COURSE INTRODUCTION.

 

Objectives

Upon completion of this chapter, you will be able to:

1.     Identify the principles of growth and development.

2.     Discuss theories of development.

3.     Describe stages of development.

4.     Identify a variety of measurements of growth and development across the age span.

5.     Discuss growth and development in relation to health assessment.

6.     Discuss factors that influence growth and development.

7.     Discuss the purpose of the nursing health history.

8.     Describe communication skills used by the professional nurse when conducting a health history.

9.     Identify barriers to effective nurse-client communication.

10.                        Describe the influence of culture on nurse-client interactions.

11.                        Discuss the professional characteristics used in establishing a nurse-client relationship.

12.                        Discuss the phases of the client interview.

13.                        Describe the components of the nursing health history.

14.                        Obtain a health history.

15.                        Develop a genogram.

Overview

• Knowledge of growth and development provides a framework for nursing assessment.

• Growth involves physical changes that can be measured.

• Development is an increase in functional complexity and skill acquisition.

• The pattern of growth and development is consistent but the rate varies as a result of hereditary and environmental factors.

Principles of growth and development

• Growth and development proceed in an orderly, sequential progression.

• Growth and development proceed in cephalocaudal and proximal to distal directions.

• Development proceeds from simple to complex.

• Differentiated development progresses from a generalized response to a skilled specific response.

Theories of development

• Classic theories of human development provide the foundation for nursing assessment.

• Researchers are developing new theoretical approaches to explain human behavior.

• Cognitive theory explores the ways people learn to think, reason, and use language.

• Psychoanalytic theory describes personality development in response to environmental changes and conflict resolution between environments and instincts.

• Psychosocial theory includes cultural and societal changes on ego development across the life span.

Stages of development

• Growth and development in infants and toddlers is rapid, transforming totally dependent neonates into active, verbal children with unique personalities.

• Preschool and school-age children expand knowledge and skills through experiences with other children and adults outside of the home.

• Adolescence marks the transition from childhood to adulthood as growth and development occur in a predictable sequence but at variable ages and rates.

• Growth and development continue throughout adulthood as individuals achieve intimacy and independence in young adulthood, attain career satisfaction in middle adulthood, and adjust to aging in late adulthood.

Growth and development in Health assessment

• Comprehensive health assessment requires the ability to interpret the ways complex interactions of physiological, cognitive, and psychological development affect an individual at a given time.

• Health assessment of growth and development includes the use of growth charts, measures of BMI, and instruments and scales to assess emotional, cognitive, and psychosocial development.

• Accurate data collection and interpretation of findings is dependent on knowledge of expectations and ranges of normal for physical as well as psychological, cognitive, and psychosocial growth and development.

Factors that influence growth and development

• Growth and development are influenced by nutrition, family, culture, ethnicity, and socioeconomic status.

• Nutrition is essential to physical and mental development.

• Families help one another to develop physically and emotionally by providing for economic and safety needs, providing support during crises, and modeling social interaction.

• Culture influences child rearing, the value of cognitive development, and attitudes toward change.

• Differences in growth and development are reported for various racial and ethnic groups.

• Socioeconomic status impacts physical and psychosocial development across the age span.

• The health history is a comprehensive record of the client’s past and current health.

• The nurse’s health history differs from that of the physician in that it focuses on the client’s response to a health concern as a whole person, rather than on the diagnosis of a disease.

• The health history is performed at the time of the initial encounter with the client and occurs before the physical assessment.

• The health history includes subjective data about wellness and illness.

Communication skills

• Communication skills are essential to establish an effective nurse-client relationship.

• Communication is the exchange of information between individuals.

• During communication, a message is transmitted by a sender to another individual. A message is heard and interpreted by the receiver.

• Encoding is the process of formulating a message for transmission to another. Encoding includes the use of words, body language, and signs to convey a message.

• Decoding is searching one’s memory, experience, and knowledge base to determine the meaning of a message.

Interactional skills

• Interactional skills are used during encoding and decoding to exchange information, develop relationships, and promote understanding of self and others.

• Listening, attending, paraphrasing, leading, questioning, reflecting, and summarizing are examples of interactional skills used in nurse-client interactions.

Barriers to effective client interaction

• False reassurance, changing the subject, passing judgment, cross-examination, and the use of technical terms are considered nontherapeutic forms of communication.

• The nontherapeutic forms of communication hinder the flow of information between the nurse and client, and may be harmful.

• Nontherapeutic techniques often make the client anxious, uncomfortable, or insecure.

• The nurse needs to be sensitive to topics related to self-image, sexuality, religion, and the use of drugs and alcohol. Lack of sensitivity will make the client uncomfortable and inhibit the communication process.

