Health Screening: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of health screening in order to:
- Apply knowledge of pathophysiology to health screening
- Identify risk factors linked to ethnicity (e.g., hypertension, diabetes)
- Perform health history/health and risk assessments (e.g., lifestyle, family and genetic history)
- Perform targeted screening assessments (e.g., vision, hearing, nutrition)
- Utilize appropriate procedure and interviewing techniques when taking the client health history
As somewhat discussed previously with the section entitled "Providing Information About Health Promotion and Maintenance Recommendations", the U.S. Preventive Services Task Force and other organizations provide screening guidelines and schedules similar to those that the CDC does for immunizations. Many of these screening recommendations are based on known pathophysiology such as the risk factors for some diseases and disorders as based on the patient's age, the client's personal past medical history and the client's family medical history.
Some examples of recommended screening tests and their relationships with pathophysiology are:
- Chlamydial Infection Screening: Although routine screening for a chlamydia infection should begin for sexually active women 25 years and younger, as based on the knowledge that this age group is at greatest risk for this infection, it is also recommended for clients with an impaired immune system and among those clients with multiple sexual partners.
- Colorectal Cancer Screening: The U.S. Preventive Services Task Force recommends colorectal cancer for clients of both genders beginning at 50 years of age, however, this screening may begin at a younger age and more frequently than normally recommended when the client has a pathological risk factors associated with this frequently occurring type of cancer.
- Depression Screening: Based on the psychological link between major life events and poor coping skills with depression, for example, depression screening may be done as based on these client characteristics and needs.
- Breast Cancer Screening: Although the U.S. Preventive Services Task Force recommends a screening mammography every one to two years for women over 40 years of age, this governmental body also recommends a screening mammography at an earlier age and more frequently among women with a family or personal history of breast cancer and/or the presence of a pathological finding such as a palpable mass or lump in the breast.
Nurses instruct, prepare and assist clients for screening examinations that can identify diseases, infections and other disorders in their earliest stages. Nurse check and follow up on the results of clients' screening tests such as a colonoscopy screening test, a stool for occult blood, a Papanicolaou test, and a screening mammography. Results are also reported to the patient's doctor and entered into the patient's medical record, according to the facility's specific policies and procedures.
The role of ethnicity in terms of risk factors is an area of ongoing research. Although there appears that they are some correlations between some ethnicities and disease, these correlations may be just that and not a causal relationship. For example, genetic patterns and abnormalities may place a person at risk for some diseases but the presence of other factors, such as screening and maintaining a healthy life style, can help to prevent it from every occurring. Despite the risk factor trends discussed below, these risk factors can be used as a guideline for assessments; these risk factor trends should not be considered a hard and fast rule for all members of an ethnic group.
- Sickle Cell Anemia: African and Latin Americans, Saudi Arabians, Southern Europeans and some clients from some Mediterranean nations
- Hypertension: African Americans, Pacific Islanders , Native Americans, Alaskan natives, Hispanic and Caribbean clients
- Thalassemia: Clients with a Mediterranean ethnicity
- Diabetes: African Americans, Caribbeans, Native Americans and clients from India, Pakistan and Bangladesh
- Cancer: Caucasians and clients from Scotland and Ireland
- Tay Sachs Disease: Ashkenazi Jewish people
- Psychiatric Mental Health Disorders: African Americans and Native Americans
- Cystic Fibrosis: Clients with a European ethnicity
The purpose of the health history is to collect data and information about the patient's and family's current and past states of health, their risks, their strengths, weaknesses, and their needs.
This data collected for the health history includes primary and secondary data, subjective and objective data; and it can also consist of quantitative or qualitative data. As you will now learn, these classifications of data and information are not always mutually exclusive.
An example of primary data is information that you get directly from the patient and secondary data is information that you collect from sources other than the patient. An example of primary data is information that the client tells you about their family history; and an example of secondary data could be information that a spouse or other family member has told you and it can also include data and information that is gathered by reviewing the medical records, such as progress notes, of the client during last acute care hospitalization.
Objective data is empirical data that is measurable and observable with the senses such as feeling, smelling, and seeing and also amenable to empirical validation. On the other hand, subjective data is not empirical and it is not able to be objectively measured and observed despite the fact that the registered nurse can make inferences from it and make conclusions about it when the nurse applies their critical thinking and professional judgment skills.
Some objective data that can be collected during the client's health history include a skin rash that is visible to the nurse and some subjective data that can be collected can include statements made by the client in reference to their chief complaint. For example, the client may state "I have chest pain" or "I am short of breath even when I am only walking". This subjective data is documented and recorded using the exact words of the client within quotation marks. As you can see, these subjective statements are not only subjective data; these statements are also primary data because it comes directly from the client and not from other sources. These two patient statements about their chief complaint are an example of how some of these classifications of data are not mutually exclusive. Some data can be classified in more than one way.
Quantitative data is numerical data like laboratory results and the data that is collected with vital signs measurements. Qualitative data is narrative information like the patient's description of their pain in terms of its intensity.
Data and information that is collected for the health history is obtained with an interview process. Two kinds of questions are used during this interview to collect data. These questions are open ended and closed ended questions.
Closed ended questions are answered with a simple "no" or "yes" answer. An example of a closed ended question is "Are you married?" another closed ended question could be "Have you ever been pregnant before?" The answer will be yes or no to both of these questions. On the other hand, an open ended question, which elicits more data and information than a closed ended question, requires more than a simple yes or no.
