Health History and Assessment Techniques Purpose

Health History and Assessment Techniques
Purpose
-Identify patient’s health strengths
-Discover patient health conditions
-Bridge data collection and physical examination
The Interview
Contract
- The interview as a contract between patient and nurse
• Time and place
• Introduction and explanation Purpose
• Length
• Expectations
• Presence of others
• Confidentiality
• Costs
Data Collection
- Patient History: subjective data
- Physical exam: objective data
Reasons for Seeking Health Care
- A brief spontaneous statement from patient
- Gathering Subjective data
• What the person says about their-self
• Patient is in charge
• Patient does relinquish some control
Process of Communication
- Sending
- Receiving
- Internalfactors
• Liking others
• Empathy
• Ability to listen
- External factors
• Ensure privacy
• Refuse interruptions
• Physical environment
• Dress
• Note-taking
• Tape and video recording
Documentation Challenges
- Impedes eye contact
- Attention-shifting
- Interruption of patient’s narrative flow
- Impedes observation of nonverbal behavior
- Can be threatening
Techniques of Communication
- Introducing the interview
- Working phase
• Open-ended questions
• Closed or direct questions
- Responses—assisting the narrative
• Facilitation
• Clarification
• Silence
• Confrontation
• Reflection
• Interpretation
• Empathy
• Explanation
• Summary
Ten Traps of Interviewing
- Providing false reassurance
- Giving unwanted advice
- Using authority
- Using avoidance language
- Engaging in distancing
- Using professional jargon
- Using leading or biased questions
- Talking too much
- Interrupting
- Using “Why” questions
Nonverbal Skills
- Posture
- Gestures
- Voice
- Touch
- Physical Appearance
- Facial Expression
- EyeContact
Closing the Interview
- Summary or final statement
- Leave gracefully
Older Adult Development of Care
- Meaning of life
- Takes longer
- Needs greater response
Patient’s with Special Needs
- Hearing impaired
- Acutely Ill
- Under the Influence
- Flirtatious
- Emotional
- Violent
Cross Cultural or Intracultural communication
- Cultural perspectives on professional interactions
- Etiquette
- Space and distance
Cultural considerations on gender and sexual orientation
Cultural Barriers
- Working with or without and Interpreter
- Nonverbal communication
- Touch
The Complete Health History
Major Components Health Assessment
- Biographic / demographic
- Reason for seeking health care
- Present illness or health status
- Community considerations
- Past Health history
- Family Health history
- Environmental history
- Psychosocial / Cultural / Developmental history
- Review Systems
- Functional Assessment
Health History Documentation
- Biographical Data
- Past history
- Family history
- Review of systems
- Reason for seeking health care
- Present health or history of present illness
- Functional assessment of activities of daily living (ADLs)
Biographic Data
- Name
- Address
- Phone number
- Age
- Birthdate
- Gender
- Gender
- Marital Status
- Race
- Ethic Origin
- Occupation
Reason for Seeking Care
- Symptom
• Subjective information from patient
- Sign
• Objective abnormality
• Detectable on physical exam or in laboratory reports
Present Health or History of Present Illness
- Characteristics of symptom
• Location
• Quantity or severity
• Setting
• Associated factors
• Character or quality
• Timing
• Aggravating or relieving factors
• Patient’s perception
- PQRST mnemonic
P: Provocative or palliative
Q: Quality or quantity
R: Region or radiation
S: Severity scale
T: Timing
U: Understand patient’s perception
Past Health History
- Childhood illnesses
- Accidents or injuries
- Serious or chronic illnesses
- Hospitalizations
- Operations
- Obstetric history
- Immunizations
- Last examination date
- Allergies
- Current medications
Family History
- First generation family health history: causes of illness or death (ex: heart disease, diabetes, cancer, etc.)
- Health history of signification other, children
- Any prolonged contact to communicable diseases
Review of Symptoms
- General overall health state
- Skin
- Nose and sinuses
- Hair
- Mouth and throat
- Head
- Respiratory system
- Eyes
- Breast
- Ears
- Axilla
- Neck
- Cardiovascular system
- Peripheral vascular system
- Gastrointestinal system
- Urinary system
- Genital system
- Sexual health
- Musculoskeletal system
- Neurologic system
- Hematologic system
- eEndocrine system
Functional Assessment (including ADLs)
- Self-esteem, self-concept
- Activity/exercise
- Sleep/rest
- Nutrition/elimination
- Interpersonal relationships/resources
- Spiritual resources
- Coping and stress management
Perception of Health
- Personal habits
• Tobacco
• Alcohol
• Street drugs
- Environment/hazards
- Intimate partner violence
- Occupational health
- How do you define health?
