HA LEC

• Assessing

  The systematic and continuous collection, organization, validation, and documentation of data
• Nursing Health History & Physical Examination

  two aspects of assessing a client's health status
• Nursing Process (ADPIE)


  Assessing, Diagnosing, Planning, Implementing, Evaluating
• Collecting Data


  observing, interviewing, examining
• Organizing Data


  Uses a format that organizes the assessment data systematically. Often referred to as nursing health history, nursing assessment or nursing database form
• Validating Data


  Compare subjective and objective data in order to verify the client's statements with your observations.
• Nursing Assessment


  Includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs Subjective and Objective Data collection are an integral part of this process.
• Comprehensive Assessment


  Accounts the patient's story, it establishes a complete database for problem identification, reference and future comparison.Includes all the elements of the health history and the complete physical examination
• Focused Assessment


  To determine the status of a specific problem identified in earlier assessment. Addresses focused concerns or symptoms Ex.: facial expression, mood, body habits and conditioning, skin conditions
• Palpation


  Is the examination of the body using the sense of touch - Assess areas of skin elevation, depression, warmth, or tenderness, lymph nodes, pulses, contours and sizes of organs and masses, and crepitus in the joints
• Percussion


  The act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt. To evoke a sound wave such as resonance or dullness from the underlying tissue or organs
• Auscultation


  The process of listening to sounds produced within the body. To detect the characteristics of heart, lung, and bowel sounds
• Comprehensive Health History


  Used to gather data which are subjective and explore past and present problems.
• Subjective Data


  Information given verbally by the patient. The symptoms and history, from Chief Complaint through Review of Systems.Ex.: "It feels like my skin is burning and pricked with needles at the same time."
• Objective Data


  Factual data that are observed by the nurse & could be noted by any other skilled observer.Ex.: "Temp. 37.6°C, O2 Sat. 98%"
• Inspection


  The visual examination, which is assessed by using the sense of sight.
• Chief Complaint(s)


  One or more symptoms or concerns causing the patient to seek care.
• Identifying Data/Biographic Data


  name, address, age, gender, occupation, marital status
• Source of History/Data


  Primary - patient

  
  

  Secondary - be family member, friend, letter of referral or medical records

  
  

  If appropriate, establish source of referral, because a written report may be needed
• Present Illness


  Complete, clear, and chronologic account of the problems prompting the client to seek care
• Past Illness


  refers to any medical condition or disease that a person has experienced or recovered from prior to the present time.
• Family History


  Record if any of the following condition are present or absent in the family.
• Personal and Social History

  Occupation, last year of schooling, home situation and significant others, sources of stress (both recent and long term), important life experiences, leisure activities, religious affiliations and spiritual beliefs, ADL's, exercise, diet, safety measure and alternative health care practices
• Active Listening


  Be aware of the patient's emotional state, and using verbal and nonverbal skills to encourage the speaker to continue and expand.
• Review of Systems


  Head to toe assessment that would uncover overlooked problems. Some clinicians do _____ of ______ during physical examination
• Empathic Response


  Empathy is part of establishing and strengthening rapport with patients
• Guided Questioning


  Moving from open-ended to focused questions. Asking a series of questions, one at a time
• Nonverbal Communication


  Being sensitive to nonverbal cues allows you to "read the patient" more effectively and send messages of your own
• Validation


  Legitimize or validate his or her emotional experience.
• Reassurance


  Effective reassurance is identifying and accepting the patient's feelings without offering reassurance at that moment.
• Partnering


  Make patients feel that no matter what happens, you will continue to provide their care.
• Summarization


  It indicates to the patient that you have been listening carefully.
• Transitions


  To put the patient more at ease, tell them when you are changing directions during the interview
• Empowering the Patient


  Evoke the patient's perspective. Convey interest in the person, not just the problem. Follow the patient's leads. Elicit and validate emotional content
• Sequence and Context of the Interview: Greetings


  _______ the patient and introduce yourself; shake hands if possible. Give the patient your undivided attention.
• Sequence and Context of the Interview: Establishing the agenda


  Begin with open-ended questions that allow full freedom of response
• Sequence and Context of the Interview: Inviting the patient's story

  Ask about the foremost concern by saying "Tell me more about..."Avoid biasing the patient's story; do not inject new information and do not interrupt too early.
• Sequence and Context of the Interview: Exploring the patient's perspective


  Feelings, Ideas, effect on Function, and Expectations (FIFE)
• Sequence and Context of the Interview: Identifying and responding the the patient's emotional cues


  Direct statement(s) by the patient of explanations, emotions, expectations, and effects of the illness - Expression of feelings about the illness without naming the illness
• OLD CART


  Onset, Location, Duration, Character, Aggravating/Alleviating Factors, Radiation, and Timing