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2015 NURS1004 Physical Dimensions of Being Human Week 7 Health assessment workshop report Learning objectives: Demonstrate beginning interviewing skiils whilst obtaining a health history of a fellow student. Demonstrate active listening skills required when undertaking a health history interview of a fellow student. Demonstrate the skills required to obtain vital signs including documentation on appropriate forms. Describe the skills required to validate data obtained from the health history interview and vital signs data collection. List and describe the psychosocial lifespan considerations for the pre-schooler and the primary school age child. Please view the following videos and answer the questions below before attending the session: Techniques of Interviewing Topic 1.2 Nursing Health Assessment Video Series Walters Kluwer| Lippincott Williams and Wilkins Health History Taking Topic 1.3 Nursing Health Assessment Video Series Walters Kluwer| Lippincott Williams and Wilkins Validating documenting & analysing data Topic 1.5 Nursing Health Assessment Video Series Walters Kluwer| Lippincott Williams and Wilkin. After watching the videos complete the following questions: 1. Primary data is described as: 2. Data collected from a previous assessment is classed as Primary or secondary data? 3. What is the difference between a sign and a symptom? 4. What does each letter of the mnemonic OLDSCART stand for? 5. List three pieces of information that from part of the past medical history for the person. 6. Assessment of the person’s functional health patterns can reveal important information about the person’s quality of life. List the 11 functional health patterns 7. The nurse will ask questions related to Activities of daily living (ADL’s) provide insight into how the person manages everyday activities. List the ADL’s covered in the video. 8. List two benefits of electronic health records Please read the following text before attending the session: Berman et al (2015) Kozier and Erb’s Fundamentals of Nursing 3rd Australian Edn Pearson, Frenchs Forest. Source: Jarvis, C & Denmead, E (Australian adapting author) 2012, chapter 7 ‘The health history’, in Student laboratory manual for physical examination and health assessment, Australian and New Zealand edition, Saunders Elsevier, Sydney, pp. 65–73. Chapter 12 Assessing pp. 211-230 NB Box 12.1 Components of A Nursing Health History pp. 218 Activity: Performing a health history assessment on a client Using the following proforma – collect a co-student’s health history in class. Remember to use the OLDSCART mnemonic when you wish to discuss your client’s symptoms more deeply: Onset, Location, Duration, Severity, Characteristics, Associated Factors, Relieving/Aggravating factors, Treatment. The health history Date ................................................................................... Interview conducted by Designation ................................................... ...................................................................... Medical Record Number ..................................................... 1. Biographical data Name .............................................................................................................................................................................................. Address .......................................................................................................................................................................................... Contact phone Date of birth ............................................................. .................................................................. ......................................................................................... Age ................ Occupation Gender ..................................... Mobile phone Birthplace .................................................................................. ........................................................................................ .......................................................................................................... Marital status .................................................................................. ...................................................................................................................................................................................... Employer ........................................................................................................................................................................................ Nationality ................................................................................................... Medicare number Interpreter required? ........................................... ............................................................................................................................................................................ Private Heath Fund Details Advanced care directive? ....................................................................................................................................... Details: .......................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... 2. History obtained from ................................................................................................................................................................... 3. Reason/s for seeking care ............................................................................................................................................................ .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... 4. Present health or history of present illness ................................................................................................................................ .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... Page 2 of 7 5. Past health General health ................................................................................................................................................................................ .......................................................................................................................................................................................................... Childhood illnesses ......................................................................................................................................................................... .......................................................................................................................................................................................................... Accidents or injuries ........................................................................................................................................................................ .......................................................................................................................................................................................................... Serious or chronic illnesses ............................................................................................................................................................. .......................................................................................................................................................................................................... Hospitalisations ............................................................................................................................................................................... .......................................................................................................................................................................................................... Operations ...................................................................................................................................................................................... .......................................................................................................................................................................................................... Obstetric history Gravida .............................................................................................................................................................................. .................................... Term (# Pregnancies) .................................... Preterm (# Term pregnancies) Term / Incomplete ................................... .......................................... (# Preterm pregnancies) Children Living ......................................................................................................... (# Terminations / Miscarriages) Course of pregnancy ....................................................................................................................................................................... .......................................................................................................................................................................................................... (Date delivery, length of pregnancy, length of labour, baby’s weight and sex, vaginal delivery / caesarean section, complications, baby’s condition) Immunisations Tetanus Current Select ................................................................................................................... Influenza Current Select ................................................................................................................... Pneumococcus Current Select ................................................................................................................... Other ............................................................................................................................................................................... ........................................................................................................................................................................................... Last GP visit date ............................................................................................................................................................................ Health Screening Dentist ...................................................................... Vision ................................................................................... Hearing ..................................................................... ECG ................................................................................... CXR ..................................................................... Other ................................................................................... Allergies: Allergens and reaction – allergy bracelet applied Drugs / medications Food Select ........................................................................................... ......................................................................................................................................................... ............................................................................................................................................................................... Latex / other Comments .................................................................................................................................................................... ....................................................................................................................................................................... .......................................................................................................................................................................................... Infection control Transmission-based precautions Notifiable disease ..................................................................................................................................... ............................................................................................................................................................ 