Examples of open ended question are "Tell me about what you were doing when your pain started" and
"Which members of your family have had diabetes?" As you can see from these examples, open ended questions give us fuller and deeper data and information than closed ended questions.
A complete health history consists of:
- Essential demographic data
- The patient's chief complaint
- The patient's past medical history
- The family's current and past medical history
- The client's psychological history
- The client's social history
- Life style choices
- The client's spiritual/religious beliefs and practices
- The client's cultural background, beliefs and practices
- The patient's utilization of and access to health care services including health promotion activities
Some health histories are modified somewhat according to the specific developmental milestones such as infancy and pregnancy.
Some demographic data and information that are collected during the health history are the patient's name, address, contact information, health insurance information, age, marital status, and occupation.
Nurses collect data and information about the patient's chief complaint by asking an open ended question such as "Why did you come to the emergency room today?" The patient will likely respond to this question with data and information about their chief complaint. Although the data relating to the client's chief complaint is subjective data and it may not be completely accurate, it will give you insight into the client and their concerns, including pain. For example, when the client responds to your question about why they have presented into the emergency department with a statement like "I am having a heart attack" or "I have indigestion", it does not necessarily mean that the client is actually having indigestion or a heart attack; however it provides the nurse with insight into the client's chief complaint.
The client's past medical history portion of the health history is comprised of data and information about the client's immunizations, prior surgeries, significant injuries and trauma, childhood illnesses, previous hospitalizations, a history of any acute or chronic illnesses, all allergies including those to medications, foods and environmental allergens, current medications, supplements, and over the counter preparations that they are currently taking as well as a history of adverse events and reactions such as those associated with latex, medications and anesthesia.
The current medical history is a further exploration of the patient's chief complaint in terms of the patient's symptoms, when the symptoms began, things that make the symptoms worse, things that precipitate the symptoms, things that decrease the severity of the symptoms, the location of the symptoms, how often the symptoms occur, and the characteristics of the chief complaint. For example, if the client is complaining and/or concerned about wound drainage, the nurse would ask the client about the amount, color and consistency of the drainage; similarly, when the client expresses pain, the nurse would further explore this pain with the client in order to assess its characteristics such as its intensity on a scale of 1 to 10 and other distinguishing characteristics such as whether or not the pain is crushing, aching, or burning, for example.
During the past and current family history phase of the health history, the nurse collects data and information about relatives' health histories including the presence of any commonly occurring chronic and acute diseases which have a familial tendency to run in families. Some of these diseases and disorders, in addition to genetic diseases and disorders, include diabetes, obesity, heart disease, psychological disorders, hypertension, and cancer.
These family histories typically cover the history of the client's parents, siblings, children, grandchildren and grandparents on the maternal and paternal side of the family including either their current age or their age at the time of death.
At times charts like a genogram are used to compile the family history for a simpler and easier analysis of this intergeneration data.
The client's psychological history is comprised of the client's past and present stressors, and the client's coping mechanisms, mood, affect, thought processes, and any history of an acute or chronic psychological disorder or abuse and neglect; and the social history consists of the client's economic status, the family unit, their level of education, their interrelationships and their employment status.
Some of the cultural data that is collected include the person's ethnic and cultural customs, beliefs, practices, and preferences. Religious and spiritual data includes customs, beliefs, practices and preferences.
Data relating to the patient's utilization of and access to health care services including health promotion activities are also collected. The patient's patterns of health care are determined in terms of what type of health care resources they utilize and whether or not these resources and services are accessible to them.
As briefly mentioned in the section entitled "Applying a Knowledge of Pathophysiology to Health Screening", in addition to routine and recommended screenings, some screening is targeted at populations that have the risk for a particular disorder or disease. Some targeted screenings may screen for visual, auditory and nutritional deficits and disorders when the client is at risk and/or a possible impairment has to be ruled out, for example.
Targeted assessments relating to nutritional status may be indicated when an infant or young child is listless and not gaining weight according the established criteria; an adolescent may be target screened for visual acuity when a high school teacher reports that the teen does not seem to be able to read things on the blackboard; and a toddler may be target screened when the parent reports that the child is not responding to their name.
In addition to the types of interview questions that are appropriately used to collect health history data and information, there are other techniques and interventions, such as those below, that should be employed when taking a client's health history.
- Establish an open, trusting, caring, compassionate, nonjudgmental client-nurse relationship.
- Establish and maintain an environment that is comfortable, private, and without any distractions or districting noises or sounds.
- Identify and correct any barriers to communication. For example, if the client needs a professional interpreter, get one.
- Use therapeutic communication techniques and strategies such as clarification, active listening, summarizing and others and avoid all non-therapeutic communication such as intrusive probing, medical jargon and false reassurances, all of which were more fully described in the "Integrated Process: Communication and Documentation".
- Validate all of the collected data and information with the client.
- Document all the collected data in a complete and accurate manner.
- Aging Process
- Anti/Intra/Postpartum and Newborn Care
- Developmental Stages and Transitions
- Health Promotion/Disease Prevention
- Health Screening (Currently here)
- High Risk Behaviors
- Lifestyle Choices
- Self Care
- Techniques of Physical Assessment