Health Assessment

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Health Assessment

• Patrick Heyman, PhD, ARNP

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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

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Wholistic Assessment and Documentation
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Health Assessment

• What is Health?
• Medical Model
• Functional Model
• Wellness Model
• System Stability
• Homeostasis dynamic balancing
• Allostasis

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Assessment

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

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Neuman Systems Model

• Person Variables
• Physiological
• Psychological
• Socio-cultural
• Developmental
• Spiritual

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Wholistic Assessment

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

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Documentation

• Legal record
• If you dont document it, you didnt do it
• HIPPA
• When turning in assignments regarding real
  patients, use patients initials only.
• If making a copy of part of a chart for reference
  for an assignment, obscure identifiers.

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Kinds of Data

• Datum piece of information
• Database Collection of all data concerning a
  patient
• Subjective data
• Symptoms
• Objective data
• Signs

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Documentation Considerations

• Narrative vs. Charting by exception
• Appropriate use of abbreviations
• Appropriate use of medical terminology
• Models
• HP
• SOAP subjective, objective, assessment, plan
• DAR data, action, response
• DARP data action, response, plan

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Talking to the Patient
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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

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Basic Interviewing Techniques

• Dress
• Professional
• Not imposing
• Patient Centric Interview
• Open ended questions
• Empathy Not Sympathy
• Provider centric

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Basic Interviewing Techniques

• Interviewer centric
• Use of silence
• Time
• Attention
• Schedule

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Interviewing Stages

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

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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.

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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

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Related words

• Subculture
• Ethnocentrism
• Prejudice
• Stereotype
• Discrimination

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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

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View of Health and Illness

• Freedom from disease
• Able to go to work
• Feel good
• Pathogenesis
• Biomedical
• Naturalistic
• Magico-Religious

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Family relationships

• Who makes decisions
• Who counts as family
• Loyalty to the family

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Communication patterns

• Language
• Dialects, slang, and vague language
• Conversational style
• Silence

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Communication Patterns

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