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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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