The influence of culture on nurse-client interactions

• Differences in culture have an impact on the interactions between the nurse and the client. The nurse must recognize and adapt to cultural differences.

• Diversity refers to culture, ethnicity, religion, nationality, intelligence, education, and health status. Any of the factors associated with diversity can impact the encoding and decoding of a message.

• The nurse must strive to avoid stereotyping and bias in client interactions.

• The nurse must be sensitive to cultural differences in the use and interpretation of body language.

• The use of translators is recommended when interviewing clients who do not speak the same language as the nurse.

Professional characteristics to enhance the nurse-client interaction

• Clients are more willing to discuss health issues in a trusting, helping relationship. Helping individuals possess the following characteristics: positive regard, empathy, genuineness, and concreteness.

• Positive regard means respect for another’s worth and dignity.

• Empathy is the capacity to respond to another’s feelings and experiences as if they were one’s own.

• Genuineness is the ability to present oneself honestly and spontaneously.

• Concreteness means speaking in specific terms.

The health history interview

• The health history interview is planned, formal interaction between the nurse and the client.

• The source of information for the health history must be able to provide accurate and reliable information.

• The primary source for health history information is the client.

• Clients who may be unable to provide accurate and reliable information include infants and children, developmentally challenged clients, disoriented or emotionally disturbed individuals, aphasic persons, or those who do not speak a common language.

• Secondary sources of information for the health history include individuals who have known the client for some time, generally a significant other.

• Client records and charts are secondary sources of information for the health history.

• The health history interview occurs in three phases. The preinteraction phase occurs before the nurse meets the client. The initial interview is the second phase of the health history interview. The focused interview is the third phase of the health history interview.

Glossary

 

adolescent   Marks the transition from childhood to adulthood, 12 to 19 or 20 years.

cephalocaudal   Head to toe, direction.

cognitive theory   How people learn to think, reason, and use language.

development   An orderly, progressive increase in the complexity of the total person. It involves the continuous, irreversible, complex evolution of intelligence, personality, creativity, sociability, and morality.

growth   Measurable physical change and increase in size; indicators of growth include height, weight, bone size, and dentition.

infant   A baby from 1 month of age to 1 year.

middle adulthood   Person 40 to 65 years, signals a halfway point, with as many years behind an individual as potentially ahead.

older adulthood   States that culture and society influence development across the entire life span.

preschool    A child 3 to 5 years of age, with appearance and proportions closer to those of adults.

psychoanalytic theory   Defines the structure of personality as consisting of three parts: the id, the ego, and the superego.

psychosocial theory   States that culture and society influence development across the entire life span.

school-age   Begins about the age of 6 years, when deciduous teeth are shed, and ends with the onset of puberty at about 12 years.

toddler   Child of 1 to 3 years of age.

young adult    Person aged 20 to 40 years, establishes a new life on a chosen career path and in a lifestyle independent of parents.

assessment   Step 1 of the nursing process; is the collection, organization, and validation of subjective and objective data.

client record   A legal document used to plan care, to communicate information between and among healthcare providers, and to monitor quality of care.

communication   Exchange of information, feelings, thoughts, and ideas.

confidentiality   Information sharing is limited to those directly involved in client care.

critical thinking   A process of purposeful and creative thinking about resolutions of problems or the development of ways to manage situations.

documentation   A legal document used to plan care, to communicate information between and among healthcare providers, and to monitor quality of care.

focused interview   An interview that enables the nurse to clarify points, to obtain missing information, and to follow up on verbal and nonverbal cues identified in the health history.

formal teaching   Occurs in response to an identified learning need of an individual, group, or community.

health assessment   A systematic method of collecting data about a client for the purpose of determining the client’s current and ongoing health status, predicting risks to health, and identifying health-promoting activities.

health history   Information about the client’s health in his or her own words and based on the client’s own perceptions. Includes biographical data, perceptions about health, past and present history of illness and injury, family history, a review of systems, and health patterns and practices.

health   A state of complete physical, mental, and social well-being.

holism   Considering more than the physiological health status of a client, including all factors that impact the client’s physical and emotional well-being.

informal teaching   Occurs as a natural part of a client encounter, may provide instructions, explain a question or procedure, or reduce anxiety.

interpretation of findings   Making determinations about all of the data collected in the health assessment process.

interview   Subjective data gathering, including the health history and focused interview, including primary and secondary sources.

nursing diagnosis   Step 2 of the nursing process, the nurse uses critical thinking and applies knowledge from the sciences and other disciplines to analyze and synthesize the data.

nursing process   A systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client.

objective data   Data observed or measured by the professional nurse, also known as overt data or a sign since it is detected by the nurse. This data can be seen, felt, heard, or measured.

