data Collection (Cont’d)

Clarification is used to gather more information.

Restatement is repeating in different words what client says to confirm interpretation.

Reflection is repeating what client said and encourages elaboration or more information.

Confrontation is used when inconsistencies are noted between client report and nurse’s observations.◦ Use tone of voice to convey confusion or possible

misunderstanding.

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Techniques That Enhance Data Collection (Cont’d)

Interpretation is used to share conclusions drawn from data.◦ Client may then confirm, deny, or revise.

Summary condenses and orders data to clarify sequence of events for client’s clarity.◦ Emphasizes data related to health promotion,

disease protection, and resolving health problems

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Techniques That Diminish Data Collection Using medical terminology confusing to client◦May not understand question or be embarrassed to

request clarification, and therefore give inaccurate data

Expressing value judgments Giving false reassurance Interrupting while clients are talking Having an authoritarian or paternalistic

demeanor Asking “Why” questions that may threaten

clients and make them defensive

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Managing Awkward Moments

• Displays of emotion▫Crying is natural and should be expected.

It may indicate need for follow-up. A compassionate response enhances relationship.

▫Anger is uncomfortable for client and nurse. Deal with it directly. Identify source of anger: you or another person. Discuss approaches and acknowledge feelings. If client unable to continue, honor request to work with

another nurse.

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Challenges to the Interview Managing overly talkative clients

Overly detailed problems may become distraction.

Re-focus interview on events relative to present.Re-direct conversation with close-ended

questions that may help reduce distractions.

•SilenceNecessary for clients to reflect and gather courage to

address painful topics or issuesFeedback that client is not ready to discuss topic or

that the approach needs to be evaluatedBecome comfortable with silence

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Challenges to the Interview (Cont’d)

Others in the room◦ Don’t assume relationships, best to clarify.◦ Parent or guardian may answer for child.◦ Interview adolescents directly.◦ For adults unable to answer, another person may

assist. Client should be involved to the extent of capabilities. When able to answer, direct questions to client. If others in room, obtain client’s permission.

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The Health History

1. Types of health histories2. Components of the health history3. Personal and psychosocial history4. Review of systems5. Health history based on functional

health patterns

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Types of Health Histories (Cont’d)

Comprehensive health history History for problem-based or

focused health assessment Episodic or follow-up assessment ◦Focuses on specific problems for

which client is already receiving treatment◦Assesses for changes since last

visit

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Types of Health Histories (Cont’d)

• History for problem-based or focused health assessment▫Data that are limited in scope to specific problem▫Detailed enough that nurse may be aware of other

health-related data affecting the current problem▫ Focused interview also used when client seeks to

address urgent problems such as relief from asthma attacks or chest pain Further data may be collected once client is stabilized.

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Components of the Complete Health History

Biographical Information

Reason for Seeking Care

Client expectations

History of Present Illness/Present

Health Status

Past Health History

Family History

Environmental History

Personal & Psychosocial

History (Spiritual)

Review of Systems

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Types of Health HistoriesComplete◦Generalized◦Comprehensive

Focused◦Problem oriented

On-going

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Types of Health HistoriesComplete◦Generalized◦Comprehensive

Focused◦Problem oriented

On-going

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Health History Based on Functional Health Patterns

Not all histories are organized by body systems.

Nurses may use a common interview format based on functional health patterns.◦ Database for organizing client information

Functional health patterns collects and organizes data in 11 areas.

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Health History Based on Functional Health Patterns (Cont’d)

Health perception–health management

Nutrition-metabolism,nutrition-metabolic

Elimination Activity-exercise Cognitive-perception Sleep-rest

Self-perception– self-concept

Role-relationship Sexuality-

reproduction Coping-stress

tolerance Values-belief

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Biographical InformationFactual demographic data about the

patient◦Name◦Age◦Marital Status◦Address◦Occupation◦Primary Care Provider◦Primary Language Spoken

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Reason for Seeking Care

Chief complaint or presenting problem◦Brief statement regarding purpose for visit◦Recorded in direct quotes from client◦Multiple reasons: list and prioritize◦ Client may not give reasons until comfortable◦ Client condition determines next step

Urgencies requires expediency Bibliographic data delayed Data analysis to determine cause and develop

plan

“I’ve had pains in my

stomach for the past

3 days”

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Present Health Status

Focus on client conditions.◦ Health conditions, acute and chronic

Duration and impact on daily lives For example, diabetes, hypertension, heart disease,

sickle cell anemia, cancer, seizures, pulmonary disease, arthritis, mental illness

◦Medications and reasons for taking each Prescriptions Over-the-counter Herbal preparations

◦ Allergies (true reaction or sensitivity?)

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Present Health Status (Cont’d)

Allergies◦ Foods ◦Medications ◦ Environmental factors◦ Contact substances◦ Specifically ask about substances client could be

exposed to in health care setting, such as latex and iodine.