- How do you view your situation now?
- What are your concerns/goals?
- What do you think will happen in the future?
- What do you expect from your health care providers?
Assessment Techniques and the Clinical Setting
Cultivating your Senses
- Inspection
• Do not rush
• Compare patient’s right side with left side
• Use good lighting
• Obtain adequate exposure (of the patient)
• Will include instruments in many body systems
- Otoscope/ophthalmoscope
- Penlight
- Palpation
• Purpose
• Use different parts of the hands
• Light vs. deep palpation
- Texture
- Temperature
- Moisture
- Swelling
- Crepitation
- Rigidity or spasticity
- Vibration or pulsation
- Organ location and size
- Presence of lumps or masses
- Presence of tenderness or pain
• Fingertips—best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps
• A grasping action of the fingers and thumb—to detect the position, shape, and consistency of an organ or mass
• The dorsa (backs) of hands and fingers—best for determining temperature because the skin here is thinner than on the palms
• Base of fingers or ulnar surface of the hand—best for vibration
- Percussion
• Purpose
• Indirect percussion
- Stationary hand
- Striking hand
- Characteristics of percussion notes
- Resonant
- Tympany
- Flat
- Hyperresonant
- Dull
TONE
QUALITY
PITCH
EXAMPLE
Typmany
Drumlike
High
Gastric Bubbles
Resonance
Hollow
Low
Healthy Lungs
Hyperresonance
Booming
Very Loud
Emphysemic Lungs
Flatness
Very Dull
High
Muscle Bone
Thudlike
Soft to Moderate
Liver, Spleen, Heart
- Auscultation
Dullness
• Listening to sounds produced by
the body through a stethoscope
• Stethoscope blocks extraneous room sounds
Equipment
• Stethescope
- Fit and quality of equipment
- Slope of earpiece
- Diaphragm and bell end-pieces
- Am I hearing ok?
• Setting
- Exam room
- Exam table
- Platform scale with height attachment
- Skinfoldcalipers
- Sphygmomanometer
- Stethoscope with diaphragm and bell
- Thermometer
- Pulse oximeter (in hospital setting)
- Flashlight or penlight
Safe Environment
- Clean the equipment
- Clean vs. used area for handling equipment
- Nosocomial infections
- Handwashing or alcohol-based hand rub
- Wear gloves
- Standard precautions
- Transmission-based precautions
The Aging Adult Exam
- Position
- Preparation
- Sequence
- Pocket vision screener
- Skin-markingpen
- Flexible tape measure and ruler
- Reflex hammer
- Sharp object (split tongue blade)
- Cleangloves
- Otoscope/ophthalmoscope
- Tuning fork
- Nasal speculum (if not available use otoscope)
- Tongue depressor
The Clinical Setting
- General approach
• Patient’s emotional state
- Hands on
• Examiner’s emotional state
• Measurement and vital signs
• Begin with person’s hands
• Examination sequence
• Concentrate on one step at a time
• Brief health teaching •
When findings are complicated
• Summarize findings for person
General Assessment Techniques, Vital Signs and Pain
General Survey, Measurement and Vital Signs
Objective Data: The General Survey
Physical Appearance
Body Structure
Age
Sex
Level of consciousness
Skin color
Facial features
Stature
Nutrition
Symmetry
Posture
Position
Body build, contour
Mobility
Behavior
Gait
Range of Motion
Facial expression
Mood and affect
Speech
Dress
Personal hygiene
Measurement
Weight
Balance scale
Recommended range for height
Height
Vital Signs
Temperature
Hypothalamus as thermostat mechanism
Influences on temperature
- Diurnal cycle
- Menstrual cycle
- Exercise
- Age
Temperature Routes
Oral
Electronic thermometer
Axillary
Rectal
Tympanic membrane thermometer
Blood Pressure
Systolic pressure
Diastolic pressure
Pulse pressure
Mean arterial pressure
