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