Nursing Health History

1 NURSING PROCESS Six Phases of the Nursing Process 1.

Assessment. Is collecting, validating, organizing and recording data about the client’s health status (may be an individual, family or community).  

Purpose: To establish a data base. Activities During Assessment:  Collection of data.

 Methods of Collection of Data: a. Interview. Planned purposeful conversation. Nursing Health History Components of Nursing Health History 1. Biographic data. Name, address, age, race. Sex, marital status, occupation and religion. 2. Chief complaint or reason for visit. The primary reason given by the client as to why he sought consultation or hospitalization. 3. History of Present Illness. Includes the following:  Usual health status.  Elaboration of the chief complaint.  Relevant family history and disability assessment. 4. Past health history. Includes childhood illness, childhood immunizations, allergies, accidents and injuries, hospitalization and medications. 5. Family history of illness. Includes ages of siblings, parents and grandparents and their current state of health or the cause of death. Reveals risk factors for certain disease - DM, HPN, CA, Obesity etc. 6. Review of systems. Review of all health problems by body system. It is through which the functioning of the major organ system can be assessed. 7. Lifestyle/ Usual patterns of daily life. Includes personal habits, diet, sleep/rest patterns, activities of daily living and recreations/ hobbies. These data provide basis for planning health promotion, maintenance and restoration. 8. Social data. Includes family relationships, ethnic affiliation, educational history, occupational history, economic status.

2 9. Psychologic data. Includes general survey of appearance and behavior, major stressors, usual coping pattern, communication style, self-concept and mood.

10. Patterns of Health Care. Includes health care resources. b. Observation. E.g. use of senses, use of units of measure, physical examination techniques, interpretation of laboratory results. Frameworks for health Assessment 1.

Functional health Framework. Evaluates the effects of the mind, body and environment in relation to a person's ability to perform the tasks of daily living. This health assessment framework organizes data collection in terms of Gordon's 11 functional health patterns:           

Health perception and health management Activity and exercise Nutrition and metabolism Elimination Sleep and rest Cognition and perception Self - perception and self - concept Roles and relationships Coping and stress tolerance Sexuality and reproduction Values and beliefs

2. Head - to - Toe Framework. This system of collecting data starts from the head and proceeds systematically to the toes.  General: General health state, VS and weight, nutritional status  Head: hair, scalp, eyes, ears, oral cavity, cranial nerves  Neck  Chest  Abdomen  Extremities  Genitals  Rectum Physical Health Examination 

Conducted from the head to the toes (cephalo-caudal technique): skin, hair, nails, head, face, ears, eyes, nose, sinuses, mouth, throat, neck, breasts, and axillae, thorax/back, heart and peripheral vessels, upper extremities, abdomen, anus and rectum, genitals, and lower extremities.

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Determine the mental status and LOC or state of awareness at the beginning of physical examination.

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Protect the client's privacy during the entire procedure. Invasive procedures cause feelings of embarrassment.

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Prepare the needed articles and equipment before start of procedure. To conserve time, effort and prevent fatigue in the client.

Modes of Examination 2. Inspection. Assessing by using the sense of sight. 3. Palpation. Examining the body using the sense of touch. Use the fatpads of the fingers. 4. Percussion. Tapping body parts to produce sounds. 5. Auscultation. Listening to body sounds with the use of stethoscope Positions 1.

Dorsal recumbent. Back-lying position with the knees flexed and hips externally rotated. 2. Dorsal/supine. Back-lying position with or without a pillow. 3. Sitting or seated, position. Back unsupported and legs hanging freely. 4. Fowler’s a. Semi-Fowler’s. Head of bed elevated at 15-45 degree angle. b. High Fowler’s. Head of bed raised at 80 – 90 degree angle. 5. Lithotomy. Back-lying position with feet supported in stirrups. 6. Genupectoral/Knee-Chest. Kneeling position with torso at 90 degrees angle to hips. 7. Lateral Side. Lying position. 8. Sim's. Semi -prone position. 9. Prone. Face-lying position, with the head turned to side. Also abdomen-lying position.

Special Nursing Considerations 1. The sequence of methods for physical examination of the abdomen is as follows: Inspection, Auscultation, Percussion and Palpation. No abdominal palpation among clients with tumor of the liver or the kidneys. 2.

During physical examination of the abdomen, it is important to flex the knees to relax the abdominal muscles, thereby facilitating the examination of abdominal organs.

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The sequence of examining the abdomen is as follows: right lower quadrant, right upper quadrant, left upper quadrant and left lower quadrant. (RLQ, RUQ, LUQ, LLQ)

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The best position when examining the chest is sitting/upright position. This permits examination of both the anterior and posterior chest.

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The best position when examining the back is standing position. This enables the examiner to assess the posture and the gait of the client.

