Health History

HEALTH  Past medical history

ASSESSMENT (N024-  Past physical issues

25)  Past psychological issues

 Social history
Chapter 1
 Cultural history
Introduction to Health
 Spiritual beliefs
Assessment
 Environmental influences
HEALTH
 Developmental level
 Relative state in which a person is
able to live to his or her potential. Physical Examination
 Includes the “7 Facets”  Structured head-to-toe examination
 Is not solely the absence of disease
or eating right  Identify changes in patient’s body
systems

The “7 Facets” of Health  Unusual or abnormal findings may

support history data or trigger new
questions
 Document all findings in a clear,
concise manner
 Collate all information with medical
records
The Nursing Process
 The overall goals:
o Extrapolate the findings

o Prioritize the findings

o Formulate the plan of care

o Implement the plan of care

Health Assessment #1
 Definition: The processes used to
evaluate the health status of a person
 Asking pertinent questions to gather
data
Purpose of Health Assessment
 Determine a patient’s health status
 Determine the patient’s risk factors
 Determine the need for health education

 Consists of:  Develop a nursing plan of care

o Comprehensive health history

o Complete physical examination

Health Assessment #2
 Every person needs to have a complete
assessment
 Ideally done on admission
 Circumstances may delay the
completion; should be completed once
situation allows
o A critically ill patient coming into
the ER—wait until patient is
stable to complete
o A patient with a professional
relationship with the nurse—just
need updates
o A patient with dementia may
require supplementation from
family
Nursing vs. Medical Assessments
 Nursing
o Focus on diagnoses and
treatment of the actual or
potential human responses
o Identifies many contributing
factors to the individual’s health
and wellness
 Medical
o Focus is on the diagnoses and
treatments of the disease
Health Care Team
 Nurse
 Physician
 Nutritionist
 Social worker
 Physical therapist
 Occupational therapist
 Speech therapist
 Dentist
Health Assessment #3
 Nurse detects areas of concern
requiring immediate attention
 Nurse uses findings to decide the areas
that take precedence
 Health promotion and disease
prevention are essential areas of patient
education
Additional Components
 Individual’s personality and attitude
 Resilience
 Family dynamics
 Access to healthcare and resources
 Nutrition
 Exercise
 Culture
 Beliefs
Healthy People 2020
 Framework that identifies risk factors,
health issues, and diseases of concern
in the United States
 Goals and objectives serve to improve
the health of individuals and
communities
 Overall goal is to increase quality of life
by creating guidelines for healthy
lifestyle
 Promotes health and disease prevention
as it impacts the quality and length of a
person’s life
 Data provided by U.S. Department of
Health and Human Services
(www.healthypeople.gov)
The Role of the Nurse #1
Role of the Nurse #2
 Use findings and decide in which areas
patient needs the most care
 Deliver care across the lifespan
 Promote health and prevent disease
 Educate and counsel individuals,
families, groups, and communities
 Determine what affects the patient’s
health
 Focus on health and goals of the patient
Role of the Nurse #3
 Oversee the holistic care of each patient
 Collect data
 Make judgments that will impact patient
safety and quality of care
 Identify what is important on a daily
basis for each patient
 Carefully watch and listen to the patient
to determine what additional questions
to ask
 Watch for subtle changes in the patient
Role of the Nurse #4
 Rely on assessment skills
 Use the “7 Facets” to assess the
patient
 Use information detected in assessment
to work with the patient to enhance
quality of life
 Learn to detect a change in patient to
enable providing best care
 Take advantage of teaching
opportunities that present with the
patient and family
 Continually reassess the patient for
changes in order to achieve the best
results
Chapter 2
Critical Thinking in
Health Assessment
The Nursing Process
 Set a goal
 Develop an action plan
 Implement the plan
 Evaluate the outcome
Types of Patient Data
 Subjective—Symptoms
o What patient tells you
o History
o Chief complaint
o Review of systems
 Objective—Signs
o What you see
o Physical examination
o Laboratory reports
o Radiologic findings
Examples of Patient Data
 Mrs. G is a 54-year-old hairdresser who
reports pressure over her left chest “like
an elephant sitting there” which radiates
to her left neck and arm.
 Mrs. G is an older, overweight white
female, who is pleasant and
cooperative. Height 5’4”, weight 150 lb.
BMI 26, BP 160/80 right arm, sitting, HR
96 and regular, respiratory rate 24 and
regular, temperature 97.5˚F oral.
Subjective Data #1
  OLD CART o Any interventions the patient has
previously tried
o Onset
Nursing Process #1
o Location
 Broad systematic framework
o Duration
 Provides methodical base
o Characteristic symptoms
 Problem-solving approach addresses
o Associated manifestations human response, needs of patient,
o Relieving factors family, and community
Nursing Process #2
o Treatment
 ADPIE
Subjective Data #2
o Assessment
 Onset
o Diagnosis
o When did the sign or symptom
begin? o Planning
 Location o Implementation
o Where is the sign or symptom o Evaluation
located?
Assessment
 Duration
 Gathering subjective and objective data
o How long has the sign or
symptom been going on?  Instrumental in devising a care plan

