Transcript
Speaker: Hello, valued listeners.
Speaker: This is Nurse Jax, and you are listening to episode one of the Health Assessment and Promotion Series of my Nurse Mastery podcast.
Speaker: This is actually my first podcast episode ever, so if it's extremely painful, please bear with me.
Speaker: Quick intro to me.
Speaker: I am a nationally certified critical care nurse currently attending Baylor University in pursuit of a doctorate of nursing practice within the FNP track there.
Speaker: My goal with this podcast is to further my own learning and knowledge and understanding and hopefully to help you with yours as well.
Speaker: I'm also lousy with dad jokes and if it isn't bad enough that I have a hostage audience while taking care of patients, I now have the unholy power to reach all of you as well.
Speaker: So here's the first dad joke ever on the podcast.
Speaker: What do you call a chicken coop with four doors?
Speaker: A chicken sedan.
Speaker: All right, now let's jump into it.
Speaker: So the following episode will be inspired from my notes that I have taken during the course of my studies.
Speaker: If I say something and your professors want something different, go with what your professors want.
Speaker: If you guys in your undergraduate studies haven't figured it out yet, you will.
Speaker: And for you graduate nurses, you know exactly what I'm talking about.
Speaker: It doesn't matter how you actually do it at work.
Speaker: It doesn't matter how you were taught to do it.
Speaker: It just matters that you do it the way that your professor wants it done because they're the ones that are giving you the grade.
Speaker: So that being said, as my disclaimer, hopefully you find the next several minutes interesting and helpful as we dive into health assessment and promotion.
Speaker: So today's topics, the general survey, the comprehensive health history, and documentation.
Speaker: As far as documentation goes for you undergraduate listeners, you might be able to just tune that out.
Speaker: It's going to be specific to the advanced nurse practitioner role rather than the bachelor's of science nurse or the registered nurse, which is going to be slightly different.
Speaker: That's what I do at work right now, all of the charting, all the clicking boxes.
Speaker: This is not going to be addressing that.
Speaker: So diving into it, the general survey.
Speaker: This starts before you even get into the room.
Speaker: You're going to think about your own state of mind.
Speaker: You're going to think about your own biases.
Speaker: Really analyze that and make sure that you walk into that room in a state of mind that you can provide a therapeutic experience to this patient.
Speaker: You should be paying attention to how you're dressed, whether or not you're well-groomed at the moment.
Speaker: Take a moment to compose yourself and give yourself the opportunity to make the best possible impression on your patient and to help them have the most therapeutic experience possible with you.
Speaker: So after you've addressed all of your own concerns, you're going to step into the room.
Speaker: First thing you're going to do is you're going to lay eyes on the patient.
Speaker: You're going to see them.
Speaker: You want to note their appearance, their hygiene, their effect, what their behavior looks like.
Speaker: What kind of facial expressions are they making?
Speaker: One thing that you don't want to miss in this initial part of your general survey is signs of pain.
Speaker: Are they holding onto one limb?
Speaker: Are they, you know,
Speaker: acting like they're guarding their abdomen.
Speaker: Do they look like they're in pain?
Speaker: Do they look nauseous?
Speaker: Do you need to go and grab an emesis bag before they ruin your nice shoes?
Speaker: All of that happens within the first five seconds as you enter the room.
Speaker: Also, you're going to be paying attention to their skin color, any lesions that you might need to assess more closely on your skin exam later.
Speaker: You're going to note their posture.
Speaker: You're going to look for any obvious deformities.
Speaker: If you have the opportunity to see them before they're sitting down,
Speaker: Note any changes in their mobility.
Speaker: Does it look like they're favoring one foot over the other?
Speaker: You're wanting to look for any clues to injury or disease that you can.
Speaker: During your general survey, you're also going to be, once you've started the exam, addressing any changes in weight, any increase or decrease in energy,
Speaker: You're going to be addressing any recent weakness, fever, chills, night sweats, anything that could cause concern for some sort of systemic issues.
Speaker: And once you've identified any of those symptoms that they might be experiencing on this general survey, you want to address possible causes.
Speaker: If you walk in on your general survey and they're holding their chest, they're in the tripod position, pursed breathing, not looking great, this probably isn't the best time for them to be having a primary care provider look at them.
Speaker: You might want to say, yeah, we need to hang on here and just go straight over to the ER next door because you don't look right.
Speaker: You know, you totally have the ability to do that as a nurse practitioner or as a nurse on that initial assessment.