physical assessment    Hands-on examination of the client, components are the survey and examination of systems.

subjective data   Information that the client experiences and communicates to the nurse, known as covert data, symptoms.

interdependent relationship   Relationships in which the individual establishes bonds with others based on trust.

psychosocial functioning   Part of an intricate set of subsystems including the way a person thinks, feels, acts, and relates to self and others. It is the ability to cope and tolerate stress, and the capacity for developing a value and belief system.

psychosocial health   Being mentally, emotionally, socially, and spiritually well.

role development   The individual’s capacity to identify and fulfill the social expectations related to the variety of roles assumed in a lifetime.

self-concept   The beliefs and feelings one holds about oneself.

stress   The body’s response to thoughts and feelings that may result in physical symptoms.

interdependent relationship   Relationships in which the individual establishes bonds with others based on trust.

psychosocial functioning   Part of an intricate set of subsystems including the way a person thinks, feels, acts, and relates to self and others. It is the ability to cope and tolerate stress, and the capacity for developing a value and belief system.

psychosocial health   Being mentally, emotionally, socially, and spiritually well.

role development   The individual’s capacity to identify and fulfill the social expectations related to the variety of roles assumed in a lifetime.

self-concept   The beliefs and feelings one holds about oneself.

stress   The body’s response to thoughts and feelings that may result in physical symptoms.

attending   Giving full time and attention to verbal and non-verbal messages.

communication   The exchange of information between individuals.

concreteness   Speaking to the client in specific terms rather than in vague generalities.

empathy   "The capacity to respond to another’s feelings and experiences as if they were your own” (Cormier, Cormier, & Weiser, 1984, p. 22)

encoding   The process of formulating a message for transmission to another person.

false reassurance   The client is assured of a positive outcome with no basis for believing in it.

focused interview   Interview used to clarify previously obtained assessment data, gather missing information about a specific health concern, update and identify new diagnostic cues as they occur, guide the direction of a physical assessment as it is being conducted, and identify or validate probable nursing diagnoses.

genogram   A pictorial representation of family relationships and medical history.

genuineness   The ability to present oneself honestly and spontaneously.

health history   A comprehensive record of the client’s past and current health history gathered during the initial health assessment interview.

health pattern   A set of related traits, habits, or acts that affect a client’s health.

interactional skills   Actions that are used during the encoding/decoding process to obtain and disseminate information, develop relationships, and promote understanding of self and others.

listening   Paying undivided attention to what the client says and does.

paraphrasing   Restating the client’s basic message to test whether it was understood.

positive regard   The ability to appreciate and respect another person’s worth and dignity with a nonjudgmental attitude.

preinteraction   The period before first meeting with the client in which the nurse reviews information and prepares for initial interview.

primary sources   The client is the best source because he can describe personal symptoms, experiences, and factors leading to the current concerns.

reflecting   Letting the client know that the nurse empathizes with the thoughts, feelings, or experiences expressed.

secondary sources   A person or record that provides additional information about the client.

summarizing   Tying together the various messages that the client has communicated throughout the interview.

 

n  Infancy – birth to 1 year

n  Toddler – 1 to 3 years

n  Preschooler – 3 to 6 years

n  School age – 6 to 12 years

n  Adolescent – 12 to 20 years

n  Early adult – 20 to 40 years

n  Middle adult – 40 to 64 years

n  Late adult – 65+ years

Developmental Considerations in Assessment

Theorists

n  Erikson – Psychodynamic theory

n  Social environment combined with biological maturation provides each individual with a set of “crises” that must be resolved

n  8 stages based on age

n  Each stage must be accomplished before moving into next stage

n  Piaget – Cognitive theory

n  How a person perceives and processes information

n  4 stages not based on age but in order

n  Each stage represents a change in how children understand their environment

Infants

n  Physical development

n Average term weight is 3.4 kg (7.5 lb). Triple birth weight by 1 year.

n Primitive reflexes that begin to disappear

n Grasp reflex disappears ~2 months

n Vision improves

n Posture, holding head up, sitting, crawling, and walking

 

n  Behavioral and Cognitive

n Trust vs. Mistrust

n Language – crying, imitate sounds (9-10 months), first word!

