Health Assesment

Assessment: The collection of data about the individual’s health state (subjective and

objective)

Subjective Data: What the person says about himself or herself during history

taking

Objective Data: What health care professionals observe by inspecting, percussing,

palpating and auscultating during the physical exam.

The Database:

The database consists of the patient’s records and lab studies. With the database you can make a clinical
judgement or diagnosis about the individual’s health state or response to actual or risk health problems
and life processes as well as diagnoses about higher levels of wellness

Purpose of Assessment:

To make a judgement or diagnosis.

The starting point of every approach to clinical reasoning is an organized assessment

It is important that your assessment be factual and complete because all healthcare

treatments and decisions are made based on the data you gather during assessment

Diagnostic Reasoning in Clinical Judgement:

Most beginning examiners perform well in gathering data, given adequate practice, but

then treat all the data as being equally important- this makes the decision making slow and laboured

Diagnostic Reasoning

is the process of analyzing health data and drawing conclusions to identify diagnoses-

it is based on the scientific method.

Diagnostic Reasoning has 4 major components:

Attending to Initially Available Cues: A cue is a piece of information, a sign or a

symptom or a piece of laboratory data

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Formulating Diagnostic Hypotheses: A hypothesis is a tentative explanation for a cue or a set of cues
that can be used as a basis for further investigation

Gathering Data Relative to the Tentative Hypothesis: You gather to support or reject the tentative
hypothesis

Evaluating Each Hypothesis with the New Data Collected: thus arriving at a final diagnosis

Once you complete data collection, develop a preliminary list of significant signs and

symptoms and all patient health needs.

Cluster or group the assessment data that appear to causal or associated. For example,

a person with acute pain: associated data may include rapid heart rate and anxiety

Validate the data you collect to make sure they are accurate

Nursing Process in Clinical Judgement

6 phases of the Nursing Process:

1. Assessment 2. Diagnosis 3. Outcome Identification 4.Planning 5. Implementation 6. Evaluation

Today we consider the nursing process to be a dynamic interactive process. In today’s

complex clinical setting, practitioners move back and forth within the steps.

The novice nurse has no experience with a specified patient population and uses rules to

guide performance.

With more time and experience, the proficient nurse understands a patient situation as

a whole rather than as a list of tasks. The nurse sees long term goals for the patient

Expert nurses vault over the steps and arrive at clinical judgement in one leap

Nursing Process in detail:

Assessment:

Collect data:

Review the clinical record

Interview

Health history

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Physical examination

Functional assessment

Consultation

Review of the literature

Diagnosis

Interpret Data: Indentify clusters of cues

Make inferences

Validate inferences

clusters of cues with definition and defining characteristics

Identify related factors

Document the diagnosis

Outcome Identification:

Identify expected outcomes

Individualize to the person

Ensure realistic and measurable outcomes

Include a time frame

Planning:

Establish priorities

Develop outcomes

Set time frames for outcomes

Identify interventions

Document plan of care

Implementation

Review the planned interventions

Schedule and coordinate the person’s total health care

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Collaborate with other team members

Supervise implementation of the care plan by delegating appropriate responsibilities

Counsel the person and significant others

Involve the person in the health care

Refer individuals who require continuing care

Document the care provided

Evaluation

Refer to established outcomes

Evaluate the individual’s condition and compare actual outcomes with expected

outcomes

Summarize the results of the evaluation

Identify reasons for the person’s failure, if indicated, to achieve expected outcomes

stated in the plan of care

Take corrective action to modify the plan of care as necessary

Document the evaluation of the person’s achievement of outcomes and the

modifications, if any, in the plan of care

Critical Thinking

Critical thinking is the means by which we learn to assess and modify, if indicated,

before acting- critical thinking is required for sound diagnostic reasoning and clinical

judgement.

In nursing, the data will be dynamic, unpredictable and ever changing. There will not

be any one protocol you can memorize that will apply to every situation.

Critical thinking enables you to:

Analyze complex data about patients

Make decisions about the patient’s problems and alternate possibilities

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Evaluate each problem to decide which applies

Decide on the most appropriate interventions for the situation

Critical thinking is not a step by step linear process, it is a multidimensional thinking process

Critical thinking dimensions: Theoretical and experiential knowledge (what to do, when

to do it and why to do it)/ Critical thinking character (A commitment to learning critical

thinking characteristics, attitudes and dispositions)/Intellectual and manual skills (assessing

systematically and psychomotor skills) = critical thinking ability.