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To palpate the neck for lymphadenopathy or enlargement of the thyroid gland, the nurse stands behind the client. If opthalmoscopy is done, darken the room for better illumination.

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If instrument vaginal examination is done, pour warm water over the vaginal speculum before use. To ensure comfort.

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If a female client is examined by a male doctor, a female nurse must be in attendance. This ensures that the procedure is done in ethical manner.

General Survey

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To assess the general appearance and behavior of an individual age, sex, race body built, ht., wt. In relation to the client's age, lifestyle and health posture and gait hygiene and grooming body and breath odor signs of distress obvious signs attitude affect and mood speech thought process

 Types of Data: a. Subjective data (symptoms). Those that can be described only by the person experiencing it. b. Objective data (signs). Those that can be observed and measured.  Sources of Data: a. Primary: Patient/ Client. b. Secondary: Family members, Significant Others, Patient's Team Members, Related Literature.

Record/Chart, Health

 Verifying/Validating Data. Making sure your information is accurate.  Organizing data. Clustering facts into groups of information.

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Diagnosing. Is a process which results to a diagnostic statement or nursing diagnosis. It is the clinical act of identifying problems. To diagnose in nursing, it means to analyze assessment information and derive meaning from this analysis.

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Purpose: To identify the client's health care needs and to prepare diagnostic statements.

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Nursing Diagnosis is a statement of client's potential or actual alteration of health status. It uses the critical-thinking skills of analysis and synthesis. Uses PRS/PES format.  P - problem  R - related to factors  S - signs and symptoms

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Activities During Diagnosing: Organize cluster or group data. Compare data against standards. Standards are accepted norms, measures, or patterns for purposes of comparison. Analyze data after comparing with standards. Identify gaps and inconsistencies in data. Determine the client's health problems, health risks, and strengths. Formulate Nursing Diagnoses statements.

Outcome Identification. Refers to formulating and documenting measurable, realistic, client - focused goals. It provides the basis for evaluating nursing diagnosis. 

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P - problem E - etiology S -signs and symptoms

Purposes:  To provide individualized care.  To promote client participation.  To plan care that is realistic and measurable.  To allow involvement of support people. Activities During Outcome Identification:  Establish priorities.  A priority is something that takes precedence in position, deemed the most important among several items. Priority setting is a decision - making process that ranks the order of nursing diagnoses in terms of importance to the client.  Establishing priorities involve the following: a. life - threatening situations should be given highest priority. b. use the principle of ABC's (airway, breathing, circulation); airway should always be given the highest priority.

6 c. use Maslow's hierarchy of needs; Physiologic needs are given priority over psychosocial needs. d. consider something that is very important to the client. e. clients with unstable condition should be given priority over those with stable conditions. f. consider the amount of time, materials, equipment to care for clients.

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g. actual problems take precedence over potential concerns.

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h. attend to the client before equipment. Nursing diagnoses are classified as high - priority, medium - priority, and low - priority.

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High - priority nursing diagnoses are those that are potentially life - threatening and require immediate action. Examples include Impaired Gas Exchange, Ineffective Breathing Pattern, Self - Directed Risk for Violence.

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Medium - priority nursing diagnoses are those that could result in unhealthy consequences, such as physical or emotional impairment, but are not life - threatening. Examples include Fatigue, Activity Intolerance, Ineffective Coping, Dysfunctional Grieving.

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Low - priority nursing diagnoses involve problems that usually can be resolved easily with minimal interventions and are unlikely to cause significant dysfunction. Examples include sensation of hunger in a client who is on NPO (nothing by mouth), in preparation for a diagnostic procedure; minimal pain on the third postoperative day, related to ambulation. Establish client’s goals and outcome criteria.  A client goal is an educated guess, made as a broad statement, about what the client’s state will be after the nursing intervention is carried out.  Behavioral goals are written to indicate a desired state. They contain an action verb and a qualifier that indicate the level of performance that needs to be achieved.  Examples of behavioral verbs used in client goals are as follows: calculate distinguish participate classify draw practice communicate explain recall compare express recite define identify record demonstrate list state describe name use construct maintain verbalize contrast perform

7  The qualifier is a description of the parameter for achieving the goal.  Goals may be short – term or long – term. Short – term goal (STG) can be met in a relatively short period (within days or less than a week). A long – term (LTG) requires more time (several weeks or months).  Outcome criteria are specific, measurable, realistic statements of goal attainment. Outcome – criteria are written in a manner that they answer the questions: who, what actions, under what circumstances, how well-stated outcome criteria are as follows: S Specific M Measurable A Attainable R Realistic T Time-framed

4. Planning. Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care. To be effective, involve the client and his family in planning. 

