Health InterviewAccording to Weber, J. & Kelley, J., (2003) “Nursing health assessment is a systematic, deliberative and interactive process by which nurses use critical thinking to collect, validate, analyse and synthesize the collected information in order to make judgement about the health status and life processes of individuals, families and communities”.
It is an essential nursing function which provides foundation for quality nursing care and intervention. Nursing Health Assessment helps to identify the strengths of the clients in promoting health and helps in identifying clients’ needs and clinical problems. With this, it helps the nurse evaluates response of the person to health problems and intervention. (Fuller ; Schaller-Ayers, 2000). There are ways of conducting assessment, one method the nurse can use is Primary Methods which includes Observation, Interviewing clients and do a head-toe examination. These requires the nurse to be very observant, have a good interviewing skills and be critical for planning and implementing the plan of care. The purpose of Nursing Health Assessment is to collect data or information from the patient that he/she presenting with and the data gathered by the nurse by taking vital signs or just by observing the client.
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It also helps the nurse to identify the abnormal from the normal, to discover the patient’s strengths, limitations and how the client can cope with resources. The whole purpose of the assessment is to know the actual problem patient has, to identify risks factors that relate to the client’s problem and helps build a good relationship with the client and family. Assessment is every day part of care within the health care professionals but there’s a slight difference in the outcome between the nurse health assessment and medical assessment. For Medical assessment, it mainly focus on the diagnosis and treatment whereas for the Nursing Health Assessment it focuses on patient as a person where optimal level of wellness is reached and this is a holistically approach by nurses.
(Peter.S, 2015).Roles of nurses vary in providing care to each client but there’s three different roles of a nurse in health assessment which have been chosen are; Firstly being an Advocator where restorative overseers accept obligation to guarantee the genuine and good benefits of patients. This is where the nurse advocate acts to protect the client and may work in collaboration with other health personnel to express clients’ wishes and information in helping to suggest treatment plan for the client. Nurses also assist clients in exercising their rights and help them speak up for themselves (Smith.Y, 2016). Example: For patients who are unwell that are unable to make decision on their own while receiving treatment. The nurse will be enquiring each and everything on behalf of the patient to other healthcare personnel about patient’s treatment plans.
Secondly, as a Teacher whereby the nurse enable customers to find out about their wellbeing and medical procedures that’s to be performed on them. Nurses are also responsible for ensuring that patients are able to understand their health, illnesses, medications, and treatments to the best of their ability. Example when patient are being discharged from hospital, the nurse has to explain to the patient when to return for follow up clinic, what medication to take at particular time, either before meal or after meal and its side effects. The nurse educates client and family members on food handling hygiene, personal hygiene or even hand washing to minimize the recurrence of infection for the patient. Family conference will be more effective as relatives will be present and the nurse can explain to the family members of what they can expect when they leave the hospital and what all they can do to help in the patient recovery. Thirdly, acts as a Caregiver where they take care of their patients in hospitals like a mother take care of their children.
The care afforded to patients depends on the needs and requirements of a patient. The care delivered to a patient depends on the stage of illness like if someone is being admitted in the Intensive Care unit will requires more care than the patient admitted in general wards. (Triotree, 2016).
Example, for patients on life saving support (I.C.U patients), personal hygiene and oral hygiene will be done by the nurses. Nurses will be feeding patients, changing of diapers, turning patient every two hours to prevent bedsores, administering medications and even monitoring patient’s vital signs every half an hour and refer accordingly.Almost everyone has had experience headache. In this write up, the mnemonic of PQRSTU will be used to determine the characteristics of headache symptoms. With P-provocative and palliative, the nurse needs to ask Mr SB as what makes the pain worse? According to Mr SB when he sees the light suddenly, he feels more pain, and what makes the pain better? Mr SB takes painkiller to reduce the pain.
Q-quality and quantity, ask Mr SB as how does the pain feels like? Is it burning, sharping, throbbing, aching or cramping? According to Mr SB, he feels its dull aching pain. R-region or radiation. Ask Mr SB how often do you feel the pain? Where actually do you feel the pain? Mr SB replies there’s tightness across his forehead. Does the pain travel/radiates to other parts of the body? At the back of his head. S-severity scale. Ask Mr SB to rate his headache using the pain scale from 0-10 and informed the nurse of his ratings. According to Mr SB its 3-4 on the pain scale.
