Health Assessment mid-term: Course Introduction, Interviewing, Health History,

• we should wash our hands and wear gloves when dealing and preventing the transmission of blood and body fluids
• - by not taking this precautions we run the risk of spreading nosicomial infections to patients

is a systematic way of collecting data about a client/patient for the purpose of determining client's health status

• - assessment 
• - diagnosis 
• - goal setting
• - plan 
• - implement
• - evaluate

it serves in the clinical process that we use

• - patients interview
• - physical exam
• - lab/diagnostic

its about collecting subjective data

we would go to the parent or spouse

- its about collecting subjective and objective information

it is about taking objective information

what the person says about himself or herself

what you observe through measurement, inspection, palpation, percussion, and auscultation

• there is a
• - sender
• - receiver
• - message
• - feedback
• - context

can be where it is actually happening. it is a wellness visit at a nurse practitioner's office or is it a crisis situation in the emergency room

is this a new occurrence or is this a reoccurring issues for the patient?

• - it is not just the use of words, it is a dynamic process that includes
• - behaviors
• - verbal and nonverbal 
• - intended or perceived

watch for the congruence of what their saying and how they are behaving

the behavior of the patient is more important

• - age
• - gender
• - language
• - preferences
• - experiences
• - personality 
• - self concept
• - values, attitude
• - cultural background
• - religious/spiritual beliefs

• the pateints may be older so asking personal questions may make them feel uncomfortable.
• - the patients may perceive you a certain way because of your age
• - be aware of generation differences

sometimes the opposite sex may not want to give intimate information b/c of the difference in gender

a language barrier can prevent you from assessing the patient to the best of your ability

the nurse must have a high EQ (emotional intelligence) b/c sometimes we have to stake a step back and try to understand that the patient may not be lashing out on you b/c of personal reasons but instead b/c that is how they respond to a crisis

• - visual (whether they are able to see you)
• - hearing (can they hear you or are having difficulty hearing you?)
• - tactile (extremities missing)

• - what is in the mind of the sender?
• - what did the sender chose to send
• - how is the message sent?
• - what is received by the receiver?
• - what does the message bring to mind in the receiver

• - to send CLEAR, HEALPFUL messages to our patients
• - INTERPRET ACCURATELY what our patients are communicating

are the words you speak, vocalizations, the tone of voice

• - denotation
• - connotation

it is the concrete definition of a word

it is the personal interpretation on what means to the person

• using medical jargon can confuse and lose the patient 
• - auscultation
• - CAT scan
• - Stool 
• - Void
• - Colon

• speed or rate at which the message is delivered
• - which includes the pauses between important ideas or concepts
• - clarity
• - timing and relevance
• - para-language

• - goal focused
• - deliberate
• - has different perspectives

• - spontaneous 
• - needs both
• - mutual sharing
• - both parties express naturally 
• - reciprocal approval 
• - terminates spontaneously

• - planning
• - needs of the pateints 
• - focus on problem solving
• - encourage patient to express feelings, concerns
• - nurse not seeking personal approval 
• - nurses terminates

• - genuineness
• - respect
• - empathy

• addressing them by name. dont make the assumption that you can call the patient by their first name unless they say so 
• - also by your tone of voice

recognizing what the patient is going through and allowing yourself to acknowledge what the patient is going through

• - it should be based on a trusting relationship 
• - privacy
• - confidentiality 
• - nonjudgmental
• - document

• - there is eye contact
• - are at the same level 
• - there is a closeness that doesn't invade personal space

• - stage I: introduction 
• - stage II: working 
• - stage III: closing

identify name , role, and purpose/ intentions

collection of patient data

thanking and acknowledging the person. also summarizing and what the information will be used for

• - open-ended questions
• - closed questions
• - facilitation
• - silence
• - reflection
• - empathy 
• - clarification
• - confrontation 
• - interpretation 
• - explanation 
• - summary

• gives patient permission to give you their story in their own word
• - how can I help you?
• - what brings you here today?

• very often yes, no questions
• - are you having pain?

done through para-language - your body position or through the nodding of your head allows the patients to tell you more

allows patient to process the question and formulate an anwer

picking up on a word that he patient said regarding the information and reflect on it allowing the patient to share more information

telling the patient what we understand allows the patients to clarify any misunderstanding

• - professional appearance 
• - posture
• - gestures and facial expression 
• - eye contact
• - voice
• - touch

• - requesting an explanation - why?
• - probing
• - offering false reassurance 
• - giving false reassurance
• - giving approval/disapproval 
• - defending
• - advising

never leave the question blank, write that the patient refused to offer this type of information

• - posing leading questions
• - interrupting the patient
• - engaging in talkativeness
• - using multiple questions
• - using medical jargon 
• - being authorative

• - use trained medical interpreter - not family or significant other
• - allow time for the patient and interpreter to converse prior to interview
• - request sentence by sentence translation 
• - allow extra time
• - use brief questions
• - maintain eye contact with the patient 
• - observe patient's nonverbal response
• - use preprinted questions if available

as a basis for planning care

• subjective information of health status including 
• - social 
• - emotional 
• - physical 
• - cultural 
• - well-being

• - complete
• - episodic
• - interval or follow-up
• - emergency

• focuses on the problem the patient has been experiencing 
• - focused on the problem on hand

checking if the treatment worked or failed stood the same

• - essential information only
• - are they on any medications? have any allergies?