Speaker: If it looks like this person is having an acute event, they need to have help above that that's going to be attained during, you know, an initial interview during a general survey.
Speaker: So last thing you're going to do with your general survey is get the vital signs.
Speaker: You want to check temperature, pulse, blood pressure, respiratory rate, and pain.
Speaker: Those five vital signs are essential.
Speaker: Some clinics might throw in a SpO2 reading on top of that to check the patient's oxygen.
Speaker: nice to have, not necessarily essential unless there is a concern for it.
Speaker: You know, if this is a long-term COPD patient and you know that this is an issue they've had in the past, yeah, throw on the SBU2 monitor.
Speaker: Especially if you have it, it doesn't cost anything to get more data.
Speaker: Okay, moving on from the general survey.
Speaker: Moving into the comprehensive health history.
Speaker: So the comprehensive health history is probably one of the most important and most neglected things that can be done
Speaker: as a nurse practitioner and as a nurse.
Speaker: Reason being, it is like trying to read a book but skipping to the end.
Speaker: You're seeing this patient now, if you don't get their health history, you're not reading into the entirety of this person's life.
Speaker: So the comprehensive health history is really your opportunity to get to know this patient in a meaningful way so that you can help them make decisions about their health care.
Speaker: So you're going to get patient identifiers.
Speaker: This is all part of just demographics, age, gender, race, marital status.
Speaker: You also want to know who's giving you the information.
Speaker: If you're doing this assessment in the ER, who's giving you the information?
Speaker: Is this their cousin?
Speaker: Is their cousin going to be fully updated on this person's health history?
Speaker: If you don't have a great source of information, still get what you can, but recognize that things might need to be changed later as more information becomes available.
Speaker: Also a part of this is going to be the chief complaint, the history of present illness, the past medical history, the family history, personal and social history, and review of systems.
Speaker: So those components are all part of your comprehensive health history, and we'll dive into a little bit to each one of those.
Speaker: The background goal for the entire process of this, beyond just collecting information, is to establish a trusting and supportive relationship with the patient.
Speaker: In my coursework, we had this really neat little
Speaker: Venn diagram that had three circles and was to gather information, build rapport and offer pertinent information.
Speaker: And you're going to be doing all three of those things simultaneously throughout this interview.
Speaker: You're going to gain information.
Speaker: You are going to express empathy about the information and you're going to offer pertinent information about that for them.
Speaker: You know, if they bring up that they had a, a motor vehicle accident in the past, you're going to say, oh man, that's awful.
Speaker: Have you had any lasting effects from that?
Speaker: And if they say, yeah, you keep on having this persistent pain in whatever extremity, you know, it really gives you the opportunity to take their history and show them that you care about them.
Speaker: Moving on, we've already prepared ourselves going into this with self-reflection.
Speaker: Hopefully, if this is an established patient, you've reviewed their chart and you can move on to setting goals for the new encounter.
Speaker: You're also going to...
Speaker: Make sure, once again, before you enter the room that you've ensured your own appearance and behavior are up to date and up to standards for patient care.
Speaker: And then adjust the environment as needed.
Speaker: You know, if you walk in and they're wincing and there's obviously a whole lot of light bothering them, you probably could dim the lights a little bit for this patient's benefit.
Speaker: Really helps to make the patient comfortable before starting this entire interview process.
Speaker: So starting out, you're going to get the chief complaint.
Speaker: And that is simply the patient's own words to state the reason they are here.
Speaker: So I have a headache.
Speaker: If you walk in and you say, so what brings you to the clinic today?
Speaker: And the patient says, I have a headache.
Speaker: That's what you write.
Speaker: That's your chief complaint.
Speaker: Patient comes in with a complaint of headache.
Speaker: But it doesn't stop there.
Speaker: Because now you're going to dive into what is the headache.
Speaker: You're going to ask about the seven attributes of a symptom.
Speaker: You're going to ask about the location of their headache.
Speaker: How does the headache feel?
Speaker: How bad is it?
Speaker: Is it constant?
Speaker: Does it vary?
Speaker: When did it start?
Speaker: You're going to ask about what causes it.
Speaker: You're going to ask about alleviating and exacerbating factors and any associated manifestations.
Speaker: So anything that's related to their headache.
Speaker: Do they get an aura before it happens?
Speaker: Do they notice that they're not able to focus or concentrate during the headache?
