March 17, 2020 o Sending: verbal/non-verbal

communication
Health Assessment
 Greater risk for
March 24, 2021 misunderstanding exists in the
health care setting
The Interview and Complete Health History
 Non-verbal cues: facial
Nursing Process expressions, behaviors
 A way of Thinking (ANA, 1998) Factors to Consider:
 Components of Nursing Process: *a circular  Physical Environment:
approach*  Room Temperature
o Assessment: Data collection  Sufficient Lighting
o Diagnosis: actual or potential health  Reduce Noise
problems  Remove distracting objects or
o Planning: Outcome identification- equipment
patient centered expected outcome  Place the distance (x2 arm length)
o Implementation: The actions that you  Arrange equal-status seating: avoid
take in the care of your patients standing
o Evaluation: Did it work? Is it  Arrange face-to-face position
effective?  Techniques of Communication
 Introducing the Interview:
Assessment  Introduce yourself (state your role)
 Types of Data Collection: Subjective and  Give the reason for the complete
Objective history
o Subjective: is collected via personal  Ask an open-ended question
communication  Introducing the Interview
 Chief Complaint of Patient
o Objective: is collected via The Working Phase:
Observations  Open-ended question
 Chest X-ray, blood and urine  Ask for narrative information
tests results  Encourages the person to respond in
 Reviewing medical records paragraphs
 Interview and Health History: Subjective…  Use it to begin the interview
 Listen carefully “tell me about it”,
Interview: Health History ‘anything else?”
 Goal of the Interview:  Close or Direct Questions
o To record a complete health history  Ask for specific information
o To identify the person’s health  Elicit a short, “yes” or “no”, one-or-two-
strengths and problems word answer, forced choice
o A bridge to the next step in data  Limit answer
collection, the physical examination  Use after the person’s opening
o The first and most important part of narrative to fill in any details
the data collection  Interview o Not to overuse
Process o Ask only one direct question at
o It collects subjective Data a time
Process of Communication  “Had you ever had pain,
 Vehicle of Interviewing: double vision, watery or
o Receiving: be interpreted in a specific redness in the eyes
context to have meaning Closing the Interview
 ‘Is there anything you would like to mention?
  Lifestyle: diet, exercise, sleep pattern,
environment, identities
Present Patient History  Feces discharge
 Onset: “Did your pain start suddenly or  Past Immunizations, surgeries
gradually get worse and worse?” This is also a
chance to ask, “What were you doing when Socioeconomic History
the pain started?”  Level of Education
 Provokes/Provocation or Palliates: Instead  Social Standing
of asking, “What provokes your pain?” use  Social and economic factors, such as income,
real, casual words. Try, “What makes your
education, employment, community safety,
pain better or worse?”
and social supports can significantly affect
 Quality & Quantity: Asking, “Is your pain
sharp or dull?” limits your patient to two how well and how long we live. These factors
choices, when their pain might not be either. affect our ability to make healthy choices,
Instead ask, “What words would you use to afford medical care and housing, manage
describe your pain?” or “What does your pain stress, and more.
feel like?”  Religion Background & Beliefs
 Region/Radiates: This is another chance to  Race, Custom
use real, conversational words during the
assessment. Asking, “Does your pain radiate?”
Review of System
sounds silly and pompous to the patient.
Instead use this question, “Point to where it  Review of all health problems by body
hurts the most. Where does your pain go from systems
there?”  It is through which the functioning of the
 Severity: Remember, pain is subjective and major organ system can be assessed.
