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Unit 1 Jarvis
(Ch. 1-4)
Assessment of the Whole Person
Includes Evidenced-Based Assessment,
Cultural Assessment,
The Interview,
and The Complete Health History
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Chapter 1 Evidence-Based
Assessment
Point of Entry in an Ongoing Process
§ Subjective data
§ What patient says about himself or herself
during history taking
§ Objective data
§ What the health care provider observes when
inspecting, percussing, palpating, and
auscultating patient during physical examination
§ Data base
§ Formed from these elements, along with the
patient’s record and laboratory studies
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Clinical Reasoning Models
§ Diagnostic
reasoning
§ The process of analyzing health data and drawing
conclusions to identify diagnoses.
§ Four
major components:
§ Attending to initially available cues
§ Formulating a diagnostic hypothesis
§ Gathering data relative to the hypothesis
§ Evaluation of each hypothesis with the data
collected
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§ Collect data
§ Review of clinical record
§ Interview
§ Health history
Nursing
Process:
Assessment
§ Physical examination
§ Functional assessment
§ Cultural and spiritual
assessment
§ Consultation
§ Review of the literature
§ Use evidence-based
assessment techniques
§ Document relevant data
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§ Interpret data
§ Identify clusters of cues
§ Make inferences
Nursing
Process:
Diagnosis
§ Validate inferences
§ Compare clusters of cues with
definitions and defining
characteristics
§ Identify related factors
§ Document the diagnosis
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Outcome Identification
§ Identify assumptions and avoid them
§ Approach problems in a nonjudgmental way to avoid bias
§ Recognize information taken for granted or fact without
evidence for it
§ Organized approach
§ Use an organized, systematic assessment format
§ Head to toe assessment
§ Validation
§ Check and corroborate accuracy and reliability of data
§ Normal and abnormal
§ Distinguish when identifying signs and symptoms
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§ Inferences or drawing valid
conclusions
§ Interpreting data and deriving correct
conclusions
§ Clustering related cues
§ Assists seeing relationships among
data
§ Finding relevance
§ Look at clusters of data and consider
which are important for health
problem
§ Inconsistencies
§ Recognize subjective data at odds
with objective data
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§ Identify patterns
§ Helps to see whole picture and
discover missing pieces of
information
§ Missing information
§ Identify gaps in data or need for
more specific interviewing or
laboratory data to make diagnosis
§ Health promotion
§ Identify and manage known risk
factors for an individual’s age
group and cultural status
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Risk diagnosis
• Identify actual and potential risks from
full list of both medical and nursing
assessment data
Set priorities (Table 1-1)
• When there is more than one diagnosis:
• First-level priority problems: emergent,
life threatening, and immediate
• Airway, Breathing, Circulation, Vital
signs
• Second-level priority problems: next in
urgency
• Third-level priority problems:
important to patient’s health but can
be addressed after more urgent
problems are addressed
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§ Collaborative problems
§ When approach to treatment
involves multiple disciplines
§ Outcomes
Nursing
Process:
Outcome
Planning
§ Determine patient-centered
expected outcomes
§ Specific,
measurable , results
expected to improve person’s
problem after treatment
§ Outcome statements include a
specific time frame
§ Example: Your patient is
reporting leg pain at a level of
8/10. The physician ordered
Morphine 1mg IV. Your goal can
read…… Patient will have a pain
level rating at 3/10 within 30
minutes.
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§ Interventions
§ Determine specific
Implementation/Evaluation
interventions that will achieve
expected outcomes
§ Interventions aim to
prevent, manage, or resolve
health problems
§ This is the health care plan
§ Evaluation and corrective
thinking
§ Analyze outcomes and apply
them for evaluation
§ Do stated outcomes match
individual’s actual progress?
§ Continually think, “What
could be done differently or
better?”
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§ Comprehensive
plan of care
and update plan
§ Record revised plan and
keep it up-to-date
§ Communicate revised plans
to multidisciplinary team
§ Be aware this is a legal
document, and accurate
recording is important for
evaluation, insurance
reimbursement, and
research
§ Evaluate
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§ Evidence-based practice (EPB)
§ Systematic approach to
practice that emphasizes the
use of best evidence in
combination with the clinician’s
experience, as well as the
patient preferences and values,
to make decisions about care
and treatment
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Chapter 2: Cultural
Assessment
§ Self awareness and knowledge
§ Key to understanding
§ Cultural Sensibility
§ Deliberate proactive behavior by health care
professionals who examine cultural situations
through thoughtful reasoning, responsiveness, and
discreet interactions
§ Cultures and Subcultures
§ Self identification
§ Help define and influence beliefs about health, illness,
coping mechanisms, and wellness behaviors
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§ Purpose is to address the multiple determinants
of health and evaluate interventions
§ Goal: To eliminate health disparities
§ Defines healthcare disparity as “a particular type of
health difference that is closely linked with social,
economic, and/or environmental disadvantage.