Alfaro-LeFevre (2004) presents the following 17 critical thinking skills, organized in

the logical progression of the ways the skills might be used in the nursing process, they are not

used separately:

Identifying assumptions: recognize that you might take info for granted

Identifying an organized and comprehensive approach to assessment

Validating: or checking for reliability of data

Distinguishing normal from abnormal: when identifying signs and symptoms

Making inferences: or drawing valid conclusions from the interpretation of data.

Clustering: related cues,w hich will help you see relationships among data.

Distinguishing relevant from irrelevant: this can be done by doing a complete phy. Exam

Recognizing inconsistencies: for example, if someone says they ran into a door

(subjective data) it is at odds with the location of the infraorbital hematoma (objective data).

There is conflicting info, you can investigate further.

Identifying patterns:helps to fill in the whole picture and discover missing pieces of info

Identifying missing information: gaps in data or a need for more data to make a diagnosis

Promoting health: by identifying risk factors and considering a patient’s social contexts.

Diagnosing actual and potential (risk) problems from the assessment data derived from

health history and physical exam

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Setting priorities when there is more than one diagnosis. For example: first level

priority problems are those that are emergent, life threatening and immediate, such as

establishing an airway or supporting breathing. Second level priority problems: are those that

are next in urgency- those requiring your prompt intervention to forestall further

deterioration, for example mental status change, acute pain, acute urinary elimination

problems. Third-level priority problems are those that are important to the patient’s health

but that can be addressed after more urgent health problems are addressed. Collaborative

problems are those in which the approach to treatment involves multiple disciplines.

Determining patient-centred expected outcomes

Determining specific interventions that will achieve your outcomes. These interventions

aim to prevent, manage, or resolve health problems. This is the health care plan.

Evaluating and correcting thinking. Look at the expected outcomes, and apply them for

evaluation. Do the stated outcomes match the individual’s actual progress?

Determining a comprehensive plan or evaluating and updating the plan.

Using a Conceptual Framework to Guide Nursing Practice

Nursing Diagnosis: it is a part of the nursing process. Nursing diagnoses are clinical

judgements about a person’s response to an actual or potential health state

The NANDA list includes 1) Actual diagnoses: existing problems that are amenable to

independent nursing interventions 2) Risk diagnoses: potential problems that an individual

does not currently have but is particularly vulnerable to developing 3) Wellness diagnoses:

which focus on strengths and reflect and individual’s transition to a higher level of wellness

A clear idea of health is disease important because this determines which assessment

data should be collected

BIOMEDICAL MODEL of health (is the Western view of health): views health as the

absence of. The person is certified as healthy when these symptoms and signs have been eliminated.

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SOCIOENVIRONMENTAL MODEL of health views health as the product of social,

economic and environmental determinants that provide incentives and barriers to the health of

individuals and communities. Social determinants of health: low income, crowded housing, lack

of affordable housing

Health Promotion:

The process of enabling people to increase control over their health and its determinants

and thereby improve their health

Health promoting actions focus on strengthening the skills and capabilities of

individuals and families and are directed toward changing social, economic and environmental

conditions to improve health

Relational Approach in Nursing Practice: recognizes that health, illness and the

meaning they hold for a person are shaped by one’s social, cultural, family, historical and

geographical contexts as well as one’s gender, age, ability etc. One of the central skills of

relational practice is REFLECTIVITY: the process of continually examining how you view

and respond to patients based on your assumptions, cultural and social orientation, past

experiences and so on.

4 Types of Databases that nurses use in practice

1.Complete (Total Health) Database:

Complete health history and a full physical examination

Describes current and past health state- for the well person- the database must describe

the person’s health state, perception of health, strengths or assets such as the ability to engage

in health maintenance or health promoting practices, support systems, current developmental

tasks and any risk factors or social issues. For the ill person- the database also includes a

description of the person’s health problems, patient’s perception of illness and response to the

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problems. Complete database for the well and ill person must screen for pathology as well as determine
the ways people respond to that pathology or to any health problem In acute hospital care, complete
database is also gathered following admission to the hospital.