Sex
Diurnal rhythm
Exercise
Stress
Physiologic factors controlling blood pressure
Peripheral vascular resistance
Volume of circulating blood
Elasticity of vessel walls
Stroke volume
Technique of measurement
Rate
- Normal rate for age group
- Bradycardia
- Tachycardia
Rhythm
- Sinus arrhythmia
Force
Elasticity
Respirations
Technique of measurement
Normal rate for age group
Ratio of pulse rate to respiratory
rate should be approximately 4:1
Korotkoff Sounds
Influences on blood pressure
Age
Race
Weight
Emotions
Pulse
Cardiac output
Viscosity
Blood pressure measurement
Sphygmomanometer
Cuff width and size
Blood pressure measurement in the arm
- Position of person
- Palpate brachial artery
- Proper inflation and deflation technique
- Korotkoff’s sounds
• I, systolic pressure
• IV, muffling of sounds
• V, diastolic pressure
The Aging Adult General Survey
- Physical Appearance
- Respirations
- Blood Pressure
- Posture
- Gait
- Weight
- Height
- Vital Signs
- Pulse
Additional Measurements
- Pulse Ox
- Doppler Technique
Promoting Health and Self Care
- Teaching Plan
- Lifestyle modification
Abnormalities in Blood Pressure
Hypotension
- In normotensive adults < 95/ 60
- In hypertensive adults < the person’s average reading, but > 95/60
Occurrence
Acute myocardial infarction
Shock
Rationale
Decrease cardiac output
Hemorrhage
Decrease in total blood volume
Vasodilation
Decrease in vascular peripheral vascular resistance
Addison’s disease (hypofunction of the adrenal glands)
Hypertension
- Essential or Primary Hypertension
• Occurs from no known cause, but is responsible
for about 95% of cases of hypertension in adults
- Major Risk Factors
• Smoking
• Dyslipidemia
• Diabetes Mellitus
• Age ≥ 60 yrs old
• Sex (men and postmenopausal women)
• Family hist of cardiovascular disease
women ≤ yrs old men ≤ 55 yrs old
- Target Organ Damage / Cardiovascular Disease (CVD)
• Heart Disease
• Left ventricular atrophy
• Angina or prior MI
• Prior coronary revascularization
• Peripheral arterial disease
• Nephropathy
• Retinopathy
• Stoke
Pain Assessment: The Fifth Vital Sign
Sources of Pain
- Visceral pain
- Deep somatic pain
- Cutaneous pain
- Referred pain
Referred Pain Common Sites
Types of Pain
Acute pain
- Short term
- Self-limiting
- Follows a predictable trajectory
- Dissipates after injury heals
Chronic pain
- Continues for 6 months or longer
- Types are malignant (cancer related) and nonmalignant
- Does not stop when injury heals
Health History Subjective Data
Pain assessment questions
- Where is your pain?
- When did your pain start?
- What does your pain feel like?
- How much pain do you have now?
- What makes the pain better or worse?
- How does pain limit your function/activities?
- How do you behave when you are in pain?
- How would others know you are in pain?
- What does pain mean to you?
- Why do you think you are having pain
Pain assessment tools
- Initial pain assessment
- Brief pain inventory
- Short-Form McGill Pain Questionnaire
- Pain rating scales
• Numeric rating scales
• Descriptor scale
Objective Data Physical Exam
Joints—note
- Size/contour/circumference
- AROM/PROM
Abdomen—inspect and palpate
- Contour/symmetry
- Guarding/organ size
Muscles/skin—inspect
- Color/swelling
- Masses/deformity
- Sensation changes
Pain behavior—inspect
- Nonverbal cues
- Acute pain behavior
- Chronic pain behavior
Sample Charting
Subjective:
Starting this A.M. patient right Great toe, swollen, red and
tender to touch. Patient ate seafood last evening.
Objective:
Patient limping, grimacing and wearing slipper on right foot.
Right great toe with severe tenderness, red, angry and edematous.
