the nursing health history
TRANSCRIPT
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THE NURSING HEALTH HISTORY
FELIPE A. MERANO, RN, MSN
Associate Professor
HEALTH ASSESSEMENT
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INTRODUCTION
OVERVIEW: HEALTH ASSESSMENT
REQUIREMENTS
Lecture : 60 %
SKL: 40%
1 Notebook: Lesson Plan
Good Background of ANATOMY & PHYSIOLOGY
Reference: Jenet Weber
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NURSING HEALTH HISTORY
The systematic collection of
subjective data (stated by the
client) and objective data
(observed by the nurse) used to
determine a clients functionalhealth pattern status.
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Physiologic Psychological
Socio-cultural
Developmental, and Spiritual client data.
The Nurse Collects Data:
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Needed in identifying NursingDiagnoses and/or
Collaborative Problems
The Nurse Collects Data:
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Wellness
Actual
Risk
Three Categories of Nursing
Diagnoses: WAR
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Wellness Diagnoses human
responses about an individual,family, or community that have a
readiness for enhancement, may
be described as opportunities for
enhancement of healthy state
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Actual Nursing Diagnosis is a
human response to healthconditions/ life processes that
currently exist in an individual,
family, or community that can be
validated by the defining
characteristics of that diagnosticcategory.
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Risk Diagnosis human
responses of an individual , familyor community and is supported
by risk factors that contribute to
increase vulnerability
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Certain physiological complicationsthat nurses monitor to detect their
onset or changes in status.
Manage by nurses using physician
prescribed and nursing prescribed
interventions to minimizedcomplications.
COLLABORATIVE PROBLEMS
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The Definitive Treatment for
Nursing Diagnosis is developed bythe nurse;
The Definitive Treatment for
Collaborative Problem is developed
by both the nurse and the
physician
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SUBJECTIVE DATA OBJECTIVE DATA
DESCRIPTION Data elicited and
verified by theclient
Data directly or indirectly
observed throughmeasurementSOURCES Client,
Family and
significantothers, Client
record,
Other health
care
professionals
Observations and physical
assessment findings of the
nurse or other health careprofessionals,
Documentation of assessments
made in client record.
Observation made by the
clients family or significant
others.
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SUBJECTIVE DATA OBJECTIVE DATA
METHODS
USED TO
OBTAIN DATA
CLIENT INTERVIEW Observation and Physical
ExaminationSKILLS
NEEDED TO
OBTAIN THE
DATA
INTERVIEW,
THERAPEUTIC
COMMUNICATION
SKILLS,
CARING ABILITYAND EMPATHY,
LISTENING SKILLS
INSPECTION
PALPATION
PERCUSSIONAUSCULTATION
EXAMPLES I have a headache
It frightens meI am not hungry
Respiration 16 per minute
BP 180/100, apical pulse 80
and irregular
X-ray firm reveals fractured
pelvis.
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WELLNESS ACTUAL RISK
CLIENTSTATUS
Human responsesto levels of
wellness that
have a readiness
for enhancement
Human responsesto health
conditions/life
processes that
exist
Human responsesthat may develop in
a vulnerable
individual, family or
community
FORMAT Readiness for
Enhanced ..
Nursing Diagnoses
and related to
clause
Risk for
COMPARISSON OF WELLNESS, RISK AND ACTUAL NURSING DIAGNOSES
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WELLNESS ACTUAL RISK
EG Readiness for
enhanced bodyimage.
Disturbed body image
related to wound onhand that is not healing
Risk for Disturbed
Body Image
Readiness for
enhanced Family
Process
Dysfunctional Family
Processes: Alcoholism
Risk for
Interrupted
Family Processes
Readiness for
Enhanced
Effective Breast
Ineffective Breast
Feeding related to poor
mother-infant
attachment
Risk for
Ineffective Breast
Feeding
Feeding
Readiness for
Enhanced Skin
Integrity
Impaired Skin integrity
related to immobility.
Risk for Impaired
Skin Integrity
COMPARISSON OF WELLNESS, RISK AND ACTUAL NURSING DIAGNOSES
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Examples of Medical Diagnoses, Nursing Diagnoses and
Collaborative Problems
MEDICAL COLLABORATIVE NURSING
FRACTUREDJAW
Potentialcomplication for
aspiration
Altered Oral mucousmembrane related to
difficulty with hygiene
secondary to fixation
devices
DIABETES
MILLITUS
Potential
Complication:
Hyperglycemia
Impaired skin integrity
related to poor circulation
to lower extremities
PNEUMONIA PotentialComplication:
Hypoglycemia,
Hypoxymia
Ineffective AirwayClearance related to
presence of excessive
mucus production
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GUIDELINES FOR OBTAINING A
NURSING HEALTH HISTORY
Phases of the Nursing Interview
Communication process that focuses on the
clients developmental, psychological, physiologic,
socio-cultural, and spiritual response that can betreated with nursing and collaborative
interventions.
INTRODUCTORY PHASE
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Phases of the Nursing Interview
INTRODUCTORY PHASE
Introduce yourself
Describe your role
Explain the purpose of interview
To collect data, to identify needs, to plan nursing care
Explain the purpose of note taking, confidentiality
and the type of questions to be asked. Provide comfort, privacy and confidentiality.
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Phases of the Nursing Interview
WORKING PHASE
Facilitate the clients comments about major
biographical data
Reasons for seeking health care, and
Functional health pattern responses.
Use: Critical Thinking Skills: observe cues, interpret
and validate information.Collaborate with the client to identify problems and
goals.
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Phases of the Nursing Interview
SUMMARY AND CLOSURE PHASE
Summarize information obtained during the
working phase and validate problems and goals
with the client.
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ASSESSMENT: STEP ONE
IN NURSING PROCESSPhases Title Description
1 ASSESSMENT Collecting subjective and objective Data
2 DIAGNOSIS Analyzing subjective and objective data to make
professional nursing judgment (nursing diagnosis,collaborative problems, referral)
3 PLANNING Determining outcome criteria and developing a
plan
4 IMPLEMENTATION Carrying out the plan
5 EVALUATION Assessing whether outcome criteria have been
met and revisiting the plan as necessary.
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TYPE OF ASSESSMENT
Initial comprehensive assessment
Ongoing or partial assessment
Focused or problem oriented assessment Emergency Assessment
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