You will collect additional information on the patient’s perception of illness, functional

ability or patterns of living, activities of daily living, health maintenance behaviours, response

to health problems, coping patterns, interaction patterns and health goals.

This approach completes the database from which the nursing diagnoses can be made

2.Episodic or Problem-Centred Database

The episodic database is for a limited or short term problem .You collect a ‘mini’ database

The database is smaller in scope and more focused, Contains mainly one problem, one cue complex, or
one body system. It is used in all settings: hospital, primary care, long term care

For example: 2 days following a surgery, a hospitalized person suddenly has a

congested cough, shortness or breath and fatigue. The history and examination focus

primarily on the respiratory and cardiovascular systems.

3.Follow-up Database

The status of any identified problems should be evaluated at regular and appropriate levels

What change has occurred? Is the problem getting better or worse? What coping strategies are used?

The follow up database is used in all settings to follow up short term or chronic health problems

4.Emergency Database

Rapid collection of data (often compiled concurrently with life saving measures)

Diagnosis must be swift and sure

For example: in a hospital emergency department, a person is brought in with suspected

substance abuse overdose. The first history questions are: “what did you take” and “when”. The

person is questioned simultaneously while his or her airway, breathing, circulation, level of

conciousness, and disability are being assessed.

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The Interview
What is the interview?

A meeting between you and your patient,The meeting’s goal is to record a complete health history

The health history helps you to begin to identify the person’s health strengths and problems and
functions as bridge to the next step in data collection which is the physical exam.

The interview is the first step in data collection and the most important part because it is the best
chance that a person has to tell you what he or she perceives his or her health state to be

The interview collects subjective data: what the person says about himself or herself

When you have a successful interview you:

Gather complete and accurate data about the person’s health state, including the

description and chronology of any symptoms of illness

Establish rapport and trust so the person feels accepted and thus free to share all relevant data

Teach the person about the health state so that the person can participate in identifying problems

Build rapport for a continuing therapeutic relationship’ this rapport facilitates future diagnoses, planning
and treatment

Begin teaching for health promotion and disease prevention

Consider the interview as being similar to a contract between you and patient. Mutual

goal is optimal health and health care for the patient. Contract’s terms include:

Time and place of the interview and succeeding physical examination

Introduction of yourself and a brief explanation of your role

The purpose of the interview , How long will it take, Expectation of participation for each person

Presence of any other people (patient’s family, other healthcare professionals)

Confidentiality and to what extent it may be limited, Any costs that the patient must pay

The Process of Communication

Communication: exchanging information so that each person clearly understands the other

Much more than talking and hearing is required, communication is all behaviour: conscious/unconscious
and verbal/nonverbal. All behaviour has meaning.

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If you do not understand each other, you have not conveyed meaning, no communication has occurred.

One of the central skills of relational practice is Reflectivity: a combination of self observation, critical
scrutiny and conscious participation and paying attention to who, how and what you are doing in the
moment as you work with the patient’s families.

Paying attention to how you are acting and what you are feeling in any particular situation, you can
begin to see how your behaviours and responses affect each other

Key Components to the process of communication:

Sending:

Verbal communication: words that you speak, vocalizations, the tone of voice

Non-verbal communication: body language, posture, gestures, facial expression, eye

contact, foot tapping, touch, even where you place your chair

Receiving:

Your words and gestures must be interpreted in a specific context to have meaning

You gave a specific context in mind when you send your words

The receiver has his or her own interpretation of them

The receiver attaches meaning based on his or her own past experiences, social and

family contexts, culture, and self concept, as well as current physical and emotional state.

Sometimes there is miscommunication, contexts do not coincide

It takes mutual understanding be the sender and receiver to have successful communication.

COMMUNICATION AND REFLECTIVITY ARE THE BASIC SKILLS

THAT CAN BE LEARNED AND POLISHED WHEN YOU ARE A BEGINNING

PRACTITIONER

Attending to Power Differentials:

Nurses and other professionals are usually in positions of power relative to patients and families

They have more knowledge about the healthcare system and have influence over the access that
patients have to health care.

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Healthcare professionals also have advantages such as education, language skills and

employment which can position them as relatively powerful in relation to patients.

