Weber Ch 1

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cswett
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100802
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Weber Ch 1
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2011-09-12 23:01:15
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Weber Health Assessment
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Reading notes from Health Assessment Ch 1
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  1. 4 Types of Assessment
    • Initial conprehensive assessment
    • Ongoing or partial assessment
    • Problem- Oriented Assessment
    • Emergency Assessment
  2. Steps of Health Assessment
    • 1. Collection of Subjective data
    • 2. Colledtion of Objective data
    • 3. Validation of data
    • 4. Documentation of data
  3. Collecting Subjective Data
    • Biographical information (name, age, religion, occupation)
    • Physical symptoms related to each body part or system
    • Past Health History
    • Family History
    • Health and lifestyle practices
  4. Collecting Objective Data
    • Physical Characteristics (skin color, posture)
    • Body functions (heart rate, respiratory rate)
    • Appearance (dress and hygiene)
    • Behavior (mood, affect)
    • Measurements (blood pressure, temperature, height, weight)
    • Results of laboratory testing (platlet count, x-ray findings)
  5. Process of Data Analysis
    • 1. Identify abnormal data and strengths
    • 2. Cluster the data
    • 3. Draw inferences and identify problems
    • 4. Propose possible nursing diagnoses
    • 5. Check for defining characteristics of those diagnoses
    • 6. Confirm or rule out nursing diagnoses
    • 7. Document conclusions
  6. Subjective data
    • Sensations or symptoms
    • Feelings
    • Perceptions
    • Desires
    • Preferences
    • Beliefs
    • Ideas
    • Values
    • Personal Information

    • can only be verified by client
    • -provide clues to possible physiologic, phychological, and sociologic problems
    • -may reveal client's risk for a problem as well as client strengths
  7. Nonverbal communication
    • Appearance
    • Demeanor
    • Facial Expressions
    • Attitude
    • Silence
    • Listeneing
  8. Vebal Communication
    • Open-ended questions - how or what
    • Close-ended questions - when or did
    • Rephrasing
    • Well-placed pharses - use to let client know you are listening - um-hum, yes, I agree
    • Inferring
    • Providing Information
  9. Health History
    • 1. Biographic data -
    • 2. Resons for seeking health care
    • 3. History of present health concern
    • 4. Past Health History
    • 5. Review of body systems (ROS) for current health problems
    • 6. Lifestyle and health practices profile
    • 7. Developmental level
  10. Symptom Analysis
    COLDSPA
    • C - Character - Describe sign or symtom
    • O - Onset - when did it start
    • L- Location - wher is it
    • D- Duration - how long does it last
    • S - Severity - How bad is it
    • P - Pattern - what makes it better or worse
    • A - Associated Factors - how it affects the client (other symptoms that occur with it - how it affects you)
  11. Palpation
    Light
    Moderate
    Deep
    Bimanual
    • Palpation consists of using parts of the hand to touch and feel for:
    • texture (rough/ smooth)
    • temperature (warm/ cool)
    • moisture (dry/ wet)
    • mobility (fixed/ movable/ still/ vibrating)
    • consistency (sift/ hard/ fluid filled)
    • strenght of pulses (strong/ weak/ thready/ bounding)
    • size (small/ medium/ large)
    • shape (well defined/ irregular)
    • degree of tenderness

    • Light Palpation - dominant hand lightly on surface of structure - feel structure in circular motion
    • -used for pulses, tenderness, surface skin texture, temperature, and moisture

    • Moderate Palpation - Depress surface 1 to 2 cm & use circular motion
    • -use to feel easily palpable body organs and masses

    • Deep palpaction - dominant hand on skin & non-dominant over to apply pressure - depress surface 2.5 -5 cm (1-2 inches)
    • -use to feel deep organs or structures covered by thick muscle

    • Bimanual Palpation - two hands placed on either side of body part - use one hand to apply pressure and the other to feel the structure
    • - used for uterus, breasts, spleen
  12. Percussion
    • produce sound waves to:
    • Elicit pain
    • Determine location, size, and shape - note changes between border of an organ and it's neighboring organ can give info about location, shape, and size
    • Determine Density - filled with air or fluid or a solid structure
    • Detect
  13. Health Assessment
    • 1) HEALTH HISTORY/INTERVIEW
    • * biographical data
    • * chief complaint / present illness
    • * past health/medical history
    • * family health history
    • * lifestyle & health practices
    • * systems review•