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Healthy People 2020
Health disparities (unfair and avoidable) adversely affect
groups who have systematically experienced greater
obstacles to health based on their:
– racial or ethnic group
– religion
– socioeconomic
status
– gender
– age
– mental health
– cognitive
– sensory
– physical disability
– sexual orientation
– gender identity
– geographic location
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§ Spirituality
§ Broad term, focused on a connection to something
larger than oneself and a belief in transcendence.
§ Religion
§ An organized system of beliefs concerning the cause,
nature, and purpose of the universe, especially belief
in a divine or superhuman power to be obeyed and
worshiped as the creator(s) and ruler(s) of the
universe
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Transcultural Expression of Pain
§ Pain
§ Derived
from the Greek word for
penalty
§ Universally recognized
phenomenon
§ Extremely important to assess
§ Ch. 11 focused exclusively on pain
§ Private
§ Subjective
§ Influenced by cultural heritage
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Chapter 3: The Interview
§ Meeting between you and the patient
§ Goals
§ Record complete health history
§ Optimal health for patient
§ Identify health strengths and problems as bridge to
physical examination
§ First and most important part of data collection
§ Collects subjective data: what the person says about his
or her perceived health state
§ Individual knows everything about his or her own health
state, and the nurse knows nothing
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The Interview
§Gather complete and accurate data about person’s
health state, including description and chronology of any
symptoms of illness
§Establish rapport
and trust so person feels
accepted and free to share all relevant data
§Teach
person about health state so that he or she may
participate in identifying problems
§Build rapport
to continue therapeutic relationship
and to facilitate future diagnoses, planning, and
treatment
§Teaching for health promotion and disease
prevention
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The Interview
§ Consider
interview a contract between nurse
and patient
§ Contract consists of spoken and unspoken rules
for behavior:
§ What person needs and expects from health
care and what health professional has to offer
§ Mutual goal is optimal health for patient
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The Interview
§ Contract
terms include:
§ Time and place of interview and physical
examination
§ Introduction of and explanation of health care
provider’s role
§ Purpose of interview
§ How long it will take
§ Expectation of participation for each person
§ Presence of others, e.g., family, etc.
§ Confidentiality and to what extent it may be
limited
§ Any costs that the patient must pay
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PROCESS OF
COMMUNICATION
§ Communication: exchanging information so that each
person clearly understands the other
§ Involves sending and receiving information
§ Communication is behavior, conscious and unconscious,
verbal and nonverbal
§ All behavior has meaning
§ Body language: posture, gestures, facial expression,
eye contact, foot tapping, touch, even where you place
your chair
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PROCESS OF
COMMUNICATION
§ Involves receiving information
§ Awareness of messages you send is only part of
process
§ Words and gestures must be interpreted in a
specific context to have meaning
§ Receiver attaches meaning determined by his or her
past experiences, culture, self-concept, and current
physical and emotional state
§ Successful communication requires mutual
understanding by sender and receiver
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Internal Factors
§ Internal
factors: what the examiner brings to
the interview
§ Liking others
§ Empathy
§ Ability to listen
§ Self awareness
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External Factors
§ External factors:
§ Ensure privacy
§ Refuse interruptions
§ Physical environment/personal space
§ Table 3.1 p. 25
§ Dress
§ Note-taking may be unavoidable
§ Cannot rely completely on memory for details of
previous illnesses or review of body systems
§ Tape and video recording
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TECHNIQUES OF
COMMUNICATION
§ Introducing the interview
§ Working
phase
phase is the data-gathering
§ Verbal skills include questions to patient and your
responses to what is said
§ Two types of questions:
§ Open-ended
§ Closed
§ Each has a different place and function in
interview
§ Table 3.2
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TECHNIQUES OF
COMMUNICATION
§ Open-ended questions
§ Ask for narrative responses
§ State topic only in general terms
§ Use them:
§ To begin interview
§ To introduce a new section of questions
§ Whenever the patient introduces new topic
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TECHNIQUES OF
COMMUNICATION (cont.)