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Purposes:  To identify the client’s goals and appropriate nursing interventions.  To direct client care activities.  To promote continuity of care.  To focus charting requirements.  To allow for delegation of specific activities. Plan nursing intervention.  To direct activities to be carried out in the implementing phase.  Nursing interventions are “any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes” (McClosky and Bulechek, 2000). They are used to monitor health status; prevent, resolve, or control a problem; assist with activities of daily living (ADL’s); or promote optimum health and independence (LeFevre, 2001).  Nursing interventions are also called nursing orders. 

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Nursing interventions are independent, dependent and interdependent activities that nurses carry out to provide client care.

Write a nursing plan of care.  The nursing plan of care is a written summary of the care that a client is to receive. It is the "blueprint" of the nursing process. 

The plan of care is nursing centered. This is essential to identify the scope and depth of the nursing practice. By focusing on the treatment of human responses to actual or potential health problems, the nurse remains in the nursing practice domain.

8 The plan of care is a step - by - step process. This is

 evidenced by the following. -

Sufficient data are collected to substantiate nursing diagnoses. At least one goal must be stated for each nursing diagnosis. Outcome criteria must be identified for each goal. Nursing interventions must be specifically designed to meet the identified goal. Each intervention should be supported by a scientific rationale. The scientific rationale is the justification or reason for carrying out the intervention. Evaluation must address whether each goal was completely met, partially met. or completely unmet.

5. Implementation. Is putting the nursing care plan into action. 

Purpose: To carry out planned nursing interventions to help the client attain goals and achieve optimal level of health.

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Activities:  Reassessing. To ensure prompt attention to emerging problems.  Set priorities. To determine the order in which nursing interventions are carried out.  Perform nursing interventions. These may be independent, dependent, or collaborative measures.  Record actions. To complete nursing interventions, relevant documentation should be done. CRITICAL TO REMEMBER: SOMETHING THAT IS NOT WRITTEN IS CONSIDERED AS NOT DONE.

Requirements of Implementation 1. Knowledge. Include intellectual skills like problem - solving, decision - making and teaching. 2. Technical Skills. To carry out treatments and procedures. 3. Communication Skills. Use of verbal and non - verbal communication to carry out planned nursing interventions. 4. Therapeutic Use of Self. It is being willing and being able to care.

9 6. Evaluation. Is assessing the client's response to nursing interventions and then comparing the response to predetermined standards or outcome criteria. 

Purpose: To appraise the extent to which goals and outcome criteria of nursing care have been achieved.

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Activities:  Collect data about the client's response.  Compare the client's response to goals and outcome criteria.  The four possible judgments that may be made are as follows:  The goal was completely met.  The goal was partially met.  The goal was completely unmet.  New problems or nursing diagnosis have developed.  Analyze the reasons for the outcomes.  Modify care plan as needed

Characteristics of Nursing Process       

Problem-oriented. It is comparable with scientific problem-solving approach. Orderly, planned, step by step (systematic). Open to accepting new information during its application. It is flexible to meet the unique needs of client, family, group or community (dynamic). Interpersonal. It requires that the nurse communicate directly and consistently with the client. Permits creativity among nurses and clients in devising ways to solve the health problems. Cyclical. Steps may overlap because they are interrelated. Universal. It is applicable to individuals, families and communities.

Benefits of the Nursing Process for the Clients 1. Quality client care. It meets standards of care. 2. Continuity of care. 3. Participation by the clients in their health care. This reflects respect for human dignity. Benefits of the Nursing Process for the Nurse 1. Consistent and systematic nursing education. 2. Job satisfaction. 3. Professional growth. 4. Avoidance of legal action. 5. Meeting professional nursing standards. 6. Meeting standards of accredited hospitals.

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The Heart of the Nursing Process

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K – Knowledge; S – Skills; and C – Caring Knowledge – broad, varied Skills

A. Manual Technical Skills

B. Intellectual Critical Thinking  Careful deliberate, goal directed – to solve problems/  Make decisions  Good habits of inquiry  Check for evidence  Keeping an open mind  Avoid jumping into conclusions

C. Interpersonal To establish positive interpersonal relationships, with clients, co-workers (requires communication skills)

Caring – Willingness and Ability to Care

Being able to care Understanding ourselves

To be more able to understand others

To be more objective / non-judgmental      

Requires ability to listen empathetically. Listen with intent. Enter into another’s way of thinking and viewing the world. Connecting with another’s feelings and perceptions. Identifying with another’s struggles, frustrations and desires. Then, being able to detach from feelings and returning to our own frame of reference.

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Willingness to Care Keep the focus on what is best for the patient.

11  Respect the beliefs / values of others.  Stay involved.  Maintain a healthy lifestyle.

1. 2. 3. 4. 5. 6. 7. 8. 9.

Caring Behaviors Inspiring someone / instilling hope and faith. Demonstrating patience, compassion and willingness to persevere. Offering companionship. Helping someone stay in touch with positive aspect of his life. Demonstrating thoughtfulness. Bending the rules when it really counts. Doing the “little things” Keeping someone informed. Showing your human side by sharing “stories”