    • 2) HEALTH EXAMINATION
    • * general survey / appearance / developmental stage
    • * vital signs
    • * head-to-toe physical assessment

    • VARIATIONS (age, culture, religion)
  14. Assessment
    Collection of data aboutstate of an individual’shealth
  15. Models of Health
    • • Biomedical model of systems review - physicians (illness-health continum)
    • • Functional patterns ofhealth
    • Personalitydevelopment/stages(Erikson, 1963)
    • • Health promotion anddisease prevention(NANDA taxonomy) - Nurses
  16. MURDER INC
    • M - Musculoskeletal
    • U - Urinary
    • R - Respiratory
    • D - Digestive
    • E - Endocrine
    • R - Reproductive
    • I - Integumentary
    • N - Neuro
    • C - Cardiac

    out of order
  17. Erikson's Human Development
    • Infant – trust, < 1yr.
    • • Toddler – autonomy,1-3 yrs.
    • • Preschool – initiative,3-5 yrs.
    • • School – industry, 6-12 yrs.
    • • Adolescent – identity,13-20 yrs.
    • Young adult –intimacy. 20-35 yrs.
    • • Middle adult –generativity, 35-65yrs.
    • • Older adult – egointegrity, > 65 yrs.
    • – Young old 65-74yrs (Retirement)
    • – Middle old 75-84yrs. (Independence)
    • – Old old > 85 yrs. (Dealing with dealth of loved ones)
  18. NANDA Taxonomy II
    PES
    • • Health promotion
    • • Nutrition
    • • Elimination
    • • Activity/res
    • t• Perception/cognition
    • • Self-perception
    • • Role relationships
    • • Sexuality
    • • Coping/stresstolerance
    • • Life principles
    • • Safety/protection
    • • Comfort
    • • Growth/development

    • “PES”
    • P - Problem (Nanda)
    • E - Etiology R/T
    • S - Signs/ Symptoms - AEB

    Nursing Care Plan - should be working with patient to set goals and achieve them
  19. 3 Levels Health Promotion
    • • Primary prevention - prevention of disease, immunizations, exercise (non focused)
    • • Secondary prevention - breast exams, (focused for prevention of a specific disease)
    • • Tertiary prevention - limit the diability, pt or speach therapy after a stroke
  20. Cultural Assessment

    Ethnocentrism
    • • Every client is part of a:
    • –Cultural context
    • Purnell and Paulanka (2003, p.3) …”thetotality of socially transmitted behavioral patterns, arts, beliefs, values, customs,lifeways, and all other products of humanwork and thought characteristic of a population or people that guide their worldview and decision making.”
    • –Family context
    • –Community context
    • • ALL of which affect the client’shealth
    • – Sensitive to cultural differences
    • – Not stereotyping
    • – Template for cultural assessment

    – ETHNOCENTRISM = perception that one’sworld view, beliefs, values & behaviors aresuperior to all others
  21. Culture Assessment
    • • Birth place & cultural identification - ask what culture they identify with
    • • Language(s) spoken
    • • Beliefs about health & illness
    • • Religious influences - does it effect how they recieve health care
    • • Family roles - what is not getting done with them in the hospital
    • • Dietary habits
  22. Family
    • • Older definition of family = related by marriage, birth or adoption
    • • Family = 2 or more people emotionally involved that live in close geographical proximity
  23. 3 Phases of Interview
    • 1) Introductory - Introduce self & instructor
    • - small talk to develop repoir
    • 2) Working
    • 3) Summary and Closing

    Maintain privacy & confidentiality -HIPAA
  24. Communication During Interview (Nurse v. Client)
    • • Nonverbal Communication
    • • Professional appearance
    • • Demeanor focused on client
    • • Neutral facial expressions/nonjudgmental
    • • Silence to reflect thoughts
    • • Active listening (eye contact & open bodylanguage)
  25. Nonverbal Communication Cues by Client
    • • Nonverbal Clues
    • – Physical appearance
    • – Posture
    • – Gestures
    • – Facial expression
    • – Eye contact - different by culture - some dont make eye contact
    • – Voice
    • – TouchCommunication
  26. Communication During Interview
    • • Verbal Communication
    • • Avoid biased leading questions
    • • Don’t rush interview
    • • Use open-ended questions
    • • Limit close-ended questions
    • • Provide laundry list of symptoms - try to get patient to describe pain - dont put works in their mouth
    • • Encourage client to continue -