§ Closed or direct questions
§ Ask for specific information
§ Elicit short, one-or-two word answers, a yes or no
answer, or a forced choice
§ Use them:
§ After opening narrative to fill in details person may
have left out
§ When you need many specific facts about past
health problems, or during review of systems
§ To move the interview along
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TECHNIQUES OF
COMMUNICATION
§ Responses: assisting the narrative
§ Facilitation
§ Encourages patients to say more and shows you are
interested and will listen further
§ Silent attentiveness
§ Gives patient time to think and organize what to say
without interruption from you
§ Gives you a chance to observe person unobtrusively
and note nonverbal cues
§ Reflection
§ Echoes patient’s words, repeating what person has
just said; focuses further attention on a specific
phrase; and helps person continue in his or her own
way
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TECHNIQUES OF
COMMUNICATION
§ Empathy
§ Recognizes a feeling and puts it into words
§ Names the feeling and allows expression of it
§ Patient feels accepted and can deal with feeling
openly
§ Clarification
§ Use when person’s words are ambiguous or confusing
§ Used to summarize person’s words and to simplify
them to make them clearer
§ You are asking for agreement, and the person can then
confirm or deny your understanding
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TECHNIQUES…
Note*** These next 4 responses are the
interviewer’s perspective and should only be used
when necessary
§ Confrontation
§ Frame of reference shifts from patient’s perspective to
yours
§ May focus on discrepancy or inconsistency in
person’s narrative
§ You have observed a certain action, feeling, or
statement and now focus person’s attention on it
§ You give honest feedback about what you see or feel
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TECHNIQUES OF
COMMUNICATION
§ Interpretation
§ Based on your inference or conclusion
§ It links events, makes associations, implies cause,
ascribes feelings
§ Helps person understand his or her own feelings
in relation to the verbal message
§ If your inference is incorrect, the patient may
correct it, and thus prompt further discussion of
topic
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TECHNIQUES OF
COMMUNICATION
§ Explanation
§ These statements inform the person; you share
factual and objective information offering reasons
for requirements or actions
§ Summary
§ Final review of what person has said; it condenses
facts and presents your view of health problem
§ Is a type of validation that person can agree with or
correct; both you and patient should participate
§ Occurring at the end of the interview, it signals that
termination of the interview is near
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Chapter 4: The Complete Health
History
§ Health History Sequence
1. Biographical Data
2. Source of History
3. Reason for Seeking Care
4. Present Health or History of Present Illness
5. Past Health
6. Family History
7. Review of Systems
8. Functional Assessment Including Activities of Daily
Living (ADLs)
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Health History – The Adult
§ Biographical Data
§ Name
§ Address and phone number
§ Age and birth date
§ Birthplace
§ Sex
§ Marital status
§ Race
§ Ethnic origin
§ Occupation: usual and present
§ Preferred language
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Health History
§ Source of History
§ Record who furnishes information, usually the
person, although source may be relative or friend
§ Judge reliability of informant and how willing he or
she is to communicate
§ A reliable person always gives same answers when
questions are rephrased or are repeated later in
interview
§ Note any special circumstances, such as use of
interpreter
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Health History
§ Reason for seeking care
§ Brief spontaneous statement in person’s own
words describing reason for visit
§ Symptom: subjective sensation person feels
from disorder
§ What person says is reason for seeking care is
recorded and enclosed in quotation marks to
indicate person’s exact words
§ Sign: objective abnormality that can be
detected on physical examination or in
laboratory reports
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Health History
§ Present health or history of present illness
§ Location
§ Character or quality
§ Quantity or severity
§ Timing
§ Setting
§ Aggravating or relieving factors
§ Associated factors
§ Patient’s perception
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Health History
§ Childhood
illnesses
§ Obstetric history
§ Accidents or injuries
§ Immunizations
§ Serious or chronic
§ Last examination date
illnesses
§ Allergies
§ Hospitalizations
§ Current medications
§ Operations
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Health History
§ Family History
§ Age and health or cause of death of relatives
§ Health of close family members
§ Family history of various conditions such as
asthma, heart disease, high blood pressure,
stroke, diabetes, blood disorders, cancer, sicklecell anemia, arthritis, allergies, obesity,
alcoholism, mental illness, seizure disorder,
kidney disease, and tuberculosis
§ Family tree (genogram) to show this information
clearly and concisely
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§ Cross-cultural care
§ Additional questions for new immigrants
§ Biographical data
§ Spiritual resource and religion: assess if certain
procedures cannot be done
§ Past health: what immunizations, if any
§ Health perception
§ How does person describe health and illness
§ How does person see problems he or she is now
experiencing
§ Nutrition: taboo foods or food combinations
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Health History
Review of Systems
Purpose
Evaluate the past and present health state of each
system, to double check in case any significant data
was omitted in the present illness section, and to
evaluate health promotion practices and their
meanings.