Subjective Data #3  Key points and relevant pieces of

 Characteristic symptoms
o What the symptom feels like; how
it is described; what is the
severity?
information are clustered together
 Preliminary problem list is formulated
 Assessment phase continues
throughout entire patient encounter

 Associated manifestations Diagnosis

o What else is happening when the  Based on real or potential health

problems or human responses to health
patient experiences these sign(s)
problems
or symptom(s)?
 Based on assessment data and patient
Subjective Data #4
problem list
 Relieving factors
 Sets stage for remainder of care plan
o Anything the patient has tried to
Planning
relieve the symptom
 Devise the best course of action to
address patient’s diagnoses
 Nurse and patient select goals for each
 Treatments diagnosis
  Set short-term goals (STG) and long-  Test the hypotheses and establish a
term goals (LTG) working nursing diagnosis
 Be realistic Develop a plan agreeable to the patient
 Work with patient’s goals, economic Identify Abnormal or Positive Findings
means, competing responsibilities, and
 Make a list
family structure and dynamics
o Patient’s symptoms
Implementation
 Can be completed by patient, family, or o Observed signs
health care team  Identify the positive responses
 Clearly relate to nursing diagnosis and Cluster the Findings
planned goals
 Group complaints with area in body
 Individualized for each patient
 Include information on stress level
 Modified as changes occur
 Be specific
 Support positive outcomes
 Localize symptoms and signs, if
Evaluation possible
 Continuing process to determine if goals  Include any psychosocial issues
have been attained
Interpret the Findings
 Based on patient’s condition
 Patient problems can stem from different
 Goals are realistic or appropriate causes:
 Ongoing process o Disease processes
 Confirms that nursing care is relevant o Relationships
Assessment and Diagnosis: o Nutritional
The Process of Clinical Reasoning
o Immunologic
 Three types of reasoning for clinical
problem solving: o Infectious
o Pattern recognition o Congenital
o Development of schemas o Many more
o Application of relevant basic and Make Hypotheses
clinical science
 Nature of the patient’s problem
Steps in Clinical Reasoning
 Continue learning about patterns of
 Identify abnormal or positive findings abnormal diseases and issues
 Cluster the findings  Consult clinical literature
 Interpret the findings  Evidence-based decision making
 Make hypotheses about the nature of
the patient’s problem
  As broader knowledge and experience o Order of priority
are gained, you will begin to develop
highly specific hypotheses o Separate lists for active and
inactive problems
Nursing Diagnoses
o Assign each problem a number to
 Based primarily on: be referenced in health record
o Changes in person’s life  Use list to check status of problems in
o Altered processes future visits
 Allows other health care team members
o Specific causes
to review patient status
 Complaints may not fall neatly into these
Sample Problem List
categories
Date Problem Problem
 May be related to stressful events
Entered No.
Health Maintenance 1/12/16 1 Headaches
2 Evaluated blood
 Immunizations pressure
 Screening measures 3 Overweight
4 Family stress
 Nutrition instruction 5 Tobacco use
since age 18
 Self-screening examinations 6 Low back pain
 Exercise 7 Health
maintenance
 Seat belt use 8 Occasional
incontinence
 Responding to important life event
9 History of right
Develop a Plan pyelonephritis
10 Varicose veins
 Must be agreeable to patient
 Develop and record plan for each The Challenges of Clinical Data #1
problem
 Cluster data into single versus multiple
 Specify what steps are needed problems
 Share assessment with patient o Age
 Ask the patient for his or her opinion o Timing
 Patient should always be an active o Different body systems
participant of plan
o Multisystem conditions
 Adapt and change as problems change
The Challenges of Clinical Data #2
Generating Problem List
 Sifting through an extensive array of
 List the most active and serious problem
data
first and record date of onset
 No specific method
 o Pull out separate clusters of
observations and analyze one
cluster at a time
o Ask a series of key questions to
guide in a specific direction
The Challenges of Clinical Data #3
 Assessing the quality of the data
o Subject to error
