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