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Faculty of Nursing-NC
Lecture: Abdirahman Noah
Yousuf
Muslim College
Holistic approach
1. The interview
2. Psychosocial assessment
3. Nutritional assessment
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1. Interview
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Major purpose:
To obtain health history and to elicit symptoms and the
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Working phase:
The nurse must listen and observe cues in addition to using critical
thinking skills to validate information received from the client.
The nurse identify client's problems and goals.
Termination phase:
1.The nurse summarizes information obtained during the working
phase
2. Validates problems and goals with the client.
3.Making plans to resolve the problems (nursing diagnosis and
collaborative problems are identified and discussed with the
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client)
Communications techniques during interview
A. Types of questions :
Begin with open ended questions to assess client's
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E. Specific age variations :-
Pediatric clients: validate information from parents.
F. Emotional variations:
Be calm with angry clients and simply with anxious and
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G. Cultural variations:
Be aware of possible cultural variations in the
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2-Psychosocial assessment
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Stages of Age
Infancy period: birth to 12 months
Neonatal Stage: birth-28 days
Infancy Stage: 1-12 months
Early childhood Stage: It’s refers to two integrated stages of
development
Toddler: 1 - 3years.
Preschool: 3 - 6 years.
Middle childhood 6-12 years
Late childhood:
Pre pubertal: 10 – 13 years.
Adolescence: 13 - 19 years
Young adulthood 20-40 years
Middle adulthood 40-65years
12 Late adulthood 65 and more
3-Nutritional assessment
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Major goals of nutritional assessment
1. Identification of malnutrition.
2. Identification of over consumption
3. Identification of optimal nutritional status.
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B. Biochemical Measurement
Useful in indicating malnutrition or the development of
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Nutritional assessment technique for clinical examination
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Psycho social - cultural factors: Review any thing which can
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D. Dietary analysis
Food represent cultural and ethnic background and socio-
economic status and have many emotional and
psychological meaning
Assessment includes usual foods consumed & habits of
food
The nurse ask the client to recall every thing consumed
within the past 24 hour including all foods, fluid, vitamins,
minerals or other supplements to identify the optimal meals
Should not bias the client's response to question based on
the interviewer's personal habits or knowledge of
recommended food consumption
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Diseases affected by nutritional problems
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4-Assessment of sleep-wakefulness patterns
Normal human has “homeostasis” (ability to
maintain a relative internal constancy)
Any person may complain of sleep-pattern
disturbance as a primary problem or secondary
due to another condition
1/4 of clients who seek health care complain of a
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Factors affecting length and quality of sleep
7. Tremor of hands.
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Phases of taking health history
Two phases:
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Guidelines for Taking Nursing History
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Guidelines for Taking Nursing History cont..
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Guidelines for Taking Nursing History cont..
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Types of Nursing Health History
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Components of Health History
1-Biographical Data: This includes
Full name
Address and telephone numbers (client's permanent
contact of client)
Birth date and birth place
Sex
Religion and race
Marital status
Social security number
Occupation (usual and present)
Source of referral
Usual source of healthcare
Source and reliability of information
Date of interview
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2- Chief Complaint: “Reason For Hospitalization
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SYMPTOM ANALYSIS
P Q R S T
a. Provocative or Palliative
First occurrence :
What were you doing when you first experienced or
noticed the symptom?
What to trigger it ? stress?, position?, activity?
What seems to cause it or make it worse? For a
psychological symptom.
What relieves the symptom: change diet? change
position ? take medication? being active?
Aggravation: what makes the symptom worse?
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SYMPTOM ANALYSIS
P Q R S T
b. Quality Or Quantity
QUALITY:
sounds?
QUANTITY:
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SYMPTOM ANALYSIS
P Q R S T
c. Region Or Radiation
Region:
Where does the symptom occur?
Radiation :
Does it travel down your back or arm, up your neck or
down your legs?
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SYMPTOM ANALYSIS
P Q R S T
d. Severity scale
Severity
How bad is symptom at its worst?
Course
Does the symptom seem to be getting better, getting
worse?
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SYMPTOM ANALYSIS
P Q R S T
e. Timing
Onset :
On what date did the symptom first occur?
Type of onset :
How did the symptom start; suddenly? gradually?
Frequency :
How often do you experience the symptom; hourly? daily?
weekly? Monthly?
Duration :
How long does an episode of the symptom last?
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3-History of present illness
treatment.
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Components of present illness
Introduction: "client's summary and usual
health".
Investigation of symptoms: "onset, date, gradual
or sudden, duration, frequency, location, quality,
and alleviating or aggravating factors".
Negative information.
Relevant family information.
Disability "affected the client's total life".
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4- Past Health History:
The purpose: (to identify all major past
health problems of the client).
This includes:
Childhood illness e.g. history of rheumatic
fever.
History of accidents and disabling injuries.
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Past Health History. Cont…
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5-Family History
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6-Environmental History:
Purpose
“To gather information about surroundings of
the client", including physical,
psychological, social environment, and
presence of hazards, pollutants and safety
measures."
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7- Current Health Information
Purpose: to record major current health-related
information.
Exercise patterns.
Includes:
How client and his family cope with
disease or stress, and how they respond to
illness and health.
You can assess if there is psychological or
social problem and if it affects general
health of the client.
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9- Review of Systems (ROS)
“Discussed Before”
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11- Assessment of Interpersonal Factors
This includes:
Ethnic and cultural background, spoken language, values,
health habits, and family relationship.