Lecture 1 Chapters 1-3.
Nancy Sanderson MSN, RN
1
AD PIE:
•
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 data
2




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


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
4
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

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

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


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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
6

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


Assessment
Nursing diagnosis
Goal
Implementation
Evaluation
7

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)
8
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 plan
Assists client to maximize health
potential
Amount of information gained during a
health assessment depends on several
factors including:
Context of care
Client need
Expertise of the nurse


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

10

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.
11
• Data organization involves
organizing or clustering data
that allows problems to be
clearly apparent.
• Data analysis, interpretation,
and clinical judgment
includes:
 Identification of abnormal
findings
 Correctly interpreting
findings to select
appropriate interventions
 Clinical judgment to
interpret or make
conclusions regarding
patient needs, concerns, or
health problems
•
•
Nurses provide education and care to help
meet health promotion needs.
View health care as holistic:



Mind
Body
Spirit
13
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

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
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Immunizations,
nutrition teaching,
exercise
Physical examinations,
teaching patient how to
do a breast exam
Management of
Diabetes Mellitus,
Cardiac Rehab
14
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
15


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.
16
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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:
1.
2.
3.
Become culturally competent through
sensitivity to differences between their own
culture and that of the patient.
Avoid stereo typing and assuming the
meaning of others behavior.
Develop a template that may be used for
cultural and spiritual assessment of patient
and their families.


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:



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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
19
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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.
20
•
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.
21
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Older Adult

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Hearing Impaired


Always address by last name.
Adjust pace of interview and avoid
hurrying them along.
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.
22
•
•
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
23

Check ID band with 2 identifiers
 Name
 Identification
number assigned by
health care agency
 Telephone number
 Date of birth
State your purpose &
obtain consent

24

Make environment comfortable and relaxed

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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 space
25
•
Active Listening
▫
▫
▫
▫
▫
S- Sit facing patient
O- Observe an
open posture
L- Lean towards
the patient
E- Establish and
maintain eye
contact
R- Relax
26
• 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
clients
How client is feeling at the time of
interview
Nature of information being
discussed or problem being
confronted
EMPATHY (Identifying with
feelings) vs SYMPATHY- (feeling
sorry for them) Boundaries!
Empowering vs dependency
•
Subjective data
 What the patient tells you
 Health History
 Symptoms
•
Objective data
 What examiner detects during exam
 Physical Examination
 Signs
 Labs
 Non-verbal behaviors
28
•
Patient complains of abdominal pain
•
Head pain is throbbing
•
Facial features are symmetrical
•
Heart rate is 80bpm
•
Patient feels short of breath
29
Essential 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?
30

D = Duration

Symptoms always present or do they come & go?
 If come & go, how long last?)

C = Characteristics

Describe pain/complaint.
 Ie 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
31
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R = Radiation


Does pain/complaint radiate?
T = Treatments tried
What have tried to treat pain/discomfort?
 What was outcome?

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S= Severity
How severely does this interfere with your life?
 Describe how many, the size, the amount

32
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
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Give patient a clue that interview
coming to 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
33
•
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.
34
•
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?
▫
35
•
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
36
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Interpretation is used to share
conclusions drawn from data.

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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
37
•
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.
38

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.
•Silence
Necessary for clients to reflect and gather
courage to address painful topics or issues
Feedback that client is not ready to discuss topic
or that the approach needs to be evaluated
Become comfortable with silence
39

Others in the room


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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.
40
1.
2.
3.
4.
5.
Types of health histories
Components of the health
history
Personal and psychosocial
history
Review of systems
Health history based on
functional health patterns
41
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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

42
 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
43

Complete
 Generalized
 Comprehensive

Focused
 Problem

oriented
On-going
44
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Health perception–
health management
Nutritionmetabolism,
nutrition-metabolic
Elimination
Activity-exercise
Cognitiveperception
Sleep-rest
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
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Selfperception–
self-concept
Rolerelationship
Sexualityreproduction
Coping-stress
tolerance
Values-belief
45

Factual demographic data about the
patient
Name
 Age
 Marital Status
 Address
 Occupation
 Primary Care Provider
 Primary Language Spoken

46

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
47

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?)
48

Allergies




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
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.
49


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.
50






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
51


Narrative form or illustrated
Genogram to document presence of
condition




Tool consisting of a family tree diagram depicting
members within a family over several generations
Useful in tracing diseases with genetic links
Symbols are used to indicate men and women
and those who are alive and deceased.
Include current ages of those who are alive, and
cause of and age at death of those who are
deceased.
52

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.

53
•
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?)
54


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
55
•
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?)
56
•
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
57

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
58

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?
59

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?
60

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

61



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.
62











General symptoms
Integumentary
Head and neck
Breasts
Respiratory
Cardiovascular
Gastrointestinal
Urinary system
Reproductive
Musculoskeletal
Neurologic system
63



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.
64

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.
65