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Health History
Review of Systems
´ General overall health state: Weight gain or loss over a period of
time, by diet, etc…. Unintentional?????. Fatigue, weakness, fever,
chills, etc.
´ Skin: Hx of skin disease. Eczema, hives, pigment or color change in
moles, dryness, itching, bruising, rash, lesions. Promotion of
sunscreen, hats, etc.
´ Hair: Recent hair loss, change in texture.
´ Nails: change in shape or color, brittleness.
´ Head: Headaches, head injuries, dizziness or vertigo.
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Health History
Review of Systems
´ Eyes: Last eye exam? Glasses, contact lenses. Glaucoma check?
´ Ears: earaches, infection, discharge (and characteristic of it),
tinnitus/vertigo? Method of cleaning ears?
´ Nose and Sinuses: Discharge and characteristics, frequent colds,
sinus pain, nasal obstruction, nosebleeds, allergies, hay fever,
change in sense of smell?
´ Mouth and Throat: Pain, sore throat, bleeding gums, toothache,
lesions, dysphagia, hoarseness or voice change, tonsillectomy.
Promote daily dental care, dentures, etc.
´ Neck: Pain, limited ROM, lumps, swelling, enlarged or tender
nodes, etc.
´ Breast: Pain, lumps, nipple discharge, rash, hx of breast disease,
any breast surgery. Promote self breast exams, mammograms.
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Health History
Review of Systems
´ Axilla: Tenderness, lumps
´ Respiratory system: Hx of lung dz., etc. SOB, pain, wheezing, cough,
sputum
´ Cardiovascular: CP, pressure, tightness or fullness, palpitations,
dyspnea on exertion, etc….
´ Peripheral vascular: Coldness, numbness, tingling, leg swelling,
discoloration of extremities, varicose veins
´ Gastrointestinal: Appetite, food intolerance, dysphagia, heartburn,
indigestion, pain with eating, N/V, hx of abdominal disease: gall
bladder, ulcer, jaundice, appendicitis, colitis, etc.
´ Urinary system: Frequency, urgency, nocturia, dysuria, polyuria,
straining, etc.
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Health History
Review of Systems
´ Male genital system: Pain, sores, lesions, discharge. Self testicular
exams
´ Female genital system: Menstrual history (age of onset, etc.) , LMP, etc.
Last PAP and GYN visit.
´ Sexual health: Prevention of STDs, relationship and sexual activity. Ask if
they have been with anyone with a sexually transmitted infection.
´ Musculoskeletal system: Hx of arthritis, gout, Joint health (stiffness,
etc.) , walking problems??? Uses a walker, etc?
´ Neurologic system: Hx of seizures, stroke, fainting, blackouts,
weakness, tremors, tingling/numbness (paresthesia)?
´ Hematologic system: Bleeding tendencies, excessive bruising, exposure
to toxins, radiation, blood transfusions and past reactions.
´ Endocrine system: Hx. Of DM, or diabetic symptoms, thyroid disease,
intolerance to heat or cold. Abnormal hair growth, etc.
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Health History
§ Functional
ADLs
assessment, including
§ Self-esteem,
self-concept
Activity and exercise
§ Sleep and rest
§ Nutrition and elimination
§ Interpersonal relationships and resources
§ Spiritual resources
§ Coping and stress management
§
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Health History
§ Functional
§ Personal
assessment, including ADLs
habits
§ Alcohol
§ CAGE
test
you ever thought you should Cut
down your drinking?
§ Have you ever been Annoyed by criticism
of your drinking?
§ Have you ever felt Guilty about your
drinking?
§ Do you drink in the morning, an Eye
opener?
§ Have
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Health History
§ Functional
assessment, including ADLs
§ Illicit
or street drugs
§ Environment and work hazards
§ Intimate partner violence
§ Occupational health
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Perception of Health
§ Ask questions such as:
§ How do you define health?
§ How do you view your situation now?
§ What are your concerns?
§ What do you think will happen in the future?
§ What are your health goals?
§ What do you expect from us as nurses, physicians, or
other health care providers?
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