Last Updated:Wednesday, September 04, 2002
Holistic Approach to Health
Assessment
Unit 1.
PA Nurse Practice Act and ANA defines nursing as the diagnosis and treatment of human responses to actual and potential health problems
Mr R. is a 72-year-old man who suffered a "stroke" at home two days ago. He was admitted to your unit from the emergency room after being discovered at home today by his daughter. His condition is stable but he has very limited movement in his extremities.
He shows evidence of dehydration: decreased skin turgor, dry lips and mucous membranes, low urinary output.
Height: 5" 10" Weight: 138 lbs
He is on bedrest and IV fluids.
What do we need to know?
He shows evidence of dehydration: decreased skin turgor, dry lips and mucous membranes, low urinary output.
Height: 5" 10" Weight: 138 lbs
He is on bedrest and IV fluids.
How will we answer these questions and create a systematic plan of care for Mr. R ?
Holistic Health Care
Holisitic
Encompasses many domains:
- sociocultural
- spiritual
- psychological
- sexual
- family/roles
- physical
- health beliefs
- ethical/advanced directives
Mr R. is a 72-year-old man who suffered a "stroke" at home two days ago. He was admitted to your unit from the emergency room after being discovered at home today by his daughter. His condition is stable but he has very limited movement in his extremities.
He shows evidence of dehydration: decreased skin turgor, dry lips and mucous membranes, low urinary output.
Height: 5" 10" Weight: 138 lbs
He is on bedrest and IV fluids.
How will we answer these questions and create a systematic plan of care for Mr. R ?
Nursing Process
5 steps
- Assess
- Diagnose
- Plan
- Implement
- Evaluate
OK, so we need data.
How do we get it ?
Where do we start?
Go through the process of assessment
Assessment
1. nursing history
2. physical examination
3. review records and literature
4. consultation
1. Health History
"conversation with a purpose"
Bates Why is it important?
- establish rapport, begin trusting relationship
- assess pt within the context of their life, as a whole person (holistic)
- assess functional status
- done during many phases of patient care
complete Hx may not be possible or appropriate
Scope and focus of Health History
Scope and focus of Health History varies according to pts agenda and problem clinician’s goals clinical setting
- Complete health history
- Interval health history
- Problem focused or chief complaint
As Bates says, while listening to pts story, you generate a series of hypotheses about nature of the pts complaint/concerns.
You test these hypotheses by asking for more detailed information as
appropriate.
Positive finding = more detailed questioning and assessment
- Most institutions have a nursing history or nursing admission form
- There is some organizing framework
- systems
- Gordon’s functional health patterns
- preprinted forms
- computer
- include pts perception of current health status and its meaning to pt and others
- Use interpersonal skills, communication techniques to conduct interview, obtain nursing health history
- Examples ???
- Be aware of nonverbal communication including your own!
Does the pt have the right to refuse to answer questions?
Maintain confidentiality
Components of Nursing History
Biographical information reasons for seeking health care (CC) present illness, health concern (HPI) past health history (PMH) current health status/lifestyle family history (genogram) personal/social history review of systems (ROS)
Health History
"My foot hurts."
"It feels like an elephant is sitting on my chest."
Components
7 attributes of a symptom
- location
- quality
- quantity/severity (scale)
- timing
- setting
- aggravating and alleviating factors
- associated manifestations
Past Health History (PMH)
perception of their history
Current Health Information
(Personal/Social history)
- Habits
- Drugs:
- etoh
- smoking (pack/years)
- illegal drugs
- caffeine
- Medications
- Rx
- OTC
Current Health Information (Personal/Social history)
- Exercise/Diet
- Sleep patterns
- Immunizations
- Allergies
- Screening tests
e.g. Pap smear, mammogram
BSE, TSE, colonoscopy
especially elderly Independent, need help, dependent ?
"Tell me about your day yesterday."