Toddlers

n  Physical

n Rate of growth decreasing

n Upright posture

n Improvements in fine motor skills

n  Behavioral and Cognitive

n Autonomy vs. shame and doubt

n More autonomous

n Object permanence, mental representation

n Negativism – constant protests

n Ritualism – same order

n Parallel play – mimic other children

n Telegraphic speech – few words at a time, basic commands

Growth Charts

Preschoolers

 

 

 

Physical

n  Growth of long bones

n  Begin to lost baby fat

n  Permanent teeth appear

Behavioral and Cognitive

n  Initiative vs. guilt

n  More autonomous

n  Communicate more effectively

n  Awareness of others’ needs and interests

n  Develop gender roles

n  Delayed imitation

n  Egocentrism

School Age

Physical

n  Muscles stronger and more coordinated

n  Bones replace cartilage

 

Behavioral and Cognitive

n  Industry vs. inferiority – a desire to achieve

n  Reading and writing improve

n  Manage feelings and impulses better

n  Identify sex and gender roles

n  Identify self as worthy individual

Adolescents

Physical

n  Growth spurts in height and weight

n  Menarche and thelarche in girls

Behavioral and Cognitive

n  Ego identity vs. role confusion

n  Formal operational thought

n  Identity confusion

n  May be embarrassed of own body

n  Emotional independence

n  More knowledgeable

Early Adulthood

Physical

n  Maximum potential for growth and development

n  Reduction in activity

 

Behavioral and Cognitive

n  Intimacy vs. role isolation

n  Achievements important, career

n  Mate selection

Middle Adulthood

Physical

n  Wrinkling of skin

n  Graying or loss of hair

n  Decrease in muscle mass and tone

n  Vision and hearing decrease

n  At risk populations develop

Behavioral and Cognitive

n  Generativity vs. stagnation

n  Many decisions about career, lifestyle, family – “midlife crisis”

n  Empty nest syndrome

n  Intelligence remains constant, more experience

 

Older Adulthood

 

Physical

n  Many variations

n  Chronic illnesses

n  Changes in sensation

n  Loss of lean body mass, increase in fat deposition. 

n  Posture deteriorates, wider gait

n  Poor skin turgor, xerosis (drying)

n  More prone to injury due to loss of bone mass.

 

Behavioral and Cognitive

n  Ego identity vs despair

n  Ego identity – acceptance of choices made in their lives

n  Despair - Loss of spouse can be devastating

n  Stereotyping by society – ageism

Developmental Considerations

n Infant – gentle, calm.  Primary interaction with parents

n Preschooler – be direct.  Let play with equipment.  Only concrete explanation, don’t go into detail.

n School age – they are curious. Explain how and why.  Talk to child first than parent.

n Adolescent – be respectful.  Explain everything.  Avoid silence.

n Older adults – slow down.  Be respectful, patient.  Like to tell stories.

Approach to Identifying Priorities

n   Immediate priorities (ABCs)

n  Airway

n  Breathing

n  Circulation

n  Vital Signs

n   Second-level priorities

n  Mental status change

n  Acute pain

n  Urinary elimination problems

n  Untreated medical problem (diabetic without insulin)

n  Abnormal lab values

n  Risks of infection, safety, security

n   Third-level priorities

n  Lack of knowledge

n  Activity, rest, sleep

Health History

n   Establishes a rapport – relationship, understanding, trust

n   Helps to focus on the patient’s chief concern and sets the stage for the Physical Examination (PE)

n   Less invasive than the PE

n   Types of data

n  Subjective data – what person says about himself or herself

n  Objective – what you observe during a PE

 

Open-Ended Questions

n Broadly stated and encourage an open response

n Aim is to describe problem or symptoms

n “How are you feeling?”

 

Closed or Direct Questions

n Direct and specific questions to get details

n Aim is to focus on the problem.  More specific.

n “When did the pain begin? Is the pain sharp, dull, or achy?”

Phases of an Interview

n Introduction phase

n Nurse introduces self to client

n Nurse describes purpose of interview

n Nurse describes the process of the interview so that client knows how long interview will take and what to expect

n Discussion phase

n Nurse helps discussion

n Discussion is client centered

n Nurse uses various communication techniques to collect data

n Summary phase

n Summarization of data

n Allows for clarification of data

n Provides validation to the client that nurse understands problem

Internal and External Factors of Communication

Sending Messages

n  Appearance – clothing, hair, jewelry

n  Nonverbal communication – body language (gestures, facial expressions, eye contact, touch)

n  Verbal communication – empathy.  Speech – is it clear?  Can the patient understand you?

Receiving Messages

n  Overall appearance of patient – neat? wet? orderly or rowdy?

n  Nonverbal and verbal communication

n  Listening actively – requires complete attention.  What is the pt. not saying?  Difficulty with language, pronunciation, or memory?

Enhancing Data Collection

n  Facilitation – encouraging pt. to continue talking “uh-huh, go on, tell me more”

n  Silence – giving attention to the pt. to allow her to speak. Do not interrupt.

n  Reflection – repeating what the pt. has just told you.  “So you’re saying you’ve been in pain for 5 days and it is worse when you walk?”  Promotes trust from pt.  Insures what you heard is accurate.

n  Empathy – emotions.  If pt. just found out he has cancer.  “It must be so hard on you and your family.”

n  Confrontation and Clarification – clarify inconsistencies of data. A story can change, especially with embarrassing issues.

n  Interpretation – sharing with pt. the conclusions you have drawn.

n  Explanation – inform.  Could be about diet, medication use, etc.

n  Summary – review of data gathered.