6. Family history Heart disease .................................................................................................................................................................................. High blood pressure Stroke Diabetes ........................................................................................................................................................................ ............................................................................................................................................................................................. ......................................................................................................................................................................................... Blood disorders ............................................................................................................................................................................... Breast cancer .................................................................................................................................................................................. Cancer (other) ................................................................................................................................................................................. Sickle cell Arthritis ........................................................................................................................................................................................ ........................................................................................................................................................................................... Page 3 of 7 Allergies ........................................................................................................................................................................................... .......................................................................................................................................................................................................... Asthma ........................................................................................................................................................................................... Obesity ........................................................................................................................................................................................... Alcoholism ...................................................................................................................................................................................... Mental illness .................................................................................................................................................................................. Seizure disorder .............................................................................................................................................................................. Kidney disease ................................................................................................................................................................................ .......................................................................................................................................................................................................... Tuberculosis Other ................................................................................................................................................................................... ............................................................................................................................................................................................... Review of symptoms, function and risks Include both past health problems that have been resolved and current problems, including date of onset. 7. General overall health and wellbeing Perception of health ........................................................................................................................................................................ .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... Interpersonal relationships / resources ............................................................................................................................................ Education (last level achieved) Current employment Family role? ........................................................................................................................................................ ..................................................................................................................................................................... Support systems? ............................................................................................................................................................ Values and beliefs / spiritual resources Cultural background .................................................................................................................................................. Religious / spiritual beliefs Coping and stress management Stressors in life? ............................................................................................................................................ ........................................................................................................................................................ Cultural health practices ............................................................................................................................................... ...................................................................................................................................................... .............................................................................................................................................................. Methods to relieve stress Self-concept ........................................................................................................................................ ................................................................................................................................................. .................................................................................................................................................................................... Personal strengths? ......................................................................................................................................................... Life values and belief ....................................................................................................................................................... Sleep / rest ...................................................................................................................................................................................... Sleep pattern? Aids used? ................................................................................................................................................................. ...................................................................................................................................................................... 8. Health and lifestyles management Current medications: (prescribed and OTC). Note name, purpose, dose and daily schedule. Ask specially about vitamins, oral contraceptives, aspirin, sedatives and antacids. .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... Tobacco, alcohol and recreational / street drugs Smoke cigarettes? ..................................................... Daily use for how many years Ever tried to quit? Comments Drink alcohol? ..................... ....................................... Number of packs per day Age started Succeed? ..................................................................... .......................................................................................... ............................................................................................. ....................................................................................................................................................................... ........................................................ Date last alcohol use ................................................................................ Page 4 of 7 Amount of alcohol that episode ......................................................................................................................................... Out of the last 30 days, how many days had alcohol? Ever had a drinking problem? Comments ..................................................................................................... .......................................................................................................................................... ....................................................................................................................................................................... Any use of recreational drugs? (reinforce confidentiality of information disclosed) Which ones ............................................................... Marijuana? ................................................................. Crack cocaine? ........................................................... Barbiturates? Heroin? ............................................................. .................................................................... Cocaine? ................................................................................ Amphetamines? .................................................................... LSD? ....................................................................................... Other? ................................................................................... Ever had treatment for drugs or alcohol? ........................................................................................................................... Other comments? ........................................................................................................................................................................... .......................................................................................................................................................................................................... Environmental hazards ................................................................................................................................................................... Live alone? With family? .................................................................................................................................................. Neighbourhood? .............................................................................................................................................................. Transportation? ............................................................................................................................................................... Occupational health ........................................................................................................................................................................ Worked with health hazard? ............................................................................................................................................. Health problems related to work? .................................................................................................................................... 