Health Assessment
Patrick Heyman, PhD, ARNP
Patrick Heyman, PhD, ARNP
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B.S. from Palm Beach Atlantic
BSN, MSN, PhD from University of Florida
Board Certified Nurse Practitioner
Worked in both hospital and outpatient
settings
• Also teach Ballroom and Latin dancing
• Missionary kid, grew up in Liberia, Costa
Rica, and Uruguay
Wholistic Assessment and
Documentation
Health Assessment
• What is Health?
– Medical Model
– Functional Model
– Wellness Model
– System Stability
• Homeostasis – dynamic balancing
• Allostasis
Assessment
• Nursing Process
– Assessment
– Diagnosis
– Planning
– Implementation
– Evaluation
Neuman Systems Model
• Person Variables
– Physiological
– Psychological
– Socio-cultural
– Developmental
– Spiritual
Wholistic Assessment
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Humanistic
Reductionistic vs. Wholistic
Five Person Variables
Perception of Nurse and Patient
Documentation
• Legal record
– If you don’t document it, you didn’t do it
• HIPPA
– When turning in assignments regarding real
patients, use patient’s initials only.
– If making a copy of part of a chart for
reference for an assignment, obscure
identifiers.
Kinds of Data
• Datum – piece of information
• Database – Collection of all data
concerning a patient
• Subjective data
– Symptoms
• Objective data
– Signs
Documentation Considerations
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Narrative vs. Charting by exception
Appropriate use of abbreviations
Appropriate use of medical terminology
Models
– H&P
– SOAP: subjective, objective, assessment,
plan
– DAR: data, action, response
– DARP: data action, response, plan
Talking to the Patient
Basic Interviewing Technique
• Building Rapport
– Be yourself, but not too much of yourself
– Use discretion
– Present
• Interest
• Competence
• Confidence
– Do not present
• Apathy
• Diffidence
• Arrogance
Basic Interviewing Techniques
• Dress
– Professional
– Not imposing
• Patient Centric Interview
– Open ended questions
– Empathy – Not Sympathy
• Provider centric
Basic Interviewing Techniques
• Interviewer centric
• Use of silence
• Time
– Attention
– Schedule
Interviewing Stages
• Introduction
– Establish who you are
– Establish agenda
• Working Phase
– Patient centric
– Provider Centric
• Conclusion
– Provide closure
– Establish a plan
Introductory Script
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Hello, Mr. Smith?
My name is ________.
I am a ________.
I am here to __________.
I just need to verify your id bracelet.
Do you have any questions for me before
we begin.
Cultural Considerations
• Culture - A complex pattern of shared
meanings, behaviors, and beliefs, that are
learned and acquired by a group of
people.
• Characteristics
– Learned from birth through socialization and
language
– Adapted to specific conditions
– Dynamic
– Shared by in common
Related words
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Subculture
Ethnocentrism
Prejudice
Stereotype
Discrimination
Cultural Values
• Dominant Value Orientation
– Innate Human Nature
– Relationship to nature
– Time Dimension
– Purpose of Existence
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Family
View of Health and Illness
Family relationships
Communication patterns
View of Health and Illness
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Freedom from disease
Able to go to work
Feel good
Pathogenesis
– Biomedical
– “Naturalistic”
– Magico-Religious
Family relationships
• Who makes decisions
• Who counts as family
• Loyalty to the family
Communication patterns
• Language
– Dialects, slang, and vague language
– Conversational style
– Silence
Communication Patterns
• Nonverbal
– Eye contact
– Posture
– Personal space
– Response to touch
– Orientation to time
• Expression of symptoms
– Stoic
– Expressive