o Ask open-ended questions
o Listen carefully
o Follow “yes” answers with “OLD
CART”
o Keep an open mind
o Always include worse-case
scenario
o Confer with colleagues to clarify
uncertainties
Evaluating Clinical Findings #1
 Reliability
o Do repeat measurements of the
same relatively stable
phenomenon give the same
results?
 Validity
o Does the given observation agree
with “the true state of affairs”?
Evaluating Clinical Findings #2
 Sensitivity
o When the sensitivity of a
symptom or sign is high, a
negative response rules out the
target disorder.
o “SnNout”
 Specificity
o When the specificity is high, a
positive test result rules in the
target disorder.
o “SpPin”
Lifelong Learning: Integrating Clinical
Reasoning, Assessment
Chapter 3
Interviewing and
Communication
Introduction
 Primary goal: improve the well-being of
the patient
 Threefold purpose:
o Establish a trusting and
supportive relationship
o Gather information
o Offer information
Process of Interviewing
 Health history format
o Structured framework for
organizing patient information in
written or verbal form
o Focuses on specific kinds of
information
 Interviewing process
o Demands effective
communication and relation skills
 o Need ability to elicit accurate
information
o Need interpersonal skills to
respond to patient’s feelings and
concerns
Phases of the Interview
 Pre-interview: set the stage
 Introduction: put patient at ease,
establish trust
 Working: obtain patient information
 Termination
Phase 1: Pre-interview #1
 Take time for self-reflection
o Be consistently respectful and
open
o Continual part of professional
development
 Review the medical and nursing records
o Helps gather information and
make plans
o Provides valuable information of
past history
o Be careful to avoid bias or
preventing new treatments or
approaches
Phase 1: Pre-interview #2
 Set goals for the interview
o Before meeting patient, clarify
goals
o Must balance these provider-
centered goals with patient-
centered goals
 Review clinical behavior and
appearance
o Nurse sends messages to patient
through words and behavior
o Remain calm and unhurried
o Keep the patient’s perspective in
mind to build trust
Phase 1: Pre-interview #3
 Adjust the environment
o Private and comfortable
o Part of the nurse’s job is to make
adjustment.
 Take notes
o Jot down short phrases, specific
dates, and words
o Maintain good eye contact
o Do not let note-taking, or written
or electronic forms distract you
from the patient
Phase 2: Introduction #1
 Greet the patient and establish rapport
o First impressions
o Greet patient by name and
introduce self
o Use formal title to address patient
o Acknowledge any visitors in room
o If visitors are in the room, you are
obligated to maintain patient
confidentiality; ask patient’s
permission to continue with
visitors present
o Cultural differences
Phase 2: Introduction #2
 Establish agenda
o Presenting problem/chief
complaint
o Open-ended questions
o First problem may not be the
most important one
 o Identify all concerns at beginning  Expand and clarify the patient’s story
of interview
o Use the patient’s words

o Use plain English words, not

medical jargon
Phase 3: Working Phase #1 o Establish the sequence and time
 Invite the patient’s story course

o Use a non-focusing approach to o Move back and forth from open-

tell story ended questions to increasingly
focused questions, back to open-
o Do not inject new information ended question
o Do not interrupt o Cover the seven attributes of a
symptom
o Use active listening skills
Seven Attributes of a Symptom
o Follow the patient’s leads
 OLD CART
o Use a focusing approach to
explore patient’s story in more o Onset
depth o Location
Phase 3: Working Phase #2
o Duration
 Identify and respond to the patient’s
o Characteristic symptoms
emotional cues
 Offer clues of concerns o Associated manifestations

 Respond immediately when you hear o Relieving/exacerbating factors

emotional cues o Treatment
o N – naming  OPQRST
o U – understanding o Onset
o ReS – respecting o Palliating/Provoking factors
Clues to the Patient’s Perspective on Illness o Quality
 Direct statement(s) o Radiation
 Expression of feelings about the illness
o Site
 Attempts to explain or understand
o Timing
symptoms
Phase 3: Working Phase #4
 Speech clues
 Sharing a personal story
 Generating and Testing Diagnostic
Hypotheses
 Behavior clues
Phase 3: Working Phase #3