Traps to Avoid

n  False assurances – everything’s not always ok

n  Unwanted advice – sometimes must let pt. decide.  Be objective. Give pt. all the facts.

n  Avoiding the issues – be direct and honest

n  Professional jargon

n  Biased questions – “You don’t smoke, do you?”

n  Talking too much and interrupting

n  Don’t ask “why” when the pt. might not have answer – why didn’t you stop smoking when you knew it was bad for you?

n  Answering personal questions – not necessary and might be uncomfortable. 

Interviewing Special Populations

n  Hearing Impaired

n Recognize clues such as staring at your mouth or face, speaking loudly

n Determine if there’s a better way to communicate such as writing or signing

n  Acutely Ill

n If pt. is in an emergency situation, ask priority questions first.  Use closed (direct questions).

n  Drugs or Alcohol Influenced

n Ask simple and direct questions.

n Try not to appear threatening

n  Sexually Aggressive People

n Very important to set professional boundaries

n Must make it clear you are a health professional and can best care for that person by maintaining a professional relationship

n  Crying

n It’s ok if a pt. cries.  It usually is a big relief to let out emotions.

n Do not move onto another topic.  Talk about what’s bothering him or her.

n  Anger and Threat of Violence

n Ask the pt. why they are angry and try to deal with the feelings

n If pt. becomes threatening, remember your safety comes first

n Leave the examining room and try to position yourself between the pt and the door

Domestic Violence Considerations

n  Most common people to become victims of abuse are the intimate partner and the elderly.

n  You must remember that reporting of abuse is one of the most important ways of preventing future occurrences

n  Don’t be afraid to ask the pt. if you suspect abuse.  You are an advocate for the patient.

n  Abuse Assessment Screen (AAS)

n “Because domestic violence is so common in our society, we are asking all women the following questions”

n  Document, Document, Document

n Write down direct quotes from pt. even if it includes swearing

AMA Definitions for Elder Abuse and Neglect

n  Physical abuse

n Violent acts that result or could result in injury, pain, impairment, and/or disease

n  Physical neglect

n Failure of family member or caregiver to provide basic goods and/or services such as food, shelter, health care, and medications

n  Psychological abuse

n Behaviors that result in mental anguish.  (Threats)

n  Psychological neglect

n Failing to provide basic social stimulation

n  Financial abuse

n Intentional misuse of elderly person’s financial resources without consent

n  Financial neglect

n Failure to use the assets of the elderly person to provide necessary services

Abuse Terminology

n  Abrasion

n  A wound caused by rubbing the skin or mucous membrane

n  Bruise (Contusion)

n  Superficial discoloration due to hemorrhage into the tissues from ruptured blood vessels beneath the skin surface

n  Ecchymosis

n  A hemorrhagic spot, larger than petechia, in the skin or mucous membrane, forming a nonelevated, round, or regular, blue or purplish patch

n  Hematoma

n  A localized collection of extravasated blood, usually clotted in an organ, space, or tissue

n  Hemorrhage

n  An escape of blood from a ruptured vessel, which can be external, internal, and/or into the skin or other organ

 

Abuse Pictures

n  Incision (Cut)

n  A cut or wound made by a sharp instrument

n  Laceration

n  A wound produced by tearing and/or splitting of body tissue, usually from blunt impact over a bony surface.

n  Lesion

n  Any pathologic or traumatic discoloration of tissue or loss of function

n  Patterned injury

n  An injury caused by an object that leaves a distinct pattern on the skin and/or organ

n  Petechiae

n  Small red or purple spot on the body

n  Disorders of coagulation.  Strangulation.

n  With bruising, should suspect abuse

n  Puncture

n  The act of piercing or penetrating with a pointed oubject

Components of Health History

n   The general survey

n   Fourteen cues to be observed

n  Age

n  Sex

n  Race

n  Vital Signs

n  Apparent state of health

n  Signs of distress

n  Facial expressions

n  Mood

n  State of awareness

n  Speech

n  Dress, grooming, personal hygiene

n  Nutrition

n  Stature

n  Posture and gait

n   Reasons for seeking health care

n   Health perception/Health management

n   Present health or history of present illness

n   Location

n   Quality

n   Quantity

n   Timing

n   Setting

n   Aggravating/alleviating factors

n   Associated factors

n   Client’s perception

n   Childhood illnesses

n   Adult illnesses

n Accidents/injuries

n Hospitalizations

n Surgeries

n Obstetric history

n Immunizations

n Physical examinations/dental visits

n Allergies/reactions

n Current medications

n Health maintenance

n Knowledge of current and past health and illness

n Communicable disease

n Social history

n Family history/genogram

 