T-timing (severity, onset, duration).Ask Mr SB, when did the pain start? How long does the pain last? How often do you experience the pain? When does it happen? The replied the headache started two days ago and the onset is gradual whereby it happens the night after dinner out with his co-workers. U –understand patient perception. The nurse may ask Mr SB as how does the pain affecting you? As stated by Mr SB, it affects his daily activities as he feels bit weak and can’t go to work for the past two days.Annex I: The Complete Health Interview Checklist Date: 10/08/2018Examiner: Ms ET 1. Biographical Data Name: SB Phone 2999015Address: Nabilo, Tavua, Birth date: 28/02/1978 Birthplace: Ba Maternity HospitalAge: 40 years old Gender: Male Marital Status: Married Occupation: CarpenterRace/ethnic origin: Fijian of Indian Descent Employer: Rajendra Group of Companies2.
Source and Reliability: Mr SB. He’s able to communicate well during the interview despite the pain3. Reason of Seeking Care: headache for two days4. Present Health or History of Present Illness: Questions were asked to Mr SB-what makes the pain worse and what makes the pain better? Is the pain aching, sharping, cramping? How often does he feels the pain? Where does he feels more pain? Does the pain travel? Pain rating from0-10? When did the pain started? How long does it lasts? Does he experience pain with certain activities? And how does the pain affecting Mr SB? According to Mr SB, he feels more pain when he sees the light suddenly and takes painkiller to reduce the pain. The pain is dull aching to him and feels more tightness in his forehead radiating to the back of his head which he rates his pain from3-4 on the pain scale. The pain starts two days ago that lasts for 20-25 minutes and while experiencing the pain, Mr SB doesn’t carry out normal activities which he usually does daily.5.
Past Health General Health: Mr SB overall general health status is goodChildhood Illness: NilAccidents or Injuries: NilSerious or Chronic Illness: NilHospitalizations: NilOperations: NilObstetric History: N/AGravida: N/A Term: N/A Preterm: N/A(# Pregnancies) (# Term pregnancies) (# Preterm pregnancies) Ab/incomplete; N/A Children living:N/A(# Abortions/ Miscarriages)Course of pregnancy: N/A(Date delivery, length of pregnancy, length of labour, baby’s weight and sex, vaginal delivery/caesarean section complications, baby’s condition), Immunizations: last immunization was in 2015 when he was given Tetanus Toxoid injection after dog bites his leg.Last examination date: /08/03/2015Allergies: pork Reaction: itchinessCurrent medications: Paracetamol Tablet 500mg every 8hours or when in pain.6. Family History Specify: Heart disease: Paternal Grandmother, Father Allergies: PorkHigh blood pressure: MaternalGrandmother, Mother Asthma:NilStroke: Nil Obesity: MotherDiabetes: Nil Alcoholism:NilBlood disorders: Nil Mental Illness:NilBreast Cancer: Nil Seizure disorder:NilCancer (other): Nil Kidney disease:NilSickle cell: Nil Tuberculosis: NilArthritis:NilConstruct genogram below.463677033845500463677032893036461703479803636645347980458597026543000362394534163100 Paternal side Maternal side3429023304500Key _ Male1524011366500 3390905715000 Female247652774950029146514160400285754762500 Heart Disease __ Hypertension5270512573000533401257302819405588000 Deceased 902970641340092202154610006477092710552451022354652645196850049098209721850042545863600050717451296035481457091503500501459564833542811706483350041097209436100033572459150350035382196388100035096456388104204970105411003890645105410394652522840950031381702343785004128771209613400325247020961350032334202095500003709670163893510807691629410107124514389109759951181734009283701076960002222510267950010807718483600022352083883521399584836000604520210185956945114935008712201016000347345210185Jone Mere Sakiusa RosaSeru Donu Mary Semi LiviaEroni Sainimere7. Review of Systems General Overall Health State: Mr SB weighs 76 kilogram. He’s a bit malaise, otherwise nil fever and night sweats.Skin: homogenous brown, nil erythema present but noted to have birthmark on his arm.
Nil oedematous but has rough skin texture.Hair: has straight hair, fine hair distribution, and nil alopeciaNails: has pink nail bed colour, nil clubbing and normal capillary refillHead: has normocephallic, had cephalgia for the past two days, nil head injury or any tenderness while palpating the head.Eyes: Nil opthalmitus however experience opthalmalgia when suddenly sees the light otherwise nil problem with his vision after reading the snellen chart.Ears: nil otalgia voiced by Mr SB. He hears well in both ears.