Be aware of how your power and priviledge relative to patients, families, and colleagues

are reflected in the way you communicate, both verbally and nonverbally.

Communication Skills: these include among others:

Unconditional Positive Regard:

Conveying unconditional positive regard requires a high degree of self-reflectivity,

particularly when patients or families seem to be making choices that negative health effects.

Having a generally optimistic view of people

Having an atmosphere of warmth and caring

Patient must feel that they are accepted conditionally

Respect for other people extends to respect for their control over their health

Your goal is to not make your patient’s depend on you but to help them be increasingly

responsible for themselves, to promote their growth

Empathy

Viewing the world from the other person’ frame of reference while remaining yourself

Accepting and recognizing the other person’s feeling or actions without criticism

Feeling “with the person” rather than feeling “like the person” Understand with the person how they
understand their world

Active Listening

Listening is not passive, it is active and demanding, it requires complete attention

You have to have full focus or you will miss something important

For the time of this interview, no one is more important than the client

Active listening- route to understanding, Listen to the way a person tells a story such as difficulty with
language, impaired memory, the tone of the person’s voice and even to what the person is leaving out.

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Attending to the Physical Setting:
Prepare the physical setting, the setting could be a hospital room, and examination

room in an office or clinic or person’s home. Optimal conditions important to the completion of

a smooth interview

Ensure Privacy

Aim for geographical privacy: a private room in hospital, clinic or home. If

geographical privacy is not available, ‘psychological privacy’ by curtained partitions may

suffice as long as the person feels no one can overhear the conversation and interrupt.

Refuse Interruptions:

Do not have any one interrupt your interview unless it is an emergency, An interruption can destroy the
rapport that you have spent many minutes building

Physical Environment

Set room at comfortable temperature

Provide sufficient lighting

Reduce noise. Multiple stimuli are confusing. Turn off any equipment.

Remove distracting objects or equipment. Room should convey the professional nature

of the interviewer.

Place the distance between you and the patient at about 1.5 meters (twice the arm’s

length). Any closer and you will invade the patient’s private space and you may create

anxiety. If you place the patient farther away you may seem distant and aloof.

Arrange equal status seating. Seated at eye level. Avoid facing a patient across a desk

or table because that feels like a barrier. Place chairs at 90 degress.

Avoid standing: it communicates you haste and it assumes superiority.

Arrange face to face positioning when interviewing the hospitalized or bedridden person.

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Dress:

The patient should remain in street clothes except in the case of emergency

You appearance and clothing should be appropriate to the setting and should meet

conventional standards: a uniform or lab coat, neat hair. Avoid extremes.

Note-Taking:

You might have to take notes because it is unavoidable, you cannot rely completely on memory

Note taking has its disadvantages:

It breaks eye contact too often

It shifts you attention away from the person

It can interrupt the person’s narrative flow

It impedes you observations of the patient’s nonverbal behaviour

It is threatening to the patient during the discussion of sensitive issues

Any recording you do should be secondary to the dialogue.

Tape and Video Recording:

A digital recorder or adio tape documents a complete record of what was said during the interview

A record is an excellent traching tool to study objectively your abilities as an interviewer

Audio recordings demonstrate how you can improve your communication

Also ethical considerations are necessary

Explain to the person the purpose of the recording and who will hear it, obtain consent.

Techniques of Communication

Introducing the Interview:

Address the person using surname, and shake hands if that seems comfortables

Introduce yourself and state your role in the agency (if you are a student, say so)

If you are gathering a complete history, give the reason for the interview, for example:

“Mrs. Singh, I would like to talk to you about your illness that caused you to come to the

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hospital.” “Mrs. Tang I want to ask you some questions about your health so we can identify

what is keeping you healthy and explore problems.”

If the person is in the hospital. More than one healthcare team member may be

collecting a history. Patients can feel exasperated ad that is why they believe they are

repeating the same thing unless you give a reason for the interview.

After a brief info, ask an open ended question and then let the person talk, building

rapport by letting patient discuss the concern early, no need for small talk.

The Working Phase:

The working phase is the data gathering phase

Verbal skills in this phase include your questions to the patient and your responses to

what the patient has said

2 types of questions exist:

Open Ended Questions:

It states the topic to be discussed but only in general terms.

