Health Assessment Patrick Heyman, PhD, ARNP. B.S. from Palm Beach Atlantic BSN, MSN, PhD from University of Florida Board Certified Nurse Practitioner.

Health Assessment

Patrick Heyman, PhD, ARNP

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

Wholistic Assessment and Documentation

Health Assessment

• What is Health?– Medical Model– Functional Model– Wellness Model– System Stability

• Homeostasis – dynamic balancing

• Allostasis

Assessment

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

Neuman Systems Model

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

Wholistic Assessment

• Humanistic

• Reductionistic vs. Wholistic

• Five Person Variables

• Perception of Nurse and Patient

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.

Kinds of Data

• Datum – piece of information

• Database – Collection of all data concerning a patient

• Subjective data– Symptoms

• Objective data– Signs

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

Talking to the Patient

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

Basic Interviewing Techniques

• Dress– Professional– Not imposing

• Patient Centric Interview– Open ended questions– Empathy – Not Sympathy

• Provider centric

Basic Interviewing Techniques

• Interviewer centric

• Use of silence

• Time– Attention– Schedule

Interviewing Stages

• Introduction– Establish who you are– Establish agenda

• Working Phase– Patient centric– Provider Centric

• Conclusion– Provide closure– Establish a plan

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.

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

Related words

• Subculture

• Ethnocentrism

• Prejudice

• Stereotype

• Discrimination

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

View of Health and Illness

• Freedom from disease

• Able to go to work

• Feel good

• Pathogenesis– Biomedical– “Naturalistic”– Magico-Religious

Family relationships

• Who makes decisions

• Who counts as family

• Loyalty to the family

Communication patterns

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

Communication Patterns

• Nonverbal– Eye contact– Posture– Personal space– Response to touch– Orientation to time

• Expression of symptoms– Stoic– Expressive