Transcript Introduction to HNI/HNC 370

Introduction to HNI/HNC 370
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Definition of Health
Influencing Factors
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Philosophy
Practice
Health Care System
Practices
Behaviors
Influenced by cost/insurance
Definition of Health
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Health is a dynamic state in which the
individual adapts to changes in the
internal and external environment to
maintain a state of well being. Health is
a state of complete physical, mental,
spiritual, and social well-being.
Internal Environment
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Genetic and psychiatric variables
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Intellectual and spiritual dimensions
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Physiological and physical disease
processes
External Environment
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Physical environment
Social relationships
Economic variables
Internal and external environment may
continually change; individual must adapt
to maintain a state of well being.
Theoretical Models R/T Health
Developmental theories provide a framework for the
practitioners psycho-social and cultural profile.
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Maslow’s Hierarchy of Needs:
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Cognitive Development by Piaget:
People are
innately motivated towards psychological growth, selfawareness & personal freedom.
A person
understands whatever fits into his established view of the
world, when the info does not fit, he must re-examine &
adjust his thinking to accommodate the new info. A person
should reach this level by adolescence.
Culture Transcultural Nursing
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Madeline Leininger “Theory of Transcultural
Nursing”
Defined: “Focuses upon the differences and
similarities among cultures with respect to
human healthcare, health (well-being) and
illness. Bases upon the people’s cultural
values, beliefs, practices, and use of this
knowledge to provide culturally specific or
culturally congruent nursing care.”
Cultural Assessment
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Ethnic Origin
Race
Habits/customs/beliefs
Behaviors valued by culture
Cultural sanctions and restrictions
Healing beliefs
Child rearing/child care
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Spiritual Factors
Educational Factors
Occupational Factors
Economic Factors
Assessment of the Family
Assessment of the Home
Assessment of the Community
Levels of Prevention
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I. Primary Prevention
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True Prevention
Precedes disease/dysfunction
Applied to Healthy Population
It is NOT therapeutic
Does not involve symptom ID
Secondary Prevention
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Provides screening and treats early
stages of disease.
Limits disability
Tertiary Prevention
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Occurs when a deficit or disability is
permanent or irreversible.
Focus on rehabilitation- assist person to
attain highest level of functioning.
Nursing Process
 Assessment-Data Collection
Data Validation
Organize Data
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Diagnosis
Planning
Implementation
Evaluation
Assessment
Focus: Data collection
Data collection is a systemic method of gathering
information about the client.
Method: Four Components
History taking- Primary Source-Patient
Secondary SourceMedical Records
Family
Health Professionals
Physical Examination
Lab. Results
Other sources, x-ray, MRI, CT Scan, EKG
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Types of Data
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Subjective Data: Information described
by the patient to the nurse.
Objective Data: Information collected
by using the senses, IPPA.
Inspection, percussion, palpation,
auscultation
Data Validation
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Is the patient data normal or abnormal?
Is the information collected accurate?
Data Organization
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Cluster similar data to assist in the
identification of a health pattern.
Elements of The Health
History
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Biographical Data
Chief Complaint
History of Present Illness
Past Medical History
Past Surgical History
Family History
Review of Systems
Psychosocial History
Biographical Data
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Name
Age (DOB)
Race
Sex
Birthplace
Source of HX.
Occupation
Chief Complaint
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Why is the patient seeking health care?
Should be in patient’s own words and
include a time frame when possible.
Ex. “I have a pain in my back for 3
days.”
Ex. “I haven been admitted for
evaluation of my heart.”
History of Present Illness
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A clear chronological narrative
beginning with the earliest onset of the
CC and describing its progression to the
present.
Starts with: This is a
Report of symptoms should include:
SLIDTA Foramat
SLIDTA Format
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S
L
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D
T
A
Severity
Location
Influencing Factors
Duration
Type
Associated Symptoms
Example
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CC: “I have a belly ache for two
months”
HPI: This is a thirty-one year old white female that presents
today complaining of stomach pain occurring on and off for
two months. The pain is described as burning, with a pain
level of 8/10 that often prevents her from falling asleep.
The pain is deep, approx. 4 finger breaths above the
umbilicus. Pain occurs after eating, occasionally on an
empty stomach and is relieved with Tums, 2 tablets. The
pain increases when lying down, and relieved in an upright
position. Spicy foods, nuts, fruits and vegetables increase
pain. Denies associated symptoms of nausea and
vomiting. Presented today because past remedies no
longer working.
Past Medical History (PMH)
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Communicable diseases
Immunizations
Major Illnesses-include date & place in
chronological order
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’82 NIDDM
’88 Lyme Disease
Past Surgical History (PSH)
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Same as medical history, but describes
surgical procedures
’89 L AKA
’92 R Carotid Endarterectomy
Medications
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Prescription, OTC, Dose, Route and
Frequency
Include Allergies, animals, blood,
contact agents (LATEX), food, drugs. If
none state no………..
If allergy present, describe reaction.
Social History
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Habits- Smoking (Pack Years), Alcohol
(How Much), IVDA.
Living arrangements: marital status,
employment status.
Genogram
ADL
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Nutrition-24 hour intake, approx.
amounts and time.
Exercise, recreation, rest, sleep
Ask “what is a typical day for you?”
Psychosocial History
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Interpersonal functioning: Relationships
with family, friends, spouse.
Intapersonal Functioning:Stress and
coping mechanisms. Values and Beliefs.
Review of Systems
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Reviews all current and pertinent past
symptoms to be sure that no important
clues have been overlooked, either by
the patient or practitioner.
If you obtain a Positive response, elicit
further information.
THE PATIENT’S RESPONSES ARE
RECORDED, NOT PHYSICAL FINDINGS.
IPPA
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There are four classic techniques of the
physical examination:
I Inspection
P Palpation
P Percussion
A Auscultation
Inspection
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The process of observation.
Adequate lighting and proper exposure
essential.
Preliminary Observations: Gait, ROM,
Eye Contact, Skin Color, Body
Language.
Inspection continues throughout the
examination.
Palpation
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Use of the hands/fingers to gather
information through the sense of touch.
The hand is an important diagnostic tool to
distinguish between:hard and soft, rough and
smooth, stillness from vibration.
Dorsal surface of the hand is used to
estimate temperature.
Palpation can be light (up to 1 cm) or deep
(up to 4 cm).
Light palpation should precede deep.
Ballottment
Percussion
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Striking a portion of the body to evaluate the
condition of underlying structures.
Degree of tone is determined by the density
of the medium through which sound waves
travel.
Sound vibrations are best transmitted through
firm solids, less transmission through fluid,
and poorest through air. ExampleConsolidation of advanced pneumonia.
Percussion cont.
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Tympany-Abdomen
Dullness-Liver
Resonance-Lungs
Percussion cont.
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Technique: Hold pleximeter finger flat on the surface
to be percussed using the tip of the plexor finger,
strike the dip joint of the pleximeter finger.
The strike should be brisk and short
Remove the plexor immediately after contact with the
pleximeter.
The strike should bounce off the pleximeter fingers,
not poke.
Use your sense of touch and hearing as you percuss.
Auscultation
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Try for a quiet environment.
Learn to isolate sounds.
Diaphragm transmits higher pitched
sounds, press firmly on the surface.
Bell is useful for lower pitched sounds
and to listen to a limited surface area.
Press lightly on the skin, if pressed
tightly bell becomes a diaphragm.