Speaker: Do they get nausea and vomiting along with the headache?
Speaker: So you're going to dive into that.
Speaker: And the headache is just an example.
Speaker: You're going to investigate each of these things for any symptom that the patient mentions for their chief complaint.
Speaker: We call them the seven attributes of a symptom.
Speaker: There's plenty of mnemonics out there.
Speaker: I spent the time to come up with my own.
Speaker: So simplifying it is location, quality, severity, timing, situation, better or worse, and related.
Speaker: My mnemonic for it is, little Quincy sat throwing some bait or winding rails.
Speaker: So I like going fishing.
Speaker: If that mnemonic doesn't work for you, that's okay.
Speaker: Find one that does or make your own.
Speaker: Do whatever you need to do to remember those because it's something that you really need to not miss while you're getting this chief complaint panned out.
Speaker: Along with the history of present illness and the chief complaint, you're also going to address any medications they might be taking currently related or unrelated to the chief complaint.
Speaker: any allergies that they might have, and you're also going to cover whatever habits they might have.
Speaker: Do they use drugs?
Speaker: Do they smoke?
Speaker: Do they use alcohol?
Speaker: How frequently do they consume caffeine?
Speaker: What does their diet and activity look like?
Speaker: You want to get a picture of what this person's lifestyle is.
Speaker: Once you have your chief complaint, your history of present illness, and you have their lifestyle hashed out, you're going to move on to the family history.
Speaker: So in the family history, you're going to ask about any pertinent things related to the chief complaint, but also there's a few things that you do not want to miss during your family history.
Speaker: And that is the risks for high cholesterol, diabetes, tuberculosis, mental health, stroke, hypertension, thyroid issues, renal issues,
Speaker: respiratory distress issues, any allergies, seizures, coronary artery disease, cancers, headaches, addiction, arthritis, those are all essential to cover in your family history.
Speaker: Once you have the family history hashed out,
Speaker: you are going to move on and get the personal and social histories hashed out.
Speaker: Personal and social history is a little bit different from a family history.
Speaker: You are looking into where they live, how they spend their time, what that looks like, and how that might impact their health.
Speaker: So consider their religious background.
Speaker: Consider their workplace.
Speaker: What are their living conditions like?
Speaker: And you want to possibly also determine at this time what expectations the patient has about health care.
Speaker: What's their health literacy like?
Speaker: Do they have good access to health care?
Speaker: And if not, how can you help them establish good access?
Speaker: During this time, it would also be appropriate to address whether or not there's any threatening relationships to the patient's health.
Speaker: Are there any concerns for abuse?
Speaker: If there's a family member in the room with the patient, if it seems like there's any sort of strain, don't hesitate to ask the family member to leave so that you can obtain accurate information without the duress there of a family member possibly hindering it.
Speaker: You're also going to address their sexual history and orientation during the personal and social history.
Speaker: And this is an important one that I feel like is often neglected by clinicians, and that is a spiritual history.
Speaker: My textbook, which is Bates' Guide to Physical Examination and History Taking, this is the 13th edition,
Speaker: It has a nice acronym for it for spiritual histories.
Speaker: It's called FICA.
Speaker: And that is Faith, Importance and Influence, Community and Address.
Speaker: So simply, what is the faith?
Speaker: How important is it to them?
Speaker: Do they have a community that supports them with it?
Speaker: And then address is, do you want me as your health care provider to address any spiritual issues that you might be having?
Speaker: answer from the patient might be no, and that's fine.
Speaker: But it's important that you address that and offer that so that they know that they're supported, not just on the physical side of things.
Speaker: Once you have your... So reviewing, once again, this is the comprehensive health history.
Speaker: Once you have your chief complaint, history of present illness, family history, personal and social histories, and spiritual history, you can now move on to the review of systems.
Speaker: This is going to be a head-to-toe review of subjective yes and no questions.
Speaker: You're going to go from the top of their body to the bottom, and you're going to ask questions about every part.
Speaker: Important note here, once we get into documentation, we'll talk a little bit more about this.
Speaker: This is all still subjective information, meaning that you as the clinician cannot verify it.
Speaker: If they say that they've been having headaches for 20 years, that's subjective.
Speaker: You can't verify whether or not they've actually had headaches for 20 years.
Speaker: You can trust them.
Speaker: It's not about trust.
Speaker: It's simply understanding that this is subjective information.