Use it to begin the interview, to introduce a new section of questions, and whenever the

person introduces a new topic.

Example: “Tell me how I can help you” “What brings you to the clinic (or) hospital?”

The open-ended question leaves the person free to answer in any way. It lets the person

express herself or himself fully.

As person answers, stop or listen, this involves “listening to” and “listening for”

particular things.

Listening to: how people describe health, observe nonverbal communication, listen to

beliefs about health and illness

Listening for: involves tuning into what is of particular concern to patients and

families, and listening for the emotions people convey and for the capacities and strengths that they
have.

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Closed or Direct Questions:

Closed or direct questions ask for specific information.

They elicit a short one or two word answer, a yes or no or a forced choice

Closed questions limits his or her answer

Use direct questions after the person’s opening narrative to fill in any details he or she left out

Use direct questions when you may need specific facts

You need direct questions to speed up the interview

Asking all open questions could take hours, do not over use closed questions. Follow

these guidelines: Ask only one direct question at a time. Choose language that the person

understands.

Responses: Assisting the Narrative

As the person talks, your role is to encourage free expression but not let the person

wander off course

Your responses help the teller amplify the story

Some people seek health care for short term or relatively simple needs, their history is

direct and uncomplicated, for these people, two responses (facilitation and silence) may be all

that you need to get a complete picture.

There are 9 types of verbal responses: first 5 involve your reactions to the facts or

feelings the person has communicated.

Your response focuses on the patient’s frame of reference

In the last for responses you start to express you own thoughts and feelings and the

frame of reference shifts from the patient’s perspective to yours.

In the first 5 responses, patient leads; in the last 4, you lead.

Facilitation: These responses encourage the patient to say more: “mm-hmm, go on

continue”. These reponses show the patient that you are interested and will listen further

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Silence: Silence is golden after an open ended question. Your silent attentiveness

communicates that the patient has time to think, to organize what he or she wishes to say

without interruption. Silence gives you a chance to observe the person and to note verbal cues.

Silence also lets you plan you nest approach.

Refelction: This response echoes the patient’s words. Reflection is repeating part of what

the person has said. It focuses further attention on a specific phrase and helps the person

continue in his own way. For example: “I’m here because of my water. It was cutting off”

Nurse: “It was cutting off?” Refelction can also help express feeling behind a person’s words.

The feeling is already in the statement. You focus on it and encourage the person to elaborate.

Example: Patient: “It is so hard to stay flat on my back at the hospital with this pregnancy. I

have two little ones at home and I am so worried that are not getting the care they need.”

Nurse: “You feel worried and anxious about your children?’

Empathy: An empathetic response recognizes a feeling and puts it into words. It names

the feeling and allows an expression of it. When the empathetic response is used, the patient

feels accepted and can deal with the feeling openly. For example: Patient: This is just great,

one day I have my own business directing 20 employees and here I am having to now call you

for everything” Nurse: “It must be hard- one day having so much control and now feeling so

dependent on someone else.” Do not give false reassurance. Empathy strengthens rapport.

Clarification: Use this when the person’s word choice is ambiguous or confusing (Tell

me what you mean by “tired blood”. Clarification is also used to summarize the person’s words,

simplify them to make to make them clearer. “So the heaviness in your chest comes from when

you shovel snow and then stops when you’re done?” Patient: “Yes, that’s right”

Confrontation: In the case of confrontation you have observed a certain action, feeling

or statement and you now focus the person’s attention on it. You give you honest feedback on

what you see or feel. This may focus on a discrepancy, “ You say it doesn’t hurt, but when I

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touch you here, you grimace.” Or it may focus on the person’s affect :”You look sad” or “You

sound angry”. Or you can confront the person when parts of the story are inconsistent.

Interpretation: This is based on your inference or conclusion. “It seems like every time

you feel the stomach pain, you have had some kind of stress in your life.” You run the risk of

making the wrong inference. If this is the case the person will correct it.

Explanation: You inform the person and share factual objective information. “Your

dinner comes at 5:30pm” or it may be to explain the cause. “The reason you cannot eat or

drink before your blood test is that the food will affect the test results.”

Summary: This is the final review of what you understand the person has said. It

condenses the facts and presents a survey of how you perceive the health problem or need.

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