relative to each individual patient you treat.  Review of Systems (ROS) is an inventory of
Have an open mind for any response from 0 to the body systems that is obtained through a
10. series of questions in order to identify signs
 Time/Timing: This is a reference to when the and/or symptoms which the patient may be
pain started or how long ago it started. experiencing, or system that is compromised
 U  Differential Diagnosis  For new patients, established patients who
may be having a new problem
Past Patient History  For our patients who we haven’t seen for a
 Important to note down diagnosis, baseline while, we need to update our records as to
data your general medical health
 Patient trauma history he/she experienced
 Psychiatric health history  Health in General:
 Current Medications prescribed
o Problem’s lack of energy, unexplained
 Smoke, alcohol, drug intake
weight gain or weight loss, loss of
 Immunization
appetite, fever, night sweats, pain in
Ex: “ meron po ba kayong DM, altapresyon, ca
jaws when eating, scalp, tenderness,
prior diagnosis of cancer
Family Tree
 Hereditary, Genetic Disease o Questions:
 Avoidance of particular practices because of  Do ever feel unusual fatigue?
family history of chronic illnesses Level of energy scale
 Genogram  Changes in various health
factors
Personal History  How much of a change? In
 Personal habits that contribute to different terms of weight
diseases  How would you describe your
current appetite?
  Change of sleep or habits? pleurisy, oxygen at home, coughing up
 Ear, Nose, Mouth & Throat blood, abnormal chest x-ray. Other:
o Problems difficulty with hearing, sinus  Questions:
problems, runny nose, post nasal drip,  Have you ever had pain
ringing in ears, mouth sores, loose or difficulty in walking?
teeth, ear pain, nosebleeds, sore throat, Shortness of breathing?
facial pain or numbness.  Do you smoke or drink
o Questions: alcohol?
 Do you have difficulty in
 Have you experience any head
walking upstairs?
trauma, injury, head ache,
 If you rest does your
expose to heavy toxins, vertigo,
light headedness, vision shortness of breath
cease?
blurredness, any corrective
eyewear?  Do you have wheezing
 Are you able to sleep well? sound as you breath?
 Pain in eyes, dryness?  Do you have a cough?
 How would you describe your What causes it? Are
hearing? Are there any ringing there any secretions?
in the ear? Tinnitus What color? Blood?
 Do you have any pain, or have a  GI stomach & intestines
hard time distinguishing voices o Problem’s heartburns, constipation,
in a crowded place? intolerance to certain food, diarrhea,
 Discharges in the nose? abdominal pain, difficulty swallowing,
 Any frequent sneezing? nausea, vomiting, blood in stools,
 C-V (Heart & Blood Vessels) unexplained change in bowel habits,
o Problems irregular heartbeat, racing incontinence.
heart, chest pains, swelling of feet or o Questions: Have you experience…
legs, pain in legs with walking. Other:  Chronic or past GI disorders?
o Questions:  Heart burn/sub-sternal
 Have you been experiencing burning?
chest pains?  Abdominal pain? When &
 Have you ever had any problem where?
in your heart? Describe the  Difficulty swallowing?
sensation.  Pain upon swallowing? Eat in
 Kung nagpahinga po ba kau full size?
nawawala yung chest pain?  Nausea or Vomiting?
 Have you ever experienced Frequency?
palpitation?  Abdominal swelling or
 Do you have irregular distention?
heartbeat? Irregular blood  Bloating?
pressure? Systolic and diastolic?  Jaundice (yellowish coloration
 Do you ever experience muscle of skin)?
cramping in legs when walking?  Vomiting blood (hematemesis)?
 Do you ever notice if your  Black/tarry stools?
fingers change color, pale?  Bloody stools?
 Respiratory (Lungs & Breathing)  Constipation?
 Diarrhea or other change in
o Problem’s shortness of breath, night
bowel habits?
sweats, prolonged cough, wheezing,
 Frequency of defecation
sputum production, prior tuberculosis,
 GU Kidneys & Bladder lesion, hair loss or increase, breast
o Problems: painful urination, frequent changes
urination, urgency, prostate problems, o Questions: Have you experience…
bladder problems, impotence  Hair Loss or gain unexpectedly?
o Questions: Have you experience…  Known disease?
 Chronic or past GU disorders?  Skin eruptions/rashes?
 Blood in urine? Odor?  Growths?