Patient Uric Acid level 8.5 mg/dL
Non-verbal Behaviors of Pain
Acute Pain Behaviors:
- Guarding
- Grimacing
- Vocalizations such as moaning
- Agitation, restlessness
- Stillness
- Diaphoresis
- Change in vital signs
Chronic Pain Behaviors:
- Bracing
- Rubbing
- Diminished activity
- Sighing
- Change in appetite
- Being with other people
- Movement
- Exercise
- Prayer
- Sleeping
Health History, Interview and Mental Status
Purpose of Health History
- Identify patient’s health strengths
- Discover patient health conditions
- Bridge data collection and physical examination
The Interview
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 person says about his or her perceived health state
- Individual knows everything about his or her own health state, and nurse knows nothing
Contract
The interview as a contract between patient and nurse
- Time and place
- Introduction and explanation
- Purpose
- Length
- Expectations
- Presence of others
- Confidentiality
- Costs
Data Collection
- Patient History: subjective data
- Physical exam: objective data
Reasons for Seeking Health Care
- A brief spontaneous statement from patient
- Gathering Subjective data
• What the person says about their-self
• Patient is in charge
• Patient does relinquish some control
Process of Communication
- Sending
- Receiving
- Internal factors
Techniques of Communication
- External factors
• Liking others
• Empathy
• Ability to listen
• Ensure privacy
• Refuse interruptions
• Physical environment
• Dress
• Note-taking
• Tape and video recording
- Introducing the interview
- Working phase
• Open-ended questions
• Closed or direct questions
- Responses—assisting the narrative
Documentation Challenges
- Impedes eye contact
- Attention-shifting
- Interruption of patient’s narrative flow
- Impedes observation of nonverbal behavior
- Can be threatening
Ten Traps of Interviewing
- Providing false reassurance
- Giving unwanted advice
- Using authority
- Using avoidance language
- Engaging in distancing
- Using professional jargon
- Using leading or biased questions
- Talking too much
- Interrupting
- Using “Why” questions
• Facilitation
• Silence
• Reflection
• Empathy
• Clarification
• Confrontation
• Interpretation
• Explanation
• Summary
Nonverbal Skills
- Physical Appearance
- Posture
- Gestures
- Touch
- Facial Expression
- Eye Contact
- Voice
Closing the Interview
- Summary or final statement
- Leave gracefully
Older Adult Development of Care
- Meaning of life
- Takes longer
- Needs greater response
Patient’s with Special Needs
- Hearing impaired
- Acutely Ill
- Under the Influence
- Flirtatious
- Emotional
- Violent
Cross Cultural or Intracultural communication
- Cultural perspectives on professional interactions
- Etiquette
- Space and distance
- Cultural considerations on gender and sexual orientation
Cultural Barriers
- Working with or without and Interpreter
- Nonverbal communication
- Touch
Mental Health Assessment
Defining Mental Status
- Mental status—emotional and cognitive functioning
- Mental disorder
• Organic disorder
Brain disease of known specific causes: Intoxication, Dementia
• Psychiatric mental illness
Etiology has not yet been established: Schizophrenia, Anxiety Disorders
Mental Status
- Mental status is contingent on the assessment of the clients behaviors:
- Consciousness
- Memory
- Language
- Abstract thinking
- Mood and affect
- Thought process
- Orientation
- Thought content
- Attention
- Perceptions
The Aging Adult
- No decrease in general knowledge
- Little or no loss in vocabulary
- Somewhat decrease memory processing time
- Response time is slower
- Decreased sensory perception
- Hearing changes
- Potential for increased loss
When to perform a Full Mental Status
- Behavior changes
- Brain lesions (trauma, tumor, brain attack)
- Aphasia (caused by brain damage)
- Symptoms of psychiatric mental illness
Health History Contributions
- Current illness or health problem
- Current medications known to affect mood or cognition
- Baseline educational and behavioral level
- Personal history; current stress, social habits, sleep habits, drug and alcohol use
Objective Data
Main components of a mental status examination
A—Appearance
Posture
Body movements
Dress
Grooming and hygiene
B—Behavior
Level of consciousness
Facial expression
Speech
Mood and affect
C—Cognition
Orientation
Attention span
Recent memory
Remote memory
New learning—the four unrelated words test
Judgment
T—Thought processes and perceptions
Thought processes
Thought content
Perceptions
Screen for suicidal thoughts
Supplemental Mental Status Exam
- MiniMental State
• Orientation
• Registration
• Attention and calculation
• Recall
• Language
- Quick and easy
- Standard of eleven question
- Requires 5 to 10 minutes
- Older Adult
• Brief exam for older adult in hospital
• Confusion common in aging adults and easily misdiagnosed
• Assess sensory status
Sample Charting
Appearance: Posture is erect, position is relaxed,
body movements are smooth and coordinated.