• - biographical information 
• - informant
• - reason for seeking health care - "chief complaint"

• - location
• - radiation
• - quality 
• - quantity 
• - associated symptoms
• - aggravating factors
• - alleviating factors
• - setting
• - timing
• - meaning/impact

- where is the pain located?

does the pain move from the main site to other parts of the body?

• whats does the pain feel like?
• - dull
• - burning
• - sharp
• - itchy

on a scale of 0-10, jow much pain are you feeling right now?

are you experiencing any other symptoms?

what makes the pain worse? what makes the pain better?

• Where was the person or what was the person doing when the symptom started? 
• - for example: were they shoveling snow?

• onset, duration, frequency 
• - when did the symptom first appear?
• - how long did the symptom last?
• - was it steady(constant)? or did it come and go(intermittent)?

• how it affect daily activities 
• - how has this affect you?
• - is there anything you can't do now that you could before?

• P: provokes/palliative
• Q: quality/quantity 
• R: region and radiation
• S: severity 
• T: timing
• U: understanding patient's perception

• C: character - how does it look, feel, sound, smell
• O: onset
• L: location - where, ? radiation
• D: duration
• S: severity
• P: pattern - what makes it worse/better
• A: associated manifestations
• M:what meaning does this have to you

• - medical history 
• - surgical history 
• - psych/mental health history 
• - medications: prescribed, over the counter
• - communicable diseases 
• - allergies 
• - injuries/accidents
• - childhood diseases 
• - immunization history

• - identify genetic patterns 
• - immediate blood relative
• - genogram

• - alcohol use: type, amount, frequency, CAGE
• - drug use: type, amount, frequency 
• - tobacco use: pack yr history 
• - sexual practices
• - travel history: military history 
• - education 
• - roles and responsibilities (any support at home?)
• - domestic violence

• C: Have you ever thought you should Cut down your drinking?
• A: Have you ever been Annoyed by criticism of your drinking?
• G: Have you ever felt Guilty about your drinking? 
• E: Do you drink in the morning? (i.e., an Eye opener?)

chronic health problems

yes, every patient

• - sleep
• - diet
• - exercise (FIT)
• - stress management 
• - safety devices 
• - health check-ups: traditional and alternative

• F: frequency of exercise 
• I: intensity of exercise 
• T: how many time a week

• subjective responses to series of body system questions
• - this is not the physical assessment 
• - ask questions such as: do you have these symptoms? (helps guide physical exam)

• - screening of general well-being
• - validation of complaints that caused the patient to seek health care
• - monitoring of current health problems
• - formulation of diagnosis and treatments

• - inspection (I)
• - palpation (P)
• - percussion (P)
• - auscultation (A)
• you usually follow the order IPPA, expect for the abdomen which is IAPP

• inspecting the 
• - sense of smell
• - sense of sight

• is the ac of touching the patient in a therapeutic manner. it includes
• - light palpation 
• - moderate palpation
• - deep palpation

• - superficial, delicate, gentle 
• - uses finger pads or the back of your hand

provides information on skin texture, moisture, temperature, superficial pulsations and tenderness

• - superficial, delicate, gentle 
• - uses finger pads
• - depress 1 cm below surface

provides information on skin texture, moisture, masses, fluid, muscle guarding  pulsations, and tenderness

provides information about the position of organs, masses, their size, shape, mobility and consistency 

• - uses hands
• - depress 4 to 5 cm below skin surface
• - most commonly used for assessing abdominal and reproductive structures

• - wash hands before and after the exam
• - waer gloves if indicated
• - warm hands
• - fingernails short and clean
• - inform the patient when, where, and how the touch will occur 

• - striking one object against another to cause vibrations that produce sound 
• - analyze sounds by intensity, duration, pitch 
• - any part of the body can be percussed 
• - most commonly used for abdomen and thorax

• - flatness
• - dullness
• - resonance
• - hyperresonance
• - tympany

When no air is present, over thigh muscles, bone, or over tumor

fluid filled areas, Relatively dense organ, as liver or spleen

over norma/healthyl lung tissue

• - Normal over child's lung
• - Abnormal in the adult, over lungs with increased amount of air (over inflated lungs), as in emphysema

Over air-filled viscus (e.g., the stomach, the intestine)

• - immediate or direct
• - mediate or indirect
• - direct fist
• - indirect fist

• - clean earpieces
• - point earpieces towards the nose
• - quiet room 
• - diaphragm - with pressure
• - bell - without pressure

high pitched sound

• picks up low pitched sounds
• - you don't want to press on the skin, only lightly place it