n   Nutritional-metabolic pattern

n   Elimination pattern

n   Activity-exercise pattern

n   Sleep-rest pattern

n   Cognitive-Perceptual pattern

n   Role-relationship pattern

n   Sexuality-reproductive pattern

n   Coping-stress-tolerance pattern

n   Value-belief pattern

Functional Assessment (ADLs)

n  Self esteem

n  Activity and exercise

n  Sleep patterns

n  Nutritional assessment

n  Spiritual and social supports

n  Coping mechanisms

n  Alcohol, smoking, and drug use

n  Environmental hazards such as working conditions

n  Domestic violence assessment

 

Monitoring of growth and development is an important preventive measure for:

-   assessment of  nutritional and health status;

-   early detection of growth and development disorders due to malnutrition,  illness or psychosocial problems;

-   follow-up  efficiency of the treatment.

 

Biological and social determinants of growth and development

-         genetic factors;

-         environmental factors:

* social environment (differences in ethnic groups, socioeconomic groups);

     * nutrition (obesity – main nutrition related  problem in western countries);

-         health status (health care, immunization).

 

WHO growth reference data for infants and young children

In 1977, the WHO recommended referential growth charts based on longitudinal studies of the American population. These data were collected during a time when breastfeeding was in decline and complementary foods were introduced at a very early age. A number of studies revealed significant differences in growth between breastfed and formula fed infants. Breastfed infants grow and gain weight faster in the first 2 months and then their growth and weight gain slow down.  Formula fed infants grow faster in the second half of infancy probably due to an increased intake of proteins which stimulates the growth due to the influence of some aminoacids on the secretion of insulin  or a direct influence on the secretion of IGF-1. Formula fed infants also gain higher weights and are at a greater risk for obesity.

In 1997-2003, the WHO carried out a Multicentre Growth Reference Study (MGRS) in order to develop international growth standards based on a collection of data on growth and development in 8500 breastfed infants from different ethnic and cultural backgrounds of  good socioeconomic conditions (Brazil, Ghana, India, Norway, Oman, USA) which replaced the  referential data (height, weight, weight/height ratio) based on the American population. The new referential data on a triceps and subscapular skinfold,  head and arm circumference,  body mass index (BMI) and  growth velocity of followed up parameters were published in 2006. These data are important for monitoring the childhood obesity and malnutrition. The referential data of a motor development in children up to 5 years will be also published. The revision of growth monitoring by health professionals will be undertaken afterwards.

 

 

Monitoring of growth in CR (National Institute of Public Health)

 

-         A long tradition of anthropological research of children and adolescents, first research carried out in 1895 by prof. Matiegka

-         6 nationwide anthropological surveys every ten years from 1951 to 2001

-         Basic bodily characteristics (weight, length, height,  circumference of head, chest, waist, hip, arm) obtained in the representative sample – 3-5% of the population of the given age  from 0 to 18 years (80-100.000) together with data on SES, dietary habits, sports activity, health status, etc.

-         percentile graphs - standard instruments constructed on the basis of the growth referential data related to age and gender

-         indexes calculated – BMI = weight(kg)/(height (m))²

-                                        - weight/height ratio – for younger children

-         BMI = one of the most often used indices for the evaluation of actual body mass regarding the height. The percentile chart enables to assess the corpulence of an individual with regard to a reference population.

 

1995-96 – research on head dimensions, secular trend of height has stopped in girls and boys in postpubertal age.

 

1997-99 – a semilongitudinal survey of growth in schoolchildren

2.000 schoolchildren (6 to 15 years old) from different regions (measured 6 times in 6 months intervals)

-         growth rate of basic parametres (1cm lower in girls than boys)

-         growth spurt in girls 4 months earlier than in 1975 (11 years – 7 cm/year)

-         growth spurt in boys 3 months earlier than in 1975 (13 year – 8 cm/year)

-         education of parents – correlated with the height positively and with the weight negatively

-         children with severe illness were smaller (17% children).

 

1999-2000 – prevalence of obesity (European Child Obesity Group)

-         schoolchildren – 7-11 year (1529 boys, 1493 girls)

-         in comparison to 1991 – no increase in average BMI

-         increased prevalence of extremely obese children (5 % over 97^th percentile) – found more frequently in the families with one child, in obese children  inappropriate eating habits (frequency) found

-         distribution related to residence – lower prevalence in Prague in comparison to smaller towns.