Phase 3: Working Phase #5
 Create a shared understanding of the
problem
o Explore deeper meanings
patients attach to their symptoms
o Disease/Illness distinction model
 Disease: explanation the
nurse brings to the
symptoms
 Illness: how the patient
experiences the disease
Explore the Patient’s Perspective
 FIFE
o Feelings: including fears or
concerns about the problem
o Ideas: about the nature and
cause of the problem
o Function: the effect on the
patient’s life
o Expectations: of the disease,
health care team, or health care,
based on prior experiences
Phase 3: Working Phase #6
 Negotiate a plan
o Create a complete picture of the
problem
o Basis for planning further
evaluation
o Building rapport with patient
o Develop nursing care plan
Phase 4: Termination
 Summarize important points
o Let patient know end of interview
is approaching
o Allow time for final questions
 Discuss plan
o Review plan of care
o Review follow-up
Therapeutic Communication Techniques #1
 Active listening
 Guided questioning
 Nonverbal communication
 Empathic response
 Validation
 Reassurance
 Summarization
 Transitions
 Empowering the patient
Therapeutic Communication Techniques #2
 Active listening
o Close attention to what the
patient is communicating
o Be aware of patient’s emotional
state
o Avoid drifting to next question
Therapeutic Communication Techniques #3
 Guided questioning
o Facilitate patient’s fullest
communication
o Moving from open-ended to
focused questions
 o Using questions to elicit a graded
response
o Asking a series of questions, one
at a time
o Offering multiple choices for
answers
o Clarifying what patient means
o Encouraging with continuers
o Using reflection
Therapeutic Communication Techniques #4
 Nonverbal communication
o Pay close attention to eye
contact, facial expression,
posture, head position,
movement, interpersonal
distance, placement of arms and
legs
o Match your position with the
patient’s
o Be sensitive to patient’s culture
Therapeutic Communication Techniques #5
 Empathic responses
o Identify the patient’s feelings
o Do not assume you know how the
patient is feeling; ask them
o Once you identify the feelings,
respond with understanding and
acceptance
Therapeutic Communication Techniques #6
 Validation
o Acknowledge the legitimacy of
the emotional experience
 Reassurance
o Do not provide false reassurance
o Identify and acknowledge the
patient’s feelings
o Convey information in a
competent manner
Therapeutic Communication Techniques #7
 Summarization
o Give a capsule summary of
patient’s story
o Give the patient a chance to
clarify any misunderstandings
 Transitions
o Tell patient when changing
directions during interview
o Orient patient with brief
transitional phrases
Therapeutic Communication Techniques #8
 Empowering the patient
o Evoke the patient’s perspective
o Convey interest in the person, not
just the problem
o Follow the patient’s lead
o Elicit and validate emotional
content
o Share information with patient
o Make your clinical reasoning
transparent to the patient
o Reveal the limits of your
knowledge
Adapting the Interview for Special
Patients #1
 The silent patient
o Silence has many meanings and
purposes
o Patient may be collecting
thoughts, remembering details,
deciding whether to trust you
 o Nurse should appear attentive
and give brief encouragement
o Watch patient for nonverbal cues
o Patient’s culture
o Depression or dementia
Adapting the Interview for Special Patients
#2
 The confusing patient
o Confusing array of multiple
symptoms
o Guide interview into psychosocial
assessment
o If you suspect a psychiatric or
neurologic disorder, shift to a
mental status examination
o Check responses against chart or
seek permission to speak with
family members
Adapting the Interview for Special Patients
#3
 The patient with altered capacity
o Determine “decision-making
capacity”
o Obtain patient permission to talk
to family member
o May need to find surrogate
informant or decision maker to
assist with history
o Check for durable power of
attorney for health care or a
health care proxy
o Apply same principles of
interviewing
o Always seek best-informed
source
Adapting the Interview for Special Patients
#4
 The talkative patient
o Give patient free reign for first 5
to 10 minutes
o Note patient’s culture
o Focus on what is important to the
patient
o Set limits where needed
o Do not show impatience; if time
runs out, explain need for second
meeting
o Set time limit for next
appointment
Adapting the Interview for Special Patients
#5
 The crying patient
o Crying signals strong emotions
o Offer the patient a tissue, and
allow patient to recover
o Be supportive
o Learn to accept displays of