9. Assessing activity and exercise Daily activities and effect of symptoms? Usual pattern of a typical day Ability to perform ADLs? .......................................................................................................................................... .......................................................................................................................................................... ................................................................................................................................................................. Independent or needs assistance with ADLs—select the appropriate level: Feeding Independent/Assist Bathing Independent/Assist Hygiene Independent/Assist Dressing Independent/Assist Toileting Independent/Assist Bed-to-chair transfer Independent/Assist Walking Independent/Assist Standing Independent/Assist Climbing stairs Independent/Assist Use of wheelchair, prosthesis, mobility aid? Leisure activities? .................................................................................................................................... ........................................................................................................................................................................... Exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring the body’s response to exercise) .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... Any other self-care behaviours: ....................................................................................................................................................... .......................................................................................................................................................................................................... Cardiovascular function: Praecordial or retrosternal pain Palpitation Cyanosis Dyspnoea on exertion (specify amount of exertion, e.g. walking one flight of stairs, walking from chair to bath or just talking) .......................................................................................................................................................................................................... Orthopnoea Paroxysmal nocturnal dyspnoea Nocturia Oedema History of heart murmer Hypertension Coronary artery disease Anaemia Bleeding tendency Excessive bruising Lymph node swelling Exposure to toxic agents or radiation Blood transfusion and reactions Swelling of legs (time of day, activity) Coldness, numbness and tingling ....................................................................................................................................... Discolouration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles) .......................................................................................................................................................................................................... Varicose veins or complications Intermittent claudication Thrombophlebitis Ulcers Page 5 of 7 Comments ...................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... Respiratory function: Nasal discharge and its characteristics .................................................................................................................................... Unusually frequent or severe colds Sinus pain Nasal obstruction Nosebleeds Allergies or hay fever Change in sense of smell History of lung diseases (asthma, emphysema, bronchitis, pneumonia, tuberculosis) .......................................................................................................................................................................................................... Chest pain with breathing Wheezing or noisy breathing How much activity produces shortness of breath .............................................................................................................................. Cough Sputum Haemoptysis Toxin or pollution exposure Comments Shortness of breath (colour, amount) ....................................................................... ...................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... Musculoskeletal function: History of arthritis or gout ....................................................................................................................................................... In the joints: pain, stiffness, swelling Deformity (location, migratory nature) Limitation of motion ........................................................................................... Noise with joint motion In the muscles: any pain, cramps, weakness, gait problems or problems with coordinated activities? ........................................ .......................................................................................................................................................................................................... Back pain? (location and radiation to extremities) Stiffness .................................................................................................................. Limitation of motion History of back pain History of disc disease Comments ...................................................................................................................................................................................... .......................................................................................................................................................................................................... 10. Assessing nutrition and metabolism (including skin, hair and nails) Skin: (eczema, psoriasis, hives) Sun exposure? ...................................................................................................................................................... ................................................................................................................................................................................ Hair: (loss of hair, change in texture, distribution) ............................................................................................................................ Nails: (shape and colour) ................................................................................................................................................................ Mouth, teeth and throat: .................................................................................................................................................................. Dental routine Weight: ................................................................................................................................................................................. .................. kg Recent weight loss or gain? ............................................................................................................ .......................................................................................................................................................................................................... Food and fluids in the last 24 hrs Current diet / eating habits? ..................................................................................................................................................... ............................................................................................................................................................ .......................................................................................................................................................................................................... Daily intake caffeine (coffee, tea, colas) Heartburn? .......................................................................................................................................... ...................................................................................................................................................................................... Nausea or vomiting ......................................................................................................................................................................... Liver or gallbladder disease? ........................................................................................................................................................... .......................................................................................................................................................................................................... Abdominal pain? ............................................................................................................................................................................. Endocrine dysfunction? Diabetes? ................................................................................................................................................................... ....................................................................................................................................................................................... .......................................................................................................................................................................................................... Page 6 of 7 Any other comments? ..................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... 11. Assessing renal, bladder and bowel function Voiding pattern ................................................................................................................................................................................ Frequency, urgency? Nocturia ...................................................................................................................................................................... .......................................................................................................................................................................................... Incontinence? ................................................................................................................................................................................. Fluid intake for 24 hrs Mobility to toilet? ...................................................................................................................................................................... ............................................................................................................................................................................. History of urinary system disease: .................................................................................................................................................... Kidney disease Kidney stones Urinary tract infections Prostate Pain in flank Pain in groin Pain in suprapubic region Pain in low back Comments: ..................................................................................................................................................................................... .......................................................................................................................................................................................................... Bowel function ................................................................................................................................................................................ Pattern of elimination, frequency Stool characteristics? Other comments? ..................................................................................................................................................... ...................................................................................................................................................................... ........................................................................................................................................................................... .......................................................................................................................................................................................................... 