 

2001 – 6^th  nationwide anthropological research

- anthropometric data (height, body weight and head, arm, waist and hip circumferences) on 18,584 children under 6 years of age and 40,525 school children and adolescents were collected with the participation of pediatricians, teachers (kindergartens, schools), public health staff and parents:

- the period of the fastest growth (maximum growth velocity) shifted gradually to younger age categories (13 years for boys, 11 years for girls)

- the mean age of menarché in girls was 13 years, the mean age of voice breaking in boys was 13.8 years

- these observations correspond to a more prominent  slow-down of the secular trend in height in girls and a less prominent height increment in boys

 - the proportion of 7 to 11 years old Czech children with overweight and obesity remains, in comparison with other European countries is lower, however, the increasing trend towards higher values is evident, the rates of obese children (>97^th centile) were 2.4 % for boys and 1.6 % for girls in 2001, the rates of overweight (90^th – 97^th centile) were 12.1 % for boys and 9.8 % for girls, the overwight an obesity rates in children are declining with age.

 

Growth charts

In centile charts, represented lines correspond to the 3^rd, 10^th, 25^th, 50^th, 75^th, 90^th and 97^th centiles for reference data at a given age. The 50^th centile represents the most frequent value for the body parameter found in the reference population.  Values above the middle line are higher than the average of the population of a given age while those below the middle line are lower than the average.

Under favourable conditions leading to full development of the genetic potential, i.e. when adequate health care, nutrition and socio-economic conditions are available, the growth curve of the followed child is parallel to centile curves in the range of the 25^th to 75^th centiles.

 

Growth charts based on the nationwide research are available for:

 

a) an individual assessment

- regular child growth monitoring is a part of  preventive pediatric examinations (Health and Immunization Record);

- endocrinology- used for the dg. of growth disorders;

- plastic surgery, etc.

 

b)    population groups assessment

-   environmental studies;

-   nutritional assessment (weight/height ratio, BMI, skinfolds percentile graphs).

 

The nursing process is a modified scientific method. Nursing practise was first described as a four stage nursing process by Ida Jean Orlando in 1958. It should not be confused with nursing theories or Health informatics. The diagnosis phase was added later.

The nursing process uses clinical judgement to strike a balance of epistomology between personal interpretation and research evidence in which critical thinking may play a part to categorize the clients issue and course of action. Nursing offers diverse patterns of knowing.Nursing knowledge has embraced pluralism since the 1970s.

Some authors refer to a mind map or abductive reasoning as a potential alternative strategy for organizing care. Intuition plays a part for experienced nurses.

The nursing process is goal-oriented method of caring that provides a framework to nursing care. It involves six major steps:

·         A

Assess (what data is collected?)

·        D

Diagnose (what is the problem?)

·         O

Outcome Identification - (Was originally a part of the Planning phase, but has recently been added as a new step in the complete process).

·         P

Plan (how to manage the problem)

·         I

Implement (putting plan into action)

·         R

Rationale (Scientific reason of the implementations)

·         E

Evaluate (did the plan work?)

According to some theorists, this six-steps description of the nursing process is outdated and misrepresents nursing as linear and atomic.^[7]

Assessing phase

The nurse completes an holistic nursing assessment of the needs of the individual/family/community, regardless of the reason for the encounter. The nurse collects subjective data and objectivedata using a nursing framework, such as Marjory Gordon's functional health patterns.

Models for data collection

Nursing assessments provide the starting point for determining nursing diagnoses. It is vital that a recognized nursing assessment framework is used in practice to identify the patient's* problems, risks and outcomes for enhancing health. The use of an evidence-based nursing framework such as Gordon's Functional Health Pattern Assessment should guide assessments that support nurses in determination of NANDA-I nursing diagnoses. For accurate determination of nursing diagnoses, a useful, evidence-based assessment framework is best practice.

Methods

·         Client Interview

·         Physical Examination

·         Obtaining a health history (including dietary data)

·         Family history/report

·         Diagnostic Data

·         Observation

Diagnosing phase

Nursing diagnoses represent the nurse's clinical judgment about actual or potential health problems/life process occurring with the individual, family, group or community. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the defining characteristics, related factors and/or risk factors found within the patients assessment. Multiple nursing diagnoses may be made for one client.

Planning phase

In agreement with the client, the nurse addresses each of the problems identified in the diagnosing phase. When there are multiple nursing diagnoses to be addressed, the nurse prioritizes which diagnoses will receive the most attention first according to their severity and potential for causing more serious harm. For each problem a measurable goal/outcome is set. For each goal/outcome, the nurse selects nursing interventions that will help achieve the goal/outcome. A common method of formulating the expected outcomes is to use the evidence-based Nursing Outcomes Classification to allow for the use of standardized language which improves consistency of terminology, definition and outcome measures. The interventions used in the Nursing Interventions Classification again allow for the use of standardized language which improves consistency of terminology, definition and ability to identify nursing activities, which can also be linked to nursing workload and staffing indices. The result of this phase is a nursing care plan.