emotions so you can support your
patients
Adapting the Interview for Special Patients
#6
 The angry or disruptive patient
o May have a reason to be angry
o May direct this anger toward
nurse
o Accept angry feelings
o Do not get angry in return
 o Validate their feelings without
agreeing with their reasons
o If overtly disruptive, alert security
staff
o Move to a more private location
Adapting the Interview for Special Patients
#7
 The Dying Patient
o Can be extremely challenging
patients
o Important to work through own
feelings concerning death
o Give patients opportunities to talk
about their illness if they want to
o Respect patient’s preference to
remain on social level
o Understand patient’s wishes
about treatment at end of life
Adapting the Interview for Special Patients
#8
 The Dying Patient (cont.)
o Ask patient about Advance
Directives, A Durable Power of
Attorney for Healthcare, or Do
Not resuscitate (DNR) status if
information is not found in
patient’s record
o Assist the patient in connecting
with local hospice care, if
applicable to the situation
Adapting the Interview for Special Patients
#9
 The interview across a language barrier
o Learn to work with qualified
interpreters
o Ensure interpreter understands
you need everything translated,
not condensed or summarized
o Family members may not
understand and give incomplete
information
o Make your questions clear, short,
and simple
o Speak directly to the patient
Working With an Interpreter:
Interpret Tool #1
 Introduction: Introduce all individuals
 Note Goals: Note goals of the interview
 Transparency: Everything said will be
interpreted
 Ethics: Use qualified interpreters, not
family members
 Respect Beliefs: Interpreter can help
serve as cultural broker and help explain
cultural beliefs
 Patient Focus: Interact with patient not
interpreter
Working With an Interpreter:
Interpret Tool #2
 Retain Control: Do not allow interpreter
and patient to take over conversation
 Explain: Use simple language and short
sentences
 Thanks: Thank the interpreter and the
patient for their time; note in chart the
interpreter’s name
Adapting the Interview for Special Patients
#10
 The patient with low literacy
o Assess the patient’s ability to
read before asking them to sign
anything
o Some patients are uncomfortable
disclosing their reading deficit
o Ask the patient to read
instructions you have written
 o Respond sensitively
Adapting the Interview for Special Patients
#11
 The patient with impaired hearing
o Deaf
 Find out the patient’s
preferred method of
communicating
 Find an interpreter or use
a written questionnaire
o Hard of hearing
 If patient uses a hearing
aid, ensure it is on and
working
 Eliminate background
noise
 Speak at normal volume
and rate
Adapting the Interview for Special Patients
#12
 The patient with impaired vision
o Blind
 Shake hands and establish
contact
 Orient patient to
surroundings
o Poor vision
 Encourage patient to wear
glasses whenever possible
 Use words because
posture and gestures may
not be seen
Adapting the Interview for Special Patients
#13
 The patient with cognitive disabilities
o If you suspect problems, pay
special attention to patient’s
schooling and ability to function
independently
o Assess sexual history
o If you are unsure about the
patient’s level of disability, make
a smooth transition to mental
status examination
o You may have to elicit history
from family members or
caregiver, show interest in patient
first
o Alternative or Augmentative
Communication (AAC)
Adapting the Interview for Special Patients
#14
 The patient with personal problems
o Patient may ask you for advice
outside the range of your clinical
expertise
o Ask patient what approaches they
have considered
o Related pros and cons
o What supports are available for
different choices
o Let patient talk through the
problem
Adapting the Interview for Special Patients
#15
 Sexuality in the nurse–patient
relationship
o Attraction is a normal human
response
o Recognize them and bring them
to conscious level
 o Any sexual contact or romantic o Focused on emergent problem
relationship with a patient is
Comprehensive or Focused?
unethical
 Comprehensive
o If patient makes advances, calmly
but firmly make it clear your o New patients in all settings
relationship is professional, not
personal o Provides fundamental and
personalized knowledge
o If behavior continues, leave room
and return with a chaperone o Strengthens nurse–patient
relationship
Ethics of Interviewing
o Provides baseline
 Ethics
o Creates platform for health
o A set of principles crafted through promotion\
reflection and discussion to
define what is right and wrong  Focused

