Health Assessment Lecture

• Gerontologic variation in communication, Cultural variation in communication, and Emotional variation in communication


  Special considerations during interview
• Inferring


  inferring information from what the client tells you and what you observe in the client's behavior may elicit more data or verify existing data.
• Providing information


  another important thing to consider throughout the entire interview is to provide the client with information as questions and concerns arises. Make sure you answer every question as much as you can
• Rephrasing


  - this technique helps to clarify information the client has stated. It enables you and the client to reflect on what has been said. Ex. The patient tells you that she is scared because she fears that she has some horrible disease. You may rephrase the information by saying "You are thinking that you have a serious illness?
• Well-place phrases


  listen closely to the client during his or her description and use phrases such as "um-um", "yes", or I agree" to encourage the patient to continue
• Laundry list


  provide client with a choice of words to choose. Ex. Is the pain severe/dull/sharp?
• Close-ended questions


  to focus on specific information. Ex. When did the nausea start?
• Open-ended questions


  elicits the client's feelings begins with how or what and perception. Ex. How have you been feeling lately?
• Open-ended questions, Close-ended questions, Laundry list, Well-place phrases, Rephrasing, Providing Information, Inferring


  Verbal communication
• Listening


  most important skills to learn and develop fully to collect complete and valid data from your client
• Silence


  allow you and the client to reflect and organize thoughts which facilitate a more accurate reporting and data collection
• Attitude


  one of the most important non-verbal skills to develop as a health care professional
• Facial Expression


  It is after an overlooked aspect of communication.
• Appearance, Facial expressions, Attitude, Silence, Listening


  Non-verbal communication
• Non-Verbal Communication


  the

  appearance, demeanor, posture, facial expression and attitude strongly influence how client perceives the questions you ask. Never overlook this type of communication or take it for granted
• Non-verbal communication and Verbal communication


  2 Types of Communication
• Summary and Closing Phase/ Concluding/

  Termination Phase


  During this phase, the nurse summarizes information obtained during the working phase
• Working or interaction phase


  The nurse then listen, observes cues, and uses critical thinking skills to interpret and validate information received from the client
• Working or interaction phase


  During this phase, the nurse elicits the client's comments about major geographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices and developmental level
• Introductory/preparatory/ or pre-interaction phase


  - The nurse also makes sure that the client is comfortable physically and emotionally and has privacy

  - It is also essential for the nurse to develop trust and rapport at this point in the interview
• Introductory/preparatory/ or pre-interaction phase


  the nurse explains the purpose of the interview, discusses the type of questions that will be asked, explain the reason for taking notes, and assures the client that confidential information will remain confidential
• Introductory/Preparatory/Pre-interaction phase, Working/Interaction Phase, Summary and Closing Phase/Concluding/Termination Phase


  Phases of Interview
• Interview


  Gathering information on the client's developmental, psychological, physiologic, socio cultural and spiritual statuses to identify deviation that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nurse client collaboration
• Interview


  Establishing rapport and a trusting relationship with a client to elicit accurate and meaningful information
• Evaluation


  - Assessing outcome criteria have been met and revising the plan as necessary

  - Determines that the goal has been achieve within the stated time frame
• Implementation


  - Carrying out the plan

  - Care plan is put into action

  - Independent or dependent nursing action/implementation
• Outcome Criteria


  are specific, measurable , realistic statements of goal attainment.
• Prioritization


  Life threatening, ABC's, Maslow's Needs, pain, unstable conditions, actual problems, and client's first before contraptions.
• Planning


  Involves setting priorities, stating client goals/ outcomes and selecting nursing interventions, strategies or orders to deal with the health status of the client
• Planning


  Determining outcome criteria and developing a plan
• North American Nursing Diagnosis Association


  NANDA
• Diagnosis


  clinical judgment about individuals, family or community responses to actual and potential health problems and life processes
• Diagnosis


  Basis for collecting nursing interventions to achieve outcomes for which the nurse is accountable
• Diagnosis


  Often called nursing diagnosis
• Diagnosis


  Analyzing subjective/objective data to make a professional nursing judgment
• Documenting data


  it forms the data base for the entire nursing process and provide data for all other member of the health team
• Validating assessment data


  It serves to ensure that the assessment process is not ended before all relevant data have been collected, and it helps to prevent documentation of inaccurate data
• Primary data and Secondary data


  Sources of Data
• Collecting objective data


  Directly observed by the examiner.
• COLLECTING SUBJECTIVE DATA


  SENSATIONS, SYMPTOMS (PAIN, HUNGER), FEELINGS (HAPPINESS, SADNESS), PERCEPTIONS (DESIRES, PREFERENCE, BELIEFS, IDEAS, VALUES), AND PERSONAL INFORMATION THAT CAN BE ELICITED AND VERIFIED ONLY BY THE CLIENT