King Saud University College of Nursing Health Assessment (NUR 224) General Survey & Health History Part 1 1

Outline Outline Learning objectives  Learning objectives  Health history  Definition.  Nursing vs. Medical history.  Components of health history.  How to obtain health history:  Interview  Records review  Documentation 2

3 Learning Objectives At the end of this module the learner should be able to:  Understand the structure and purpose of health history in order to collect relevant information.  Recognize the importance of applying the three phases of interview to collect a comprehensive history from clients.  Take a complete health history using standard format.  Interpret data collected in terms of chief symptoms and complaints

Definition of Health assessment Health assessment is the first step of the nursing process. It involves collecting two types of data: 1- Objective data OO btained through interviewing patient. RR eferred to as symptoms. FF eeling perception & concerns that cannot be observed by others 2- Subjective data OOOO btained through observation, standard assessment technique, laboratory & diagnostic test. RR eferred to as signs as it can be seen, heard, or felt, by someone other than the patient or client).

Purposes of health assessment Surveying the clients health status (current) and risk factors for particular health problem (potential). Surveying the clients health status (current) and risk factors for particular health problem (potential). Identifying undetected disease Identifying undetected disease Screening for a specific disease such as diabetes Screening for a specific disease such as diabetes Identifying risks for particular health problem Identifying risks for particular health problem Determining functional impact of disease (i.e. response to actual or potential health problem) Determining functional impact of disease (i.e. response to actual or potential health problem) Evaluating the effectiveness of health care plan Evaluating the effectiveness of health care plan

Three health assessment components.  Part one deals with obtaining a comprehensive health history and utilizing effective interviewing techniques.  Part two focuses on acquiring appropriate skills to perform physical examination.  Part three evaluates the client nutritional status.

Health History: Is the collection of data about an individual's health state by interviewing the client and review of records. Purpose : tto collect different type of information, to form the client’s data base, which: 1- Helps the nurse discover significant health problem 2- Used to make judgment or diagnosis about the clients past and current health status. 3- Used in developing the nursing care plan.

Difference between Nursing health history and Medical health history  Medical health history : Concentrates on symptoms and progression of diseases  Nursing health history: Focuses on the client’s functional health patterns, responses to changes in Health status & alteration in life style.

The element of health history  Biographic information: age, sex, educational level, marital status, occupation, living arrangements.  Chief complaint: the client reasons for seeking health care (usually in the clients own word).  Present health status or illness: the record of the current issue from the starting of the onset until now.

 Past Health history: general state of health, childhood, adult and psychiatric illness, accident and injuries, operations and hospitalization  Current health status: medication, allergies to food or medication, smoking, drug abuse, diet, screening test, immunization, sleep pattern, exercise, environmental hazards, and safety measures.

 Family history: age and health status of parents, siblings, and children; cause of death for immediate family members.  Psychosocial factors, lifestyles: cultural beliefs that influence health management; religious or spiritual beliefs and daily living activities.  Nutrition: dietary habits, preferences, or restrictions

Starting the interview: a. Address the client by name. b. Introduce yourself and your role. c. Explain the purpose of the interview d. Tell the client how long the interview will last e. Reassure the client that the data will be kept confidential. f. Formulate a general impression about client as a whole (posture, speech, signs of distress, facial expression, dressing, grooming and hygiene)

Observe client nonverbal message  Physical appearance  Posture Gesture  Facial expression  Eye contact  Voice

2-Working phase: It is the data gathering phase. Verbal skills for this phase include questioning the client, and the nurse responses to what the client says. Open ended question *It require patient to talk about his problem, expressing feeling, opinions, and idea * It enhance the development of nurse – patient rapport * It helps you gather more information than can be gathered with closed question * It can convey interest and trust because of the freedom it’s provides example: *Why did you come to the hospital to night? *How would you describe the problems you are having with your breathing? Closed question *It elicits yes or no answers * It limits the development of nurse patient rapport * They take less time example: * Do you ever get short of breath? *Are you the only one in your family with lung problems?

Communication skills during the interview 1-Facilitation: Use phrases to encourage the client to continue. Example: (please continue). 2-Silence: Keep silent for second to have a chance to assess the client ability to organize his thoughts. 3-Confirmation: Repeat the information given by patient to clear up any misunderstanding.

4-Clarification: To seek understanding when the client words are confusing 5-Reflection: Repeating part of what the clients has just said, to focus attention on specific phrase it demands the client’s elaboration on meaning or feeling.

6-Empathy: recognizes the feeling of the client and puts it into words. It helps the client feels accepted and can deal with the feeling openly. 7-Summary: final review of what you understand the person has said.

Ten traps of interviewing PProviding false reassurance. GGiving unwanted advice. UUsing authority. UUsing avoidance language. UUsing of professional jargons. UUsing leading or biased questions. TTalking too much. IInterrupting. BBeing judgmental. UUsage of indirect language while dealing with frightening topics

3. Closure phase: IIt is the phase that eases the closing of the interview, summarizes and sums it up.It concludes what the client and nurse agree the health state to be. RRestating the information that was covered during interview DDo not introduce any new topic SSignal that the interview is about to end (example only 2 question left, within 5 min we will finish). DDiscuss only specific points

3. Closure phase (cont.): RRequest validation of the patient/client perception EEnd the interview /conclusion brings it to close. OOffer the client chance for final addition. (ex: is there anything else you would like to mention?). TThank the client. EExplain the next steps. Plans can be made for the future.

B. Review of records:  It is an objective data collected through review of documentations related to the client health status. Such as:  Medical diagnosis.  Nursing notes.  Laboratory and diagnostic studies performed.  Referral notes.

Data documentation:  Documentation is a major part of a complete health history  Data should be recorded in a factual manner and not interpreted by the nurse. To increase accuracy the nurse should record subjective data in the client own words

23 Question?