o Medical ethics guide professional o Established patients, especially

behavior routine or urgent care visits
o Focused concerns or symptoms

 Confidentiality o Assesses symptoms restricted to

specific body system
o Paramount importance in the
nurse–patient relationship Comprehensive Adult Health History #1

o Information may only be shared  Identifying data and source of the history
with appropriate health care team  Chief complaint(s)
members
 History of Present Illness (HPI)
Chapter 4  Past history
 Family history
THE HEALTH HISTORY
 Review of systems
Types of Health History
 Health patterns
Types of Health Histories
Comprehensive Adult Health History #2
 Comprehensive Health Assessment
 Initial information
o Admission of new patient
o Date and time of history
 Focused or Problem-Oriented Assessment
o Identifying data: age, gender,
o Returning patient birth date, marital or relationship
 Follow-up History status, occupation, other as
appropriate
o Problem or treatment evaluation
 Source of history
 Emergency History
o Reliability
Comprehensive Adult Health History #3  Prescription
 Chief complaint(s)  Over-the-counter
o Make every attempt to quote the  Herbal supplements
patient’s own words.
 Vitamins/Mineral
o If there are no complaints, report supplements
goals.  Oral contraceptives
 History of present illness (HPI)  Medications borrowed
o Chronologic account of from family members or
problem(s) friends

o Onset of problem(s) Comprehensive Adult Health History #7

o The setting in which it developed  Past history: key elements (cont.)

o Any treatments o Childhood illnesses

Comprehensive Adult Health History #4  Measles, rubella, mumps,

whooping cough,
 HPI: Key elements chickenpox, rheumatic
fever, scarlet fever, polio
o Seven attributes of each principle
symptom (OLD CART or  Chronic conditions (e.g.,
OPQRST) asthma)
o Self-treatment by patient or family o Adult illnesses
o Past occurrences of the  Medical
symptom(s)
 Surgical
o Pertinent positives and/or
 Accidents
negatives from the review of
systems  Psychiatric
o Risk factors or other pertinent Comprehensive Adult Health History #8
information related to the
 Past history: key elements (cont.)
symptom
o Health maintenance
Comprehensive Adult Health History #5
 Immunizations
 Past history: key elements
 Screening tests
o Allergies
 Safety measures
 Include specific reaction
 Risk factors
 Medication, food, insects,
environmental factors  Tobacco
Comprehensive Adult Health History #6  Environmental
Hazards
 Past history: key elements (cont.)
 Substance abuse
o Medications
  Alcohol  Focus questions to distinguish use from
misuse
Alcohol and Drugs
 Adapt CAGE questions by adding “or
 Misuse of alcohol or drugs often
drugs”
contributes to symptoms.
 Ask about patterns of use
 Should routinely ask about current
and past use of alcohol or drugs,  Ask about modes of consumption
patterns of use, and family history.
 Include adolescents and older adults
in questioning.
Alcohol #1
Comprehensive Adult Health History #9
 Assess what patient considers alcohol.
 Family History
 Screening tool: CAGE
o Have you ever felt the need to
Cut down on drinking?
o Have you ever felt Annoyed by
criticism of your drinking?
o Have you ever felt Guilty about
drinking?
o Have you ever taken a drink first
thing in the morning (Eye-
opener) to steady your nerves or
get rid of a hangover?
Alcohol #2
 Positive CAGE results: 2 or more Comprehensive Adult Health History #10
affirmative answers
 Review of Systems
 If detect misuse, ask about:
o Address each body system, from
o Blackouts head to toe
o Seizures o Most questions pertain to
symptoms
o Accidents
o May uncover problems patient
o Injuries while drinking
has overlooked
o Job problems
o Do not use medical terms
o Conflicts
Review of Systems
o Legal problems  General
Illicit Drugs  Skin
  HEENT  Consciously acknowledge whatever
discomfort you are feeling. Denying
 Neck
your discomfort may lead you to
 Breasts avoid the topic altogether.