 Burning with urination?  Sores that grow and/or don't
 Urination at night? heal?
 Incontinence (unintentional  Lesions changing in size, shape,
loss of urine)? or color?
 Urgency?  Itching? Rashes?
 Frequency?  Self-Breast Examination
 Incomplete emptying?  Slow/fast duration of wound
Hesitancy? Decreased force of healing
stream? Need to void soon after  Neurologic (Brain & Nerves)
urinating? o Problems frequent headaches, doubles
 For Men: vision, vision, weakness, change in
 Erectile Dysfunction sensation, problems with walking or
(ED)? balance, dizziness, tremor, loss of
 Penile d/c or pain? consciousness, uncontrolled motions,
 Testicular pain? episodes of visual loss
 Testicular swelling, o Questions: Have you experience…
mass?  Known disease?
 Penile Ulcers or  Sudden loss of neurological
Growths? function?
Fertility problems?  Abrupt loss/change in level of
Hx STIs? consciousness?
 Musculoskeletal (Muscle, Bones, Joints)  Witnessed seizure activity?
o Problems: Joint pains, aching muscles,  Numbness?
shoulder pain, swelling of joints, joint  Weakness?
deformities, back pain.  Dizziness?
o Questions: Have you experience…  Balance problems?
 Headache
 Known disease?
 Paralysis?
 Joint pain and/or Swelling
 Long & short-term memory loss
(general comments)
 Psychiatric (Mood & Thinking)
 Muscle ache?
 Low back pain? o Problems: Insomnia, Irritability,
 Knee pain/swelling? depression, anxiety, recurrent bad
 Hand Symptoms? thoughts, mood swings, hallucinations
 Elbow symptoms? o Questions: Have you experience…
 Hip area symptoms?  Do you often feel down,
 Shoulder pain or symptoms? depressed, or hopeless?
 Weakness in Certain areas?  Do you lack interest in
 Integumentary (Skin, Hair & Breast)) activities, hobbies, and what is
o No problems persistent rash, itching, happening around you?
new skin lesion, change in existing skin
  Do you feel hopeless about the o Problems seasonal allergies, hay fever
present or future? If yes move symptoms, itching, frequent infections,
to question exposure to HIV
 Have you had thoughts about  No. of Sexual partners & type of
taking your life? When did you sexual activity?
have these thoughts and do you
have a plan to take your life?
 Have you ever attempted to
harm yourself or attempted
suicide?
 Have you been too depressed to
work, or only able to work with
difficulty?
Gordon’s Functional Health Patterns
 Do you experience ‘ups’ as well 1. Health Perception and Health
as ‘downs’ with your mood? Management
 Are your ups ‘wired’ or ‘hyper’ –  Data collection is focused on the
more than when you are just person’s perceived level of health
happy? and well-being, and on practices for
 Endocrine maintaining health.
 Habits that may be
o Problem’s intolerance to heat or cold,
detrimental to health are
menstrual irregularities, frequent also evaluated, including
hunger/urination/thirst, changes in smoking and alcohol or drug
sex drive. use.
 Does anyone in your family  Actual or potential
have diabetes, thyroid problems related to safety
problems, or another endocrine and health management
disorder? may be identified as well as
needs for modifications in
 Have you noticed a change in the home or needs for
your mood or memory?
continued care in the home.
 Have you noticed any twitching 2. Nutrition and Metabolism
or muscle spasms?  Assessment is focused on the
 Do you have numbness, tingling, pattern of food and fluid
or pain in your feet, legs, or consumption relative to metabolic
hands? need.
 Have you unintentionally  The adequacy of local nutrient
gained or lost weight? supplies is evaluated.
 Actual or potential problems related
 Have you noticed excessive to fluid balance, tissue integrity, and
thirst or urination?
host defenses may be identified as
 Have you noticed a change in well as problems with the
your energy level? gastrointestinal system.
