Health Assessment

1. Health Assessment Patrick Heyman, PhD, ARNP

2. Patrick Heyman, PhD, ARNP • B.S. from Palm Beach Atlantic • BSN, MSN, PhD from University of Florida • Board Certified Nurse Practitioner • Worked in both hospital and outpatient settings • Also teach Ballroom and Latin dancing • Missionary kid, grew up in Liberia, Costa Rica, and Uruguay

3. Wholistic Assessment and Documentation

4. Health Assessment • What is Health? • Medical Model • Functional Model • Wellness Model • System Stability • Homeostasis – dynamic balancing • Allostasis

5. Assessment • Nursing Process • Assessment • Diagnosis • Planning • Implementation • Evaluation

6. Neuman Systems Model • Person Variables • Physiological • Psychological • Socio-cultural • Developmental • Spiritual

7. Wholistic Assessment • Humanistic • Reductionistic vs. Wholistic • Five Person Variables • Perception of Nurse and Patient

8. Documentation • Legal record • If you don’t document it, you didn’t do it • HIPPA • When turning in assignments regarding real patients, use patient’s initials only. • If making a copy of part of a chart for reference for an assignment, obscure identifiers.

9. Kinds of Data • Datum – piece of information • Database – Collection of all data concerning a patient • Subjective data • Symptoms • Objective data • Signs

10. Documentation Considerations • Narrative vs. Charting by exception • Appropriate use of abbreviations • Appropriate use of medical terminology • Models • H&P • SOAP: subjective, objective, assessment, plan • DAR: data, action, response • DARP: data action, response, plan

11. Talking to the Patient

12. Basic Interviewing Technique • Building Rapport • Be yourself, but not too much of yourself • Use discretion • Present • Interest • Competence • Confidence • Do not present • Apathy • Diffidence • Arrogance

13. Basic Interviewing Techniques • Dress • Professional • Not imposing • Patient Centric Interview • Open ended questions • Empathy – Not Sympathy • Provider centric

14. Basic Interviewing Techniques • Interviewer centric • Use of silence • Time • Attention • Schedule

15. Interviewing Stages • Introduction • Establish who you are • Establish agenda • Working Phase • Patient centric • Provider Centric • Conclusion • Provide closure • Establish a plan

16. Introductory Script • Hello, Mr. Smith? • My name is ________. • I am a ________. • I am here to __________. • I just need to verify your id bracelet. • Do you have any questions for me before we begin.

17. Cultural Considerations • Culture - A complex pattern of shared meanings, behaviors, and beliefs, that are learned and acquired by a group of people. • Characteristics • Learned from birth through socialization and language • Adapted to specific conditions • Dynamic • Shared by in common

18. Related words • Subculture • Ethnocentrism • Prejudice • Stereotype • Discrimination

19. Cultural Values • Dominant Value Orientation • Innate Human Nature • Relationship to nature • Time Dimension • Purpose of Existence • Family • View of Health and Illness • Family relationships • Communication patterns

20. View of Health and Illness • Freedom from disease • Able to go to work • Feel good • Pathogenesis • Biomedical • “Naturalistic” • Magico-Religious

21. Family relationships • Who makes decisions • Who counts as family • Loyalty to the family

22. Communication patterns • Language • Dialects, slang, and vague language • Conversational style • Silence

23. Communication Patterns • Nonverbal • Eye contact • Posture • Personal space • Response to touch • Orientation to time • Expression of symptoms • Stoic • Expressive