◦ Clarify and distinguish between side-effect and allergy.

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History of Present Illness Nurse documents present illness or problem.

Further investigation of presenting problem◦ Symptom analysis is a systematic collection of data

about history of symptom status.◦ Various formats include onset, location, duration,

characteristics, severity, associated symptoms, alleviating and aggravating factors, and any self-treatments.

If general visit and no presenting problem, focus interview on current state of health.

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Past Health History Childhood Illnesses Accidents / injuries Chronic illness Medications Previous Medical Conditions/Problems Previous Hospitalizations /Surgeries◦Include type, year, and residual problems for all

above Immunizations◦Include dates and reactions

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Past Health History

Women Only◦Last menstrual period

(LMP)◦Last pregnancy Gravida Para Abortion/miscarriage◦Last pap smear

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Family History

Blood relatives: biologic parents, aunts, uncles, siblings, children, and including spouse

◦Identify genetic, familial, environmental factors that might affect current or future health status.

◦Trace back two generations to parents and grandparents.

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Family History (Cont’d) Ask about specific diseases.◦ Alzheimer’s disease◦ Cancer (all types)◦ Diabetes mellitus: (specify type 1 or type 2)◦ Coronary artery disease including myocardial infarction◦ Hypertension◦ Stroke◦ Seizure disorders ◦ Mental illness, including depression, bipolar disorder, schizophrenia◦ Alcoholism and/or drug abuse◦ Endocrine diseases◦ Kidney disease

Genogram a tool useful in tracing diseases with genetic tendencies refer to Fig. 2-3 (pg16).

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Personal & Psychosocial History• Mental Health▫Mental illnesses (anxiety, depression, etc.)▫ Stressful events

Describe stresses in life now What methods do you use to relieve stress and are they

effective?▫ Personal coping strategies

Do you have a social support network (family, friends, coworker, church?

• Personal Habits▫ Tobacco (packs/day, how long?)▫Alcohol (drinks/day, how long?)▫ Illicit Drugs (name of drug, how often, how long?)

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CAGE Questionnaire

Have you ever felt the need to Cut down on drinking? Have you ever felt Annoyed by criticism of your

drinking? Have you ever felt Guilty about drinking? Have you ever taken a drink first thing in the morning

(Eye-opener) to steady your nerves or get rid of a hangover?◦ Two or more + answers suggest alcohol misuse

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Personal & Psychosocial History This information may help identify unique patient needs,

areas for patient education, and the need for non-nursing type interventions

Family/Social Relationship◦ Role in the family◦ How getting along?◦ Domestic Violence

Diet and Nutrition◦ Record 24 hour diet recall◦Who buys and prepares food for patient?

Functional Ability Ability to perform self-care activities

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Personal & Psychosocial History• Sleep patterns▫ Short-term sleep deprivation associated with

Delay of wound healing Decreased performance and alertness Memory and cognitive impairment Stressed relationships Decreased quality of life Occupational and automotive injury

▫ Long-term Increased BP, heart attack, heart failure, stroke, obesity, diabetes

mellitus, psychiatric problems, ADD, mental impairment ▫Note: Alcohol, nicotine & caffeine are stimulants and should

be avoided 4-6 hours before bed

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Personal & Psychosocial History Health Promotion◦Exercise Type & frequency

◦Self-examination Type & frequency

◦Oral hygiene practices Frequency of brushing/ flossing

◦Date of last screening examination i.e. BP, breast, prostate, glucose, colon Immunizations

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Personal & Psychosocial History Environment (living & work environment)◦Housing & Neighborhood Type of structure, live alone, safety

◦Hazards at workplace or home?◦Use of seat belt?◦Use of sun block?◦Cigarette smoke?◦How are medications stored in the house?◦Own a gun? If yes, how stored?

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Review of Systems

Purpose is to:◦Evaluate past and present health states for each

body system◦Double check that no data were omitted in the

present illness section◦Evaluate health promotion practices

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Review of Systems

Past and present health of each body system Conduct symptom analysis when clients indicate

presence of symptoms. Medical terms◦ Define for client understanding.◦ Use for documentation and communication with

health team. Avoid repeating review of systems if present

health status section data is sufficient.

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Review of Systems (Cont’d) General symptoms Integumentary Head and neck Breasts Respiratory Cardiovascular Gastrointestinal Urinary system Reproductive Musculoskeletal Neurologic system

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Review of Systems (Cont’d)

Additional health promotion data may be collected during review of systems.

In a comprehensive health assessment, you ask most of the questions.

In a focused health assessment, you ask questions about systems related to reasons for seeking care.

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Summary

Collecting a thorough history accomplishes several goals. Establishes a therapeutic relationship with the

client Provides a snapshot of client and identifies

problems mentioned by client that can be confirmed or refuted during exam

Data must be organized, synthesized, and documented.

Organized collection of data makes documentation easier.

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