Speaker: So,
Speaker: It's important to remember, and I'm going to restate this as I did at the beginning, this entire process should be done with a cycle of making sure that you gather information, build rapport, and offer pertinent information.
Speaker: You're doing this cyclically.
Speaker: Gosh, that's hard to say during a podcast.
Speaker: Circularly, how about that?
Speaker: Throughout the entire interview, you're going to be gathering information.
Speaker: building your relationship with the patient and offering pertinent information to it.
Speaker: Now, if you do that about every little thing, you might not have time because let's be realistic, you probably only have a maximum of 20 minutes with this patient.
Speaker: So you have to prioritize a little bit, but it's still important that you're being a person and not just a robot offering medical advice.
Speaker: All right, last bit of the podcast today.
Speaker: I hope that you guys aren't bored yet.
Speaker: We're going to talk about documentation.
Speaker: So the main form of documentation used by healthcare providers in the primary care setting is the SOAP note, S-O-A-P.
Speaker: So Subjective, Objective, Assessment, and Plan.
Speaker: And this is just a really easy way to lay out the information from your interview in a summary that other healthcare providers can read and then draw pertinent information out of.
Speaker: It should also be written in a way that the patient is able to understand and read because you might want to include a copy of it for them.
Speaker: So starting with the S, subjective, you're going to take all of the information from this general survey and comprehensive health assessment and history and condense it into your subjective.
Speaker: So you're going to mention your chief complaint.
Speaker: your history of present illness, your pertinent social, family, medical histories, allergies, and current meds.
Speaker: O, objective.
Speaker: This is what you've actually observed as a clinician.
Speaker: Oftentimes, after you've finished this review of systems, you're going to do system-by-system assessment yourself and make sure that you auscultate lung sounds.
Speaker: You're going to be doing an otoscopic and an ophthalmoscopic examination.
Speaker: During O, you're going to also list any lab findings that you have.
Speaker: So this is a good place to put if you took their blood sugar, what was their blood sugar?
Speaker: If you have lab results back from a previous visit, this is a good place to list those.
Speaker: You're also going to list any imaging that was done and the results related to that.
Speaker: Following up with the objective, the only information that is objective from what we've covered today would be the vital signs.
Speaker: Everything else that we've talked about so far would be considered subjective information.
Speaker: So in your O, the only part you're including from this comprehensive health history and general survey is your vital signs.
Speaker: For A, assessment, this is your impression as the clinician about what the patient's issue is.
Speaker: This is where you're probably going to list your most likely diagnosis, and you're going to explain why you came to that conclusion,
Speaker: and draw relationships between the diagnosis and the subjective or objective data that have been identified during the assessment.
Speaker: Last is P, which is for plan.
Speaker: This is where you propose what the patient and the healthcare team need to do about the issue.
Speaker: So what therapies need to be completed, what prescriptions should be advised, and then any recommendations for lifestyle changes and follow-up.
Speaker: Once you have all that, you can condense it down.
Speaker: For tips and tricks about soap notes, there's plenty of tools out there to help you write good soap notes.
Speaker: If you are technologically savvy or looking into advanced things, look into things like Freed AI and Chat GPT.
Speaker: Both are capable of providing good soap notes.
Speaker: The neat thing about freed AI is it's actually HIPAA compliant.
Speaker: And I think it is validated as a tool for use in practice.
Speaker: But you'll have to look into regulations in your state specifically to know for sure.
Speaker: But there's plenty of tools out there to help you write comprehensive health notes, soap notes that are pertinent to the patient and don't leave anything out.
Speaker: Additional places you can look for templates.
Speaker: There's plenty of templates on Google and Pinterest.
Speaker: You may also just have a template from your organization that you need to fill out.
Speaker: Whatever it is, there are tools there to help you know what you need to do so that you don't miss anything.
Speaker: Most important thing about the soap note is it should be legible to another healthcare provider so that they can use it to make information themselves, especially if you're referring this patient to a specialist.
Speaker: The soap note should be something that specialists can read and say, oh, I see, and be useful to them.
Speaker: So this is where everything that you've done in this assessment comes to fruition.
Speaker: This is where it becomes useful and something that the patient and their healthcare team can use to make decisions.
Speaker: That's all I have to talk about today.
Speaker: I hope you enjoy the podcast.
Speaker: I
Speaker: If it needs to be shorter or longer, be sure to send me an email telling me that.
Speaker: So thank you for your attention.
Speaker: And this is Nurse Jax signing off.