 Respiratory The Sexual History

 Cardiovascular  Determine risks for pregnancy

 Gastrointestinal  Determine risks for sexually

transmitted diseases (STDs)
 Peripheral vascular
 Sexual practices may be related to
 Urinary patient’s symptoms
 Reproductive  Sexual dysfunction may result from
 Musculoskeletal use of medication or misinformation

 Psychiatric  Be matter-of-fact in questioning

 Neurologic  Use specific language

 Hematologic  Make no assumptions about the

patient
 Endocrine
The Mental Health History
Comprehensive Adult Health History #11
 Be aware of cultural constructs
 Health Patterns
 Be sensitive to reports of mood changes
o Self-perception/self-concept or symptoms of possible depression
o Value-belief  Ask open-ended questions initially, then
o Activity-exercise move to more specific
 Ask about using psychotropic
o Sleep-rest
medications
o Nutrition
 If patient seems depressed, ask about
o Role-relationship thoughts of suicide

o Coping-stress-tolerance Family Violence #1

Guidelines for Sensitive Topics  Many authorities recommend routine

 The single most important rule is to
be nonjudgmental.
 Explain why you need to know
certain information.
 Find opening questions for sensitive
topics and learn the specific kinds of
information needed for your
assessments.
screening for domestic violence.
 Start with general questions and move
to more specific.
 If abuse is suspected, it is important to
spend part of encounter alone with the
patient.
 Do not force the situation.
 Ask parents how they cope with their
crying baby.
  Be alert to nonverbal communication.
Family Violence #2
 Physical abuse should be considered in
the following situations:
o If injuries are unexplained,
inconsistent with story,
concealed, or cause
embarrassment
o If patient has delayed getting
treatment for trauma
o If a past history of repeated
injuries or “accidents”
o If patient or person close to
patient has history of alcohol or
drug abuse
o If partner tries to dominate the
interview, will not leave the room,
or seems unusually anxious or
solicitous
Documenting the Health History
 Form of documentation is frequently
computerized
 Must be accurate and thorough
Chapter 5
Cultural and Spiritual Assessment
Culture #1
The system of shared ideas, rules, and
meanings that influences how we view the
world, experience it emotionally, and behave in
relation to other people.
Culture #2
 Is not limited to ethnic or minority groups
 Defines:
o How health care information is
received
o How rights and protections are
exercised
o What is considered to be a health
problem
o How symptoms and concerns
about the problem are expressed
o Who should provide treatment for
the problem
o What type of treatment should be
given
Cultural Assessment #1
 Refers to systematic, comprehensive
examination of individuals, families,
groups, and communities regarding their
health-related cultural beliefs, values,
and practices.
 Form foundation for the clients’ plan of
care, providing valuable data for setting
mutual goals, planning care, intervening,
and evaluating the care.
Healthy People 2020
 Goal: reduce health disparities among
ethnic or cultural groups in the United
States
 OMH created National Standards for
Culturally and Linguistically Appropriate
Services in Health and Health Care (the
National CLAS Standards)
Principle Standard
Provide effective, equitable, understandable,
and respectful quality care and services that
are responsive to diverse cultural health beliefs
and practices, preferred languages, health
literacy, and other communication needs.
Governance, Leadership, & Workforce
 Advance and sustain governance and
leadership through policy, practices, and
allocated resources
 Recruit, promote, and support diverse
governance, leadership, and workforce
that are responsive to service area
 Educate and train governance,
leadership, and workforce on an
ongoing basis
Communication and Language
Assistance
 Offer language assistance to individual
with communication needs at no cost to
them or facilitate timely access to all
health care and services
 Inform all individuals of availability of
language assistance services
 Ensure the competence of individuals
providing language assistance
 Provide easy-to-understand print and
multimedia materials in common
languages of local populations
Engagement, Continuous Improvement,
and Accountability #1
 Establish culturally and linguistically
appropriate goals, policies, and
management accountability and infuse
throughout organization
 Conduct ongoing assessments and
integrate CLAS-related measures
 Collect and maintain accurate and
reliable demographic data to monitor
and evaluate impact
Engagement, Continuous Improvement,
and Accountability #2
 Partner with community to design,
implement and evaluate policies,
practices and services
 Create conflict- and grievance-resolution
processes
 Communicate the organization’s
progress to all stakeholders,
constituents, and general public
Cultural Assessment #2
 Cultural competence: recognizes the