Nose and Sinuses: nil nasal obstruction, nasal discharge and nil epistaxis.Mouth and Throat: nil dental carries, nil tonsillitis, nil gingivitis noted.Neck: nil lymphadenopathy, nil goitre noted and thyroid moves freely as Mr SB swallowsBreast: nil history of breast cancer, nil mastodynia.Axilla: nil tenderness or lumps noted..
Respiratory System: nil history of emphysema, nil coughing and nil shortness of breathCardiovascular System: has history of cardiovascular disease from paternal grandmother and Mr SB father whereas has history of hypertension from maternal grandmother as well as his mother. Otherwise for Mr SB, he’s not anaemic, nil palpitation noted as well nil murmur.Peripheral Vascular System: nil venous thrombosis noted, not feeling cold or have any tingling sensationGastrointestinal System: has good appetite, tolerating meals well. Patient defecating normal soft stool, has soft abdomen and nil constipation.
Nil rectal bleedingUrinary System: patient urinates well. Normally he usually visit the washroom twice in the night. Nil dysuria, oliguria voiced by Mr SB.Male Genital System; nil penile discharges, nil complains of penis and testicular pain.Female Genital System: Not ApplicableSexual Health: Mr SB is happily married with two children who are both in secondary level. Doesn’t use any form of contraceptives but his wife does as she got jadelle inserted. Nil problem in ejaculation.
Nil history of Sexually transmitted diseases.Musculoskeletal System: nil complains of arthralgia and myalgia voiced. Nil history of gout and arthritis. Mr SB attends to his personal hygiene unassisted.Neurologic System: nil history of seizure disorder, Mr SB feels weak but nil paresthesia. Nil delusion or hallucination noted from patient.Hematologic System: nil petechial and ecchymoses noted. Has good appetite and weight is normal for his height, nil multiple sclerosis noted.
Endocrine System: nil history of diabetes, nil skin pigmentation noted. Nil dehydration and fatigue noted.FUNCTIONAL ASSESSMENT (Including Activities of Daily Living) Self-Esteem, Self-Concept: Mr SB completed his secondary level at Form 5 and later on move to Chevalier Centre to get his certificate in Carpentry.
Mr SB is paid weekly and that’s sufficient to provide for the family needs. He attends to his personal hygiene unassisted. He value his belief and that he attend religious functions in his community.Activity/Exercise: Mr SB wakes up every morning, help in the preparation of breakfast with his wife, had breakfast and head off to work. He attends to his feeding, bathing, hygiene dressing and walking unassisted.
. He spends his leisure time with his friend fishing. He does endurance exercise when he walks to workplace every morning.
Sleep/Rest: Mr SB: has monophasic sleeping pattern. Nil sleeping aid is used.Nutrition/Elimination: He had rice curry for breakfast, fried rice for lunch and roti with curry for dinner.
Usually his wife buys food and preparing it for the family. All family members are present during meal time. Nil altered bowel and urinary elimination.Interpersonal Relationships/Resources: has a good interpersonal relationship with everyone at his house, co-workers and even his community members.
He loves his children and wife and that is why he usually takes them out for dinner monthly. He usually spends 3-4hours alone and it pleasurable for himCoping and Stress Management: Mr SB stress is mainly from workplace since he works long hours, heavy workloads and working under dangerous conditions. He manages his stress fine by talking to his wife and mend ways as he usually go out fishing with friend and takes his family out for dinner monthly to distress himself.
It’s helpful for him since his stress is work related, and being with his children and wife is a way of distressing himself.Personal Habits: `1Environmental/Hazards: Intimate Partner Violence: Occupational Health: Perception of Own Health: Spiritual Resources: Developmental stage REFERENCES:Smith.Y (2016). Roles of a Nurse. Retrieved from https://www.news-medical.net/health/Roles-of-a-Nurse.
aspxhttps://www.rnpedia.com/nursing-notes/fundamentals-in-nursing-notes/roles-function-nurse/Triotree. (2016, September 28). Role and Responsibilities of Nurses in Hospitals and Healthcare. Retrieved fromhttp://triotree.com/blog/role-and-responsibilities-of-nurses-in-hospitals-and-healthcare/Peter. S (2015).
Nursing Health Assessment. Retrieved fromhttps://www.slideshare.net/shantapeter/nursing-health-assessment-48824855Fuller, J.
& Schaller-Ayers, J., (2000). Health Assessment – A Nursing Approach.
(3rd Ed.). Philadelphia: Lippincott.Weber, J. & Kelley, J., (2003). Health Assessment in Nursing. (2nd Ed.
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