12. Assessing mental status, neurological and sensory function Mental status: Nervousness Comments: Mood change Depression ..................................................................................................................................................................................... Mental health dysfunction or hallucinations? .................................................................................................................................... Neurological function: Any head injury Dizziness (syncope) or vertigo Fainting Blackouts Motor function Tic or tremor Paralysis Coordination problems Comments: ...................................................................................................................................................................................... .......................................................................................................................................................................................................... In sensory function: Numbness and tingling (paraesthesia) Seizures? Stroke? ........................................................................................................................................................................ ........................................................................................................................................................................... Weaknesses? ................................................................................................................................................................. Memory disorders? Headaches? ......................................................................................................................................................... .................................................................................................................................................................... Eyes: Decreased acuity Blurring Blind spots Eye pain Diplopia (double vision) Redness or swelling Glaucoma Cataracts Watering or discharge Visual problems? Glasses? ............................................................................................................................................. Ears: Earaches Infections Discharge and its characteristics Tinnitus or vertigo Hearing loss Hearing aid use Page 7 of 7 How does loss affect daily life? ....................................................................................................................................................... Any exposure to environmental noise? Method of cleaning ears? Hearing difficulties? ............................................................................................................................................ ................................................................................................................................................................. ......................................................................................................................................................................... Sensory function (feet, hands) Other comments? ........................................................................................................................................................ ........................................................................................................................................................................... .......................................................................................................................................................................................................... 13. Assessing sexuality and reproductive function Breast and regional lymphatics ....................................................................................................................................................... Pain? Lumps? Discharge? Axillary tenderness? ........................................................................................................................................................ Breast awareness practices Last mammogram? Male reproductive system: .............................................................................................................................................. ............................................................................................................................................ ......................................................................................................................................................... .............................................................................................................................................................. Penis or testicular pain, lumps, discharge? Problems? ...................................................................................................................... ....................................................................................................................................................................... STI precautions? ............................................................................................................................................................. Testicular self-examination? ............................................................................................................................................. Female reproductive system: .......................................................................................................................................................... Menstrual history? ........................................................................................................................................................... Vaginal itching, discharge? Contraception? STI precautions? Pap smear? Sexual health: Any comments? .............................................................................................................................................. ................................................................................................................................................................ ............................................................................................................................................................. ..................................................................................................................................................................... ................................................................................................................................................................................. .............................................................................................................................................................................. .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... 14. Intimate partner violence: (Ask if required or if IPV suspected) How are things at home? Do you feel safe? ................................................................................................................................................................. ............................................................................................................................................................................ Have you ever been emotionally or physically abused by your partner or someone important to you? ............................................ Have you ever been hit, slapped, kicked, pushed or shoved or otherwise physically hurt by your partner or ex-partner? ................. .......................................................................................................................................................................................................... Has your partner ever forced you to have sex? Are you afraid of your partner or ex-partner? ............................................................................................................................... ................................................................................................................................... .......................................................................................................................................................................................................... Any comments? .............................................................................................................................................................................. .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... Summary statement ...................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... Patient’s health goals ...................................................................................................................................................................... .......................................................................................................................................................................................................... Page 8 of 7 .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... Page 9 of 7 Lifespan tutorial scenarios and questions. Use the information from the lectures and your readings to answer the following scenarios that will be discussed further in class. Scenario 1—Brian (4 years) Brian’s family lives in a two-storey house in an inner city area. There are 4 bedrooms (3 bedrooms and main bathroom upstairs; master bedroom, ensuite bathroom and a separate toilet downstairs), a study and a family room/children’s playroom full of toys (upstairs) and the kitchen, dining room and formal lounge (downstairs). The family have a large Mitsubishi 4wheel drive and a smaller 4 cylinder Mazda 3 in the two-car garage. They have a Rottweiler dog and a Siamese cat as pets. There is a small front garden with an oleander tree and azaleas; there is no front fence, just a low level box hedge. At the side of the house they have a fenced swimming pool and at the rear a lawn, sand pit and a trampoline. Draw a floor plan/diagram of the home and block Brian lives in. Note on the diagram what you would consider as aspects to address to prevent childhood injury for a preschool child in this type of environment. As well as the rooms within the house remember and consider the front, side and back outdoor environments. Page 10 of 7 Scenario 2—Cheryl (8 years) Cheryl is an 8-year-old girl who moved to the local public primary school midyear and has attended for 3 weeks. She appears shy, pale, thin and carries herself stiffly, displaying a constantly watchful gaze. She does not participate voluntarily in class and does not appear to have any specific friends. Her teacher has observed what appears to be jeering and laughing directed toward her in the playground during the break time, by 3 or 4 of her female classmates. As soon as Cheryl appeared to become teary the group dispersed. The teacher suspects Cheryl is suffering from bullying but when approached she indicates nothing is wrong, although she will not make eye- contact. What are the physical, socio-emotional and cognitive developmental aspects of this stage of development that may apply to the scenario? ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ Discuss the evidence/theories regarding bullying that helps explain the behaviour. ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ What is the role of the parent/family in addressing this issue? ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ Page 11 of 7 If you were a nurse caring for this child what might be some of the potential problems: o the child could face? ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ o you could face in caring for the child? ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ How would you assist Cheryl in developing resilience and self-esteem? ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ You have now completed week 7 Health assessment workshop report. Save this document and submit it on FLO in the week 7 section. Page 12 of 7