 Hematologic (Blood/Lymph)  Sample Questions:
o Problems easy bleeding, easy bruising, o Is the person well nourished?
anemia, abnormal blood tests, o How do the person’s food
leukemia, unexplained swollen areas choices compare with the
recommended food intake?
 Family history of blood diseases o Does the person have any
 Allergic/Immunologic disease that effects
nutritional-metabolic
function?
3. Elimination o Can this person express
 Data collection is focused on her/himself clearly and
excretory patterns (bowel, bladder, logically?
skin). o How educated is this
 Excretory problems such as person?
incontinence, constipation, diarrhea, o Does the person have any
and urinary retention may be disease that affects the
identified. mental and sensory
 Sample Questions: functions?
o Are the person’s excretory o If this person has pain,
functions within the normal describe it and its cause.
range? 6. Sleep & Rest
o Does the person have any  Assessment is focused on the
disease of the digestive person’s sleep, rest, and relation
system, urinary system or practices.
skin?  Dysfunctional sleep patterns,
4. Activity and Exercise fatigue, and responses to sleep
 Assessment is focused on the deprivation may be identified.
activities of daily living requiring  Sample Questions:
energy expenditure, including self- o Describe this person’s sleep-
care activities, exercise, and leisure wake cycle
activities. o Does this person appear
 The status of major body systems physically rested and relaxed?
involved with activity and exercise 7. Self-Perception and Self Concept
is evaluated, including the  Assessment is focused on the
respiratory, cardiovascular, and person’s attitudes towards self,
musculoskeletal systems. including identity, body image,
 Sample Questions: and sense of self-worth.
o How does the person  The person’s level of self-esteem
describe her/his weekly and response to threats to his or
pattern of activity and her self-concept may be identified.
leisure, exercise and  Sample Questions:
recreation? o Is there unusual about this
o Does the person have any person’s appearance?
disease that affects her/his o Does this person seem
cardio-respiratory system or comfortable with her/his
musculoskeletal system? appearance?
5. Cognition and Perception o Describe this person’s feeling
 Assessment is focused on the state.
ability to comprehend and use 8. Roles and Relationships
information and on the sensory  Assessment is focused on the
functions. person’s role in the world and
 Data pertaining to neurologic relationships with others.
functions are collected to aid this  Satisfaction with roles, role strain,
process. Sensory experiences such or dysfunctional relationship may
as pain and altered sensory input be further evaluated.
may be identified and further  Sample Questions:
evaluated. o How does this person
 Sample Questions: describe her/his various roles
o Does the person have any in life?
sensory deficits? Are they o Has, or does this person now
corrected? have positive role models for
these roles?
 o Which relationships are most o What principles did this
important to this person at person learns as a child that
present? are still important to
o Is this person currently going her/him?
through any big changes in o Does this person identify
role or relationship? What are with any cultural, ethnic,
they? religious, regional or other
9. Sexuality and Reproduction groups?
 Assessment is focused on the o What support systems does
person’s satisfaction or this person currently have?
dissatisfaction with sexuality
patterns and reproductive
functions.
 Concerns with sexuality may be
identified.
 Sample Questions:
o Is this person satisfied with
her/his situation related to
sexuality?
o How have the person’s plans
and experience matched
regarding having children?
o Does this person’s plans and
experiences matched
regarding having children?
o Does this person have any
disease/dysfunction of the
reproductive system?
10. Coping and Stress Tolerance
 Assessment is focused on the
person’s perception of stress and
on his or her coping strategies.
 Support systems are evaluated, and
symptoms of stress are noted.
 The effectiveness of a person’s
coping strategies in terms of stress
tolerance may be further evaluated.
 Sample Questions:
o How does this person
usually cope with problems?
o Do these actions help or
make things worse?
o Has this person had any
treatment for emotional
distress?
11. Values and Belief
 Assessment is focused on the
person’s values and beliefs
(including spiritual beliefs), or on
the goals that guide his or her
choices or decisions.
 Sample Questions: