History/ Exam: Ending The Admission Assessment

02Gordan(F)-02 11/29/07 5:23 PM Page 16
HISTORY/
EXAM
■ After determining that the patient was restless, the nurse generated possi-
ble explanations, obtained further information from the patient to investi-
gate the possibilities, and then made the following judgment: The patient
has Fear (surgical prognosis).
Ending the Admission Assessment

Objectives at the end of the interview and examination are:
■ Give the patient the opportunity to add information by asking if there are
any other things he or she would like to mention.
■ Summarize the assessment.
■ Make plans for treatment of the problems identified.
Sharing diagnostic judgments and intervention plans at this time may not be
possible. If so, summarize the assessment in a supportive way, using data
the patient reported. For example:
■ “Let’s both think about what might be causing your family to react this
way, and we can talk about it this afternoon.”
■ “You’ve mentioned a number of things; I think you can work out some
solutions. Let’s talk more about them tomorrow.”
In some cases you may be able to say, “You are doing so well! Just keep up
the things we talked about, and your blood pressure should be good.”
16
03Gordan(F)-03 11/29/07 5:14 PM Page 17
17
Health Perception–Health Management Pattern
The health perception–health management pattern is similar to an umbrella.
Underneath this umbrella are the 10 remaining patterns that are specific to
areas of health management.
• Nutritional – Metabolic • Self-Perception – Self-Concept

• Elimination • Role – Relationship
• Activity – Exercise • Sexuality – Reproductive
• Sleep – Rest • Coping – Stress Tolerance
• Cognitive – Perceptual • Value – Belief
In this pattern the individual, family, or community has an opportunity to

identify health-related concerns. This provides the nurse with information on
areas that may require in-depth assessment.
Why This Pattern Is Important
The following are reasons that individuals, families, and communities require
assessment of this pattern:
■ Verifies patient understanding of his or her condition so that mispercep-
tions of illness, treatment, and health-risk management can be clarified.
■ Identifies nonadherence to the therapeutic regimen and the reasons.
HEALTH
PERCEPT
03Gordan(F)-03 11/29/07 5:14 PM Page 18
HEALTH
PERCEPT
Some large studies suggest that 50% of people on medication regimens do

not adhere to their prescription.
■ Identifies need for health teaching.
■ Identifies health behaviors and values about health promotion transmitted
in the family.
■ Identifies community health services and patient access to health
education programs, health institutions, and safety programs.
Individual Assessment
The health perception–health management pattern describes the individual’s
perceived pattern of health and well-being and how health is managed. It
includes the individual’s perception of his or her health status and its rele-
vance to current activities and future planning. Also included are health-risk
management and general health-care behavior, such as:
■ Safety practices.
■ Adherence to mental and physical health promotion activities.
■ Adherence to agreed-upon medical or nursing prescriptions.
■ Follow-up care.
Individuals at Risk
Some individuals are at increased risk for problems in this area. Be sensitive
to cues when assessing individuals with any of the following characteristics:
■ Denial of illness.
■ Perceived low vulnerability.
■ Cognitive impairment.
■ Language barrier.
■ Visual or hearing deficit.
■ Complex therapeutic regimen.
■ Elderly, particularly with sensory deficits.
■ Lack of knowledge of health policies and resources.
■ Nontherapeutic relationship with care provider.
An individualized approach to assessment is necessary. Issues of concern in
various cultural, occupational, and age groups can be identified from studies
of these groups.
Assessment Items
History
■ How has your general health been?
■ If appropriate: Most important things done to keep healthy?
18
03Gordan(F)-03 11/29/07 5:14 PM Page 19
19
■ Allergies?
■ If person has an illness:
■ Action taken when symptoms perceived? Did that help?
■ What do you think caused this illness?
■ Medications taken currently? Names? Dose? Times?
• Problems in getting or taking these?
• Seem to be helping?
• Did you bring them with you?
■ Use herbs or other traditional family remedies?
■ Colds in the past year?
■ Absences from work or school lasting longer than 1 week?
■ Monthly breast self-examination? Prostate screening? Bone density?
Colonoscopy?
■ If in high-risk group:
■ Flu and pneumonia vaccinations?
■ Tetanus booster?
■ Hepatitis?
■ Other age-appropriate immunizations?
■ Use cigarettes? Drugs? Alcohol? When was your last drink?
■ Accidents in the past year, either at home, work, or while driving? Wear
seat belts?
■ Falls in the past year? (See Fall Risk Factor Checklist at the end of this tab
to evaluate risk for falls.)
■ In the past, easy to find ways to follow doctors’ or nurses’ suggestions
about health management?
■ If appropriate: What things are important to you while you are here? How
can we be helpful?
Examination
■ General appearance.
For in-depth assessment of nonadherence or noncompliance, use the
Assessment of Medication and Treatment Self-Management Checklist below.
Diagnostic Categories
The following nursing diagnoses from the NANDA International Taxonomy II

(2007) describe diagnostic judgments about individuals. Blue type indicates
diagnoses developed by the author, not yet reviewed by NANDA, but found
useful in clinical practice (Gordon, 2006):
■ Health-Seeking Behaviors (Specify): Active seeking (by a person in
stable health) of ways to alter personal health habits or the environment
to move toward a higher level of health.
■ Risk-Prone Health Behavior: Inability to modify lifestyle/behaviors in a
manner consistent with a change in health status.
HEALTH
PERCEPT
03Gordan(F)-03 11/29/07 5:14 PM Page 20
HEALTH
PERCEPT
■ Ineffective Health Maintenance (Specify): Inability to identify basic

health practices, manage own health, or seek help to maintain health.
■ Ineffective Therapeutic Regimen Management (Specify Area):
Pattern of regulating and integrating into daily living a program for treat-
ment of illness and its sequelae not meeting specific health goals (specify
medication, activity, other treatment regimen, or health promotion
disease/prevention).
■ Risk for Ineffective Therapeutic Regimen Management (Specify
Area): Presence of risk factors for difficulty in regulating and integrating a
treatment or prevention program into daily living.
■ Readiness for Enhanced Therapeutic Regimen Management: Pattern
of regulating or integrating into daily living a program for treatment of
illness and its sequelae that is sufficient for meeting health-related goals
and can be strengthened.
■ Effective Therapeutic Regimen Management (Specify Area):
Satisfactory pattern of regulating and integrating into daily living a
program for treatment of illness and its sequelae.
■ Noncompliance (Specify Area): Nonadherence to a therapeutic recom-
mendation following informed decision and expressed intention to attain
therapeutic goals (specify drug or treatment program, dietary prescription,
observation and reporting of symptoms, follow-up care, health-promoting
behaviors).
■ Risk for Noncompliance (Specify Area): Presence of risk factors for
nonadherence to therapeutic recommendations following informed
decision and expressed intention to adhere or to attain therapeutic goals.
■ Contamination: Exposure to environmental contaminants in doses
sufficient to cause adverse health effects.
■ Risk for Contamination: Accentuated risk for exposure to environmen-
tal contaminants in doses sufficient to cause adverse health effects.
■ Readiness for Enhanced Immunization Status: Pattern of conforming
to local, national, or international standards of immunization to prevent
infectious disease(s) that is sufficient to protect a person, family, or
community and can be strengthened.
■ Risk for Infection (Specify Type): Presence of increased risk for
invasion by pathogenic organisms (specify respiratory, urinary tract, skin).
■ Risk for Injury: Presence of risk factors for injury as a result of environ-
mental conditions interacting with adaptive and defensive resources.
■ Risk for Trauma: Presence of risk factors for accidental tissue injury, such
as a wound, burn, or fracture.
■ Risk for Falls: Increased susceptibility for falling that may cause physical
harm.
■ Risk for Perioperative-Positioning Injury: Presence of risk factors for
injury as a result of the environmental conditions found in the periopera-
tive setting.
20

History/ Exam: Ending The Admission Assessment

Uploaded by

Copyright:

Available Formats

History/ Exam: Ending The Admission Assessment

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

History/ Exam: Ending The Admission Assessment

Uploaded by

Copyright:

Available Formats

02Gordan(F)-02 11/29/07 5:23 PM Page 16

Ending the Admission Assessment

• Nutritional – Metabolic • Self-Perception – Self-Concept

In this pattern the individual, family, or community has an opportunity to

Why This Pattern Is Important

Some large studies suggest that 50% of people on medication regimens do

The following nursing diagnoses from the NANDA International Taxonomy II

■ Ineffective Health Maintenance (Specify): Inability to identify basic

You might also like