NUR 103: Health Assessment

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NUR 103 Health Assessment

• Health History

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Factors influencing the interview

• Approach
• Environment
• Confidentiality
• Note Taking
• Time, Length, Duration, Biases and Preconceptions

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Interview Contract

• Time and Place
• Introductions
• Purpose
• Length
• Expectations
• Presence of others
• Confidentiality
• Costs

4
Interview Approach

• Privacy
• Interruptions
• Physical Environment
• Dress
• Note taking
• Biases and misconceptions

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Stages of the Interview Process

• Introduction
• Working ( subjective and objective information)
• Closing or Termination

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Therapeutic Interviewing Techniques

• Open ended questions
• Closed ended questions
• Facilitating
• Using silence
• Reflection
• Empathy
• Clarification
• Interpretation
• Summary

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Non-Therapeutic Interviewing Techniques

• Biased Questions
• False Reassurance
• Giving Advice
• Why Questions

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Elements of a Comprehensive Health History

• Biographic Data
• Chief complaint
• History of present illness (symptom analysis)
• Past medical history (family history)
• Review of systems
• Functional assessment
• Alternative therapies
• Cultural influences

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Elements of a Comprehensive Health History

• Biographical data
• Name address
• age
• birthday, year of birth
• sex
• marital status
• race
• ethnic origin
• occupation
• phone number

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Elements of a Comprehensive Health History

• Chief Complaint
• This is a brief spontaneous statement in the
  persons own words that describes the reason the
  client is seeking medical care. What ever the
  client states is the reason for seeking care is
  recorded, and enclosed in quotation marks to
  indicate the clients exact words.

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Elements of a Comprehensive Health History

• History of Present Illness ( symptom analysis)
• 1. For a well client, this is a short statement
  of general health
• 2. For the client who is experiencing
  alterations
• in health status, this is a chronological
  record of the reason for seeking care and
  should include a symptom analysis

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Elements of a Comprehensive Health History

• Past Medical History should include
• Childhood illnesses
• Accidents or injuries
• Serious or chronic illnesses
• Hospitalizations
• Operations
• Obstetric history
• Immunizations
• Last examination date
• Allergies
• Current Medications
• Family History

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Elements of a Comprehensive Health History

• Components of a Review of the Systems
• General overall state of health
• Skin
• Ears
• Hair
• Head
• Eyes
• Nose and sinuses
• Mouth and throat
• Neck
• Breast and axilla

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Elements of a Comprehensive Health History

• Components of a Review of the Systems
• Respiratory
• Cardiovascular
• Peripheral vascular
• Gastrointestinal
• Urinary
• Male/female genital
• Sexual health
• Musculoskeletal
• Neurologic
• Hematologic
• Endocrine
• Health Promotion

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Elements of a Comprehensive Health History

• Components of a Functional Assessment
• Self esteem/Self concept
• Activity/Exercise
• Sleep/rest
• Nutrition/elimination
• Interpersonal relationships
• Coping and stress management
• Personal habits
• Environmental Hazards
• Occupational health
• Alternative therapies
• Cultural influences

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Elements of a Comprehensive Health History

• Documentation Guidelines
• Normal health findings
• Alterations in health findings