health assessment

• Communication

  Influenced by the sender, the message, and the receiver
• Effective communication


  Involves feedback
• Verbal communication


  Conscious use of spoken or written word
• Nonverbal communication


  Less conscious than verbal, either reinforces or contradicts what is said
• Types of nonverbal communication

  • Posture & Gait
  • Facial expression
  • Hand movements and gestures
• Touch


  One of the most effective nonverbal ways to express feelings of comfort, love, affection, security etc.
• Eye contact


  Suggests respect and a willingness to listen and to keep communication open
• Blank stare


  Can indicate daydreaming or inattentiveness
• In some cultures, people are taught to avoid eye contact or, out of respect, not to make eye contact with a superior
• Facial expressions


  Convey anger, joy, suspicion etc.
• Helping relationship


  Also referred to as interpersonal relationships and therapeutic relationships, may develop within minutes, or over the course of weeks of interacting with a client
• Nurse-client relationship which results in harmony and healing


  • Clients are helped with managing problems and effectively developing unused or underused opportunities more fully & to become better at helping themselves in their everyday lives
• Role of the nurse


  • Being sensitive to self and others
  • Assisting with the gratification of the patient's physical, emotional, and spiritual needs through the nurse's knowledge and skill
  • Development of mutual trust, respect and acceptance between nurse and client
  • The underlying belief that the nurse cares about the client and wants to help
  • Nurturing of faith and hope
• Phases of therapeutic nurse-client relationship

  • Pre-interaction
  • Orientation/introductory Period
  • Working
  • Termination
• Pre-interaction phase


  Data gathering about the client occurs, including: name, address, age, medical history, social history
• Introductory/orientation/pre-helping phase


  Nurse/client relationship is initiated by opening of the relationship, clarification of the problem, and structure and formulation of the contract (obligations to be met by both nurse and client)
• Working phase


  Exploration and understanding of thoughts and feeling occur, taking action is initiated
• Communication techniques


  • Open ended questions (ask for narrative information)
  • Closed ended questions (Asks for specific information)
• Effective communication among health professionals is as important as the promotion of therapeutic communication between the nurse and client
• Tools for communicating with other members of the health team

  • Records
  • Conferences
  • Reports
  • Consultations
  • Referrals
  • Patient rounds
  • Follow-up care
• Prior to taking a client's health history it is important to ensure that the time and place selected for the interview are appropriate (for example privacy, patient comfort)
• Health history aids with diagnosis, treatment decisions, and establishment of trust and rapport between patient and health professionals
• Components of a client's health record

  • Biographic data
  • Chief complaint
  • History of present complaint
  • Past medical health history
  • Family history
  • Social history
  • Drug history (including allergies)
  • Physical examination
  • Laboratory and diagnostic test
• Health history components


  • Sequence
  • Biographical data
  • Reason for seeking care
  • Present health or history of present illness
  • Past health history
  • Family history
  • Review of systems
  • Functional assessment or activities of daily living (ADLs)
• Present illness

  • Medications
  • Allergies
  • Alcohol and drug use