    • • Active listening
    • • Facilitation - um-hum, yes, I agree
    • • Clarification - what do you mean when you say that?
    • • Restatement - Paraphrase so confirm understanding
    • • Reflection - Repeat it right back - word for word
    • • Confrontation - not accusatory -when data is conflicting - I'm confused here...let's go over this again
    • • Interpretation
    • • Summary
  27. BAD Communication Techniques
    • • Providing false assurance
    • • Giving unwanted advice
    • • Using authority
    • • Using avoidance
    • • Engaging in distancing
    • • Using professional jargon
    • • Using leading orbiased questions
    • • Talking too much
    • • Interrupting
    • • Using “why”questions
  28. Special Interview Considerations
    • • Pediatric Client -
    • • Information from caregiver
    • • Prenatal care / labor & delivery
    • • Nutrition (breast v. bottle)
    • • Developmental milestones
    • • Immunizations

    • • Gerontology Client
    • • Obtain history in a calm, unrushedmanner
    • • Avoid medical jargon
    • • Be respectful (Mr. or Mrs.)
    • • Impaired hearing & sight (face to face to read lips)
    • • Basic activities of daily living
    • • Medications - reconcilitaion - tell me every pill & every suppliment you put in your mouth over a 24 hour period
    • • Subtle physical changes not necessarily due to aging
    • • Include family member if confused

    • • Culturally Diverse Client
    • • Reluctant to reveal personal information
    • • Avoid slang language
    • • Nonverbal communication
    • • Time orientation (past,present or future)
    • • Interpreter

    • • Emotionally Upset Client
    • • Angry – don’t hurry; simple concise Q’s- you seem upset, is there something going on?, would you like to talk about it?
    • • Anxiety – don’t argue; calm/reassure; allow to ventilate
    • • Depressed – avoid upbeat, express interest
    • • Manipulative – set limits vs. reasonable request
    • • Seductive – limit sexual behavior; other coping mechanisms
    • • Sensitive Issues – ask permission;nonjudgmental; referrals to pastoral counselor
  29. Health History
    • • Biographical data
    • • Chief complaint/reason for seeking care
    • • Past health history
    • • Family medical history
    • • Lifestyle & health practices
    • • Developmental level (Erikson)
    • • Systems review
  30. Biographic Data
    • • Name
    • • Address
    • • Phone number
    • • Date of birth
    • • Race
    • • Occupation - Retired - what did they used to do?
    • • Marital status/contact person
    • • Religion - is there any religious things that we need to know that will impact your care
  31. Cheif Complaint/ Present Health
    • • Present health status
    • • History of present illness
    • • Symptoms -COLDSPA
  32. Past Health History
    • • Childhood illnesses
    • • Accidents or injuries
    • • Serious or chronic illnesses
    • • Hospitalizations
    • • Operations
    • • Obstetric history
    • • Immunizations
    • • Last examination dates
    • • Allergies
    • • Current medications
  33. Lifestyle & Health Practices
    • • Nutrition (food diary) - esp on people who live alone
    • Tell me what you've had to eat in the last 24 hours
    • Is this typical for you?
    • • Activity/Exercise
    • • Sleep/Rest
    • • Interpersonal Relationships/Resources
    • • Coping and Stress Management (job)
    • -supported at home? family support
    • -do you have a lot of stress in your life
    • • Substance abuse (alcohol, tobacco, streetdrugs)
    • -any illegal drug use now or in the past?
    • • Environmental/occupational hazards
    • • Self-esteem, Self-concept (Erikson)
  34. Closing the Interview
    • • THE NURSE SUMMARIZES THE INFORMATION
    • • ENSURES THEPERSON HAS UNDERSTOOD MAJOR POINTS DISCUSSED
    • • SET JOINT GOALS TOACHIEVE
    • • DOCUMENTATION

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