need for a set of skills necessary to care
for people of different cultures
 The nurse needs to see herself or
himself becoming culturally competent,
not being culturally competent.
 Cultural sensibility: a deliberative pro-
active behavior by health care providers
who examine cultural situations through
thoughtful reasoning, responsiveness
and discreet (attentive, considerate and
observant) interactions
 Cultural humility: process that requires
humility as individuals continually
engage in self-reflection and self-critique
as lifelong learners and reflective
practitioners.
Self-Reflection
 Am I aware of my biases? Prejudices?
Stereotypes?
 Am I comfortable interacting with people
from different cultures?
 Do I seek out experiences with other
cultures?
 Do I seek out opportunities to learn
about other cultures?
 Do I respect the beliefs of individuals
from other cultures?
 Do I know how to access language
interpreter services for patient?
Dimensions of Cultural Humility #1
 Self-awareness
o Learn own biases
o Explore own cultural identity
 Describe yourself
 What aspects of your
family do you identify with?
How are you different?
  How do these identities
influence your beliefs and
behaviors?
Dimensions of Cultural Humility #2
 Respectful Communication
o Work to eliminate assumptions
o Learn directly from patients
o RESPECT model
 Rapport, Empathy,
Support, Partnership,
Explanations, Cultural
competence, Trust
Dimensions of Cultural Humility #3
 Collaborative Partnerships
o Build patient relationship on
respect and mutually acceptable
plans
o Listen to and validate feelings of
anger or shame
o Reexamine own beliefs about
what is the “right approach” to
clinical care
o Be flexible and creative as shared
plans are developed
Transcultural Perspectives on the Health
History
 Knowledge of cultural or minority groups
will help you better understand and
interpret the patient’s needs.
 General precepts
o Nonverbal communication
o Silence
o Distance between patient and
interviewer
o Eye contact
o Modesty
o Use of touch
Health Assessment #1
 Communication and language
 Family structure
 Family roles and organization
 Social networks
 Educational background and learning
style
 Nutrition
Health Assessment #2
 Child-bearing and child-rearing
practices
 High-risk behaviors
 Health care beliefs and practices
 Health care practitioners
 Spirituality and religion
Health Assessment #2
 Child-bearing and child-rearing practices
 High-risk behaviors
 Health care beliefs and practices
 Health care practitioners
 Spirituality and religion
Reason for Seeking Care
 Patients may interpret symptoms per
their cultural view.
 Cultural-bound syndromes
o “Illnesses” defined by a particular
culture, but no corresponding
illness in Western medicine
 Symptoms may be attributed to actions
of another individual.
o Referral to healer of the patient’s
culture
Spiritual Assessment #1
 Spirituality: “all behaviors that give
meaning to life and provide strength to
the individual”
 Religion: a system of beliefs or a
practice of worship
 Spiritual distress may be a response
to illness or health issues.
 Must be able to recognize that a
patient has spiritual needs
 Listening is an important part of being
present with a patient.
Spiritual Assessment #2
 Nursing presence is often what patients
value most.
 Observe nonverbal cues.
 Key nursing action is to listen, not talk.
 Encourage the patient to express
feelings and concerns.
 The nurse should not offer solutions.
 Help the patient identify the problem and
resources used in the past to cope with
problems.
Stoll’s Guidelines for Spiritual
Assessment #1
 Concept of God or Deity
o Is religion or God significant to
you? If yes, can you describe
how?
o Is prayer helpful to you? What
happens when you pray?
o Does a God or deity function in
your personal life? If yes, can you
describe how?
o How would you describe your
God or what you worship?
Stoll’s Guidelines for Spiritual Assessment
#2
 Sources of Hope and Strength
o Who is the most important person
to you?
o To whom do you turn when you
need help? Are they available?
o In what ways do they help?
o What is your source of strength
and hope?
o What helps the most when you
are afraid or need special help?
Stoll’s Guidelines for Spiritual Assessment
#3
 Religious Practices
o Do you feel your faith (or
religion) is helpful to you? If
yes, would you tell me how?
o Are there any religious
practices that are important to
you?
o Has being sick (or what has
happened to you) made any
difference in your practice of
praying or religious practices?
o What religious books or
symbols are helpful for you?
Stoll’s Guidelines for Spiritual Assessment
#4
 Relation Between Spiritual Beliefs and
Health
o What has bothered you most
about being sick (or what is
happening to you)?
o What do you think is going to
happen to you?
o Has being sick (or what has
happened to you) made any
 difference in your feelings about
God or the practice of your faith?
o Is there anything that is especially
frightening or meaningful to you
now?