Physical abuse
Child abuse
Family Health History
2. Physical Examination
Techniques of Physical Assessment
And then remember the Dick-and-Jane books and the first word you learned - the biggest word of all -
Look
deliberate visual exam
gather data with hands via sense of touch
feel skin and underlying tissue to detect/describe:
temp, texture, vibration, pulsation
mass,size, consistency, tenderness
tap body surfaces to produce
vibration and sound
listen to sounds produced by body
heart, lung , bowel sounds, BP
Review of Systems
Review of Systems
Skin, Head, Neck
Ears, Nose, Mouth, Throat and Sinuses
Eyes
Breast
Abdomen/GI
Thoracic/Respiratory
Cardiovascular
Musculoskeletal
Neurologic
GU *
Holistic/Psychosocial assessment includes...
- Developmental
- Cultural
- Spiritual
- Sexual
Developmental Assessment
- assumes progression, stages
Why do we want to know if someone is age/stage appropriate?
Why do we want to know if someone is age/stage appropriate?
- forms a basis for holistic care
- provides benchmarks, helps us organize
- helps us plan care and pt/family teaching
- people in crisis may regress
Developmental Assessment
Infancy- birth to 12 months
Toddler 1- 3 years
Preschool 3- 6
School age 6- 12
Adolescence 13-20
Young adult 20 to 30-35
Middle adult 30-35 to 65-70
Late adult 65-70 to 95+
Erikson’s Eight Stages
of Development Stage Task Threat
(Developmental Milestones)
Infant Trust Mistrust
Toddler Autonomy Shame,doubt
Preschooler Initiative Guilt
School age Industry Inferiority
Adolescent Identity Confusion
Early adult Intimacy Isolation
Middle " Generativity Selfabsorption
Late " Integrity Despair
Piaget’s Stages Sensorimotor 0 - 2 physical objects
of Cognitive Development
Preoperational 2 - 7 symbols,language
Concrete ops 7 -11 abstract,
relationships
Formal ops 11-15 logical thought
Cultural Considerations
Spiritual Considerations
Specific questions
1995 study published in the Journal of Psychosomatic Medicine examined factors that correlated with successful coronary artery bypass surgery. Researchers found that the degree of religious faith and spiritual meaning in patient’s lives was the single best predictor of survival of surgery.
Referenced in
Dossey, B. & Dossey, L. (1998). Attending to holistic care. American Journal of Nursing,98(8), 35-38.
Sexual considerations
1. Health History
2. Physical Exam
3. Review
diagnostic test results, medical records
literature
4. Consult with other HCP
After you establish a data base through assessment, you:
Nursing Orders
Mr R. is a 72-year-old man who suffered a "stroke" at home two days ago. He was admitted to your unit from the emergency room after being discovered at home today by his daughter. His condition is stable but he has very limited movement in his extremities.
He shows evidence of dehydration: decreased skin turgor, dry lips and mucous membranes, low urinary output.
Height: 5" 10" Weight: 138 lbs
He is on bedrest and IV fluids.
What are some possible patient problems?
What are the appropriate nursing diagnoses?
P: high risk for impaired skin integrity
E: immobility, dehydration
Goal:
TPW maintain intact skin.
Expected Outcomes: The pt will
1. change position every 2 hours
2. avoid pressure on bony prominences
3. maintain clean, well-hydrated skin
4. Drink 1000 cc liquid/24 hours 7 - 3 500 cc 3 - 11 400 cc 11- 7 100 cc
Expected Outcomes: The pt will
1. change position every 2 hours
2. avoid pressure on bony prominences
3. maintain clean, well-hydrated skin
4. Drink 1000 cc liquid/24 hours 7 - 3 500 cc 3 - 11 400 cc
11- 7 100 cc
Nursing Orders ?
1.TNW
2.
3.
4.
Goal:
TPW maintain intact skin.
Expected Outcomes: The pt will Nursing Orders: The nurse will:
1. change position every 2 hours
2. avoid pressure on bony prominences
3. maintain clean, well-hydrated skin
4. Drink 1000 cc liquid/24 hours 7 - 3 500 cc 3 - 11 400 cc
11- 7 100 cc
Scientific Rationale ? Evaluation ?
You’ve got it!
Questions ?
Comments ?
What do we mean by
VITAL SIGNS?, TPR, BP
What do you remember about taking VITAL SIGNS?