Behavior: Patient is alert, active, appropriate facial
expressions, speech clear, affect appropriate
Cognitive function: oriented times 3, cooperative,
recent and remote memory intact, able to recall
four unrelated words at 5, 10 and 30 minute intervals,
discharge plans is to return home, return to work and
continue with outpatient therapy once a week.
Thought processes: Perception logical and coherent,
no suicidal ideation present.
Set Test
- Developed specifically for the aging adult
- Original study tested 65 to 85 year olds
- Test take less then 5 minutes
- Patient to name 10 items
- In four categories
• Fruit, animals, colors and towns (FACT)
• 1 point for each correct answer
• Max score 40
- No score over 25 is indicative of having dementia
- Set test scores of less than 15 indicate dementia
- Scores between 15 and 24 show less likely hood of being
diagnosed with dementia
- Do not use Set Test on the hearing or verbally impaired
Abnormal Findings
Lethargic (somnolent)
Alert
Stupor or semicoma
Coma
Acute confusional state (delirium)
Elation
Euphoria Flat affect (blunted affect)
Depersonalization (lack of ego boundaries)
Anxiety
Inappropriate affect
Fear
Irritation Ambivalence
Rage
Depression
Liability
Obtunded
Domestic Violence Assessment
Intimate Partner Violence Defined
- Evidence or threat of physical/sexual violence
- Psychological/emotional abuse and/or coercive tactics after physical violence
- Between spouses, nonmarital partners, or former spouses or partners (CDC)
Elder Abuse and Neglect Defined
- Physical abuse—violence
- Physical neglect—failure to provide basic services
- Psychological abuse—mental anguish
- Psychological neglect—failure to provide stimulation
- Financial abuse—intentional misuse of resources
- Financial neglect—failure to use assets
Health Effects of Violence
- Injury
- Chronic health problems
• Neurologic
• Gastrointestinal
• Gynecologic
• Chronic pain
- More visits, more costs
Mental Health Effects of Violence
- Depression
- Suicide
- Symptoms of posttraumatic stress disorder
- Substance abuse
Reproductive Health Effects on Violence
- Chronic pelvic pain
- Unintended Pregnancy
- Sexually transmitted infections, including HIV
- Urinary tract infections
Screen for Domestic Violence
- How to screen
- Assessment
- History
- Physical examination
- Documentation
Abuse Assessment Screening (AAS)
- When you argue, are you ever afraid of your partner?
- Does your partner try to emotionally hurt you?
- Does your partner try to control you?
- Has your partner ever physically hurt you?
- Did your partner ever physically hurt you when you were pregnant?
- Has your partner ever forced you into sex?
Elder Abuse Screening Questions
- Has anyone:
• Ever touched you inappropriately?
• Made you do things you didn’t want to do?
• Taken things that were yours without asking?
• Physically hurt you?
• Scolded or threatened you?
• Failed to help you take care of yourself?
- Have you signed documents you didn’t understand?
- Are you afraid of anyone at home?
- Are you alone a lot?
Protocol for Screening Summary: Women over 14 years old
- All women over the age of 14 years
- Primary care: every visit
- Emergency/urgent care: all women, all visits
- OB/GYN: each prenatal/family planning visit; all visits in STD and abortion clinics
- Mental health: every assessment
- Inpatient: all admissions/discharges
Assessment
- Screen for intimate partner violence/elder abuse
- Use the Abuse Assessment Screen or elder abuse screen
- Follow up on all “yes” answers
Physical Exam and Documentation of Abuse
- Detailed nonbiased notes
- Use of injury maps
- Photographic documentation
- Complete head-to-toe exam checking for:
• Bruise/contusion
• Laceration/avulsion
• Ecchymosis/purpura
• Cut/sharp injury • Petechia/purpura
• Stab wounds
• Rug burn/friction abrasion
• Hematoma
• Incision/cut
- Suspect intimate partner violence when she says “No” to the Abuse Assessment Screen but there are indicators
and/or conditions associated with intimate partner violence.
Role of the Registered Nurse
Legal
Registered Nurse will:
Delegate selected health assessment activities to the LPN who contributes to data
collection by reporting assessment findings to the RN.
Nursing Care Plan
Registered Nurse will:
Interprets and analyzes this data to identify nursing diagnoses, establish nursing care goals,
and develop, impletment and evaluate a plan of individualized patient care