A nursing care plan outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified bynursing assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.

1.   Its focus is holistic, and is based on the clinical judgment of the nurse, using assessment data collected from a nursing framework.

2.   It is based upon identifiable nursing diagnoses (actual, risk or health promotion) - clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes.

3.   It focuses on client-specific nursing outcomes that are realistic for the care recipient

4.   It includes nursing interventions which are focused on the etiologic or risk factors of the identified nursing diagnoses.

5.   It is a product of a deliberate systematic process.

6.   It relates to the future

The nursing care plan consists of a nursing diagnosis with defining characteristics (subjective and objective data that support the diagnosis), related factors or risk factors, expected outcomes/goals, and nursing interventions.

Implementing phase

The nurse implements the nursing care plan, performing the determined interventions that were selected to help meet the goals/outcomes that were established. Delegated tasks and the monitoring of them is included here as well.

Evaluating phase

The nurse evaluates the progress toward the goals/outcomes identified in the previous phases. If progress towards the goal is slow, or if regression has occurred, the nurse must change the plan of care accordingly. Conversely

The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the individual/family/community has. The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well.

·         Cyclic and dynamic

·         Goal directed and client centered

·         Interpersonal and collaborative

·         Universally applicable

·         Systematic

The entire process is recorded or documented in order to inform all members of the health care team.

The Nursing Process

The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care.

Assessment
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.

Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.

Outcomes/Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.

Implementation
Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.

Evaluation
Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

The medical history or (medical) case history (also called anamnesis, especially historically)(abbr. Hx) of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.

The information obtained in this way, together with clinical examination, enables the physician to form a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis.

Example

A practitioner typically asks questions to obtain the following information about the patient:

·         Identification and demographics: name, age, height, weight.

·         The "chief complaint (CC)" - the major health problem or concern, and its time course (e.g. chest pain for past 4 hours).

·         History of the present illness (HPI) - details about the complaints, enumerated in the CC. (Also often called 'History of presenting complaint' or HPC.)

·         Past medical history (PMH) (including major illnesses, any previous surgery/operations (sometimes distinguished as "Past Surgical History" or PSH), any current ongoing illness, e.g. diabetes).

·         Review of systems (ROS) Systematic questioning about different organ systems

·         Family diseases - especially those relevant to the patient's chief complaint.

·         Childhood diseases - this is very important in pediatrics.

·         Social history (medicine) - including living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, otherrecreational drug use), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets.

·         Regular and acute medications (including those prescribed by doctors, and others obtained over-the-counter or alternative medicine)

·         Allergies - to medications, food, latex, and other environmental factors

·         Sexual history, obstetric/gynecological history, and so on, as appropriate.

·         Conclusion & closure

History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practiced by busy clinicians). Computerized history-taking could be an integral part of clinical decision support systems.

Whatever system a specific condition may seem restricted to, all the other systems are usually reviewed in a comprehensive history. The review of systems often includes all the main systems in the body that may provide an opportunity to mention symptoms or concerns that the individual may have failed to mention in the history. Health care professionals may structure the review of systems as follows:

·         Cardiovascular system(chest pain, dysponea, ankle swelling, palpitations) are the most important symptoms and you can ask for a brief description for each of the positive symptoms.

·         Respiratory system (cough, haemoptysis, wheezing, pain localized to the chest that might increase with inspiration or expiration).

·         Gastrointestinal system (change in weight, flatulence and heart burn, dysphagia, abdominal pain, vomiting, bowel habit).

·         Genitourinary system (frequency in urination, pain with micturition, urine color, any urethral discharge, altered bladder control like urgency in urination or incontinance, menstruation and sexual activity).

·         Nervous system (Headache, loss of consciousness, diziness and vertigo, speech and related functions like reading and writing skills and memory).

·         Cranial nerves symptoms (Vision, diplopia, facial numbness, deafness, oropharyngial dysphagia, limb motor or sensory symptoms and loss of coordination).

·         Endocrine system (weight loss, polydipsia, polyuria, increased appetite and irritability).

·         Musculoskeletal system (any bone or joint pain accompanied by joint swelling or tenderness, aggavating and reliefing factors for the pain and any positive family history for joint disease).

·         Skin (any skin rash, recent change in cosmetics and the use of sunscreen creams when exposed to sun).

Factors that inhibit a proper medical history taking include physical inability of the patient to communicate with the physician, such as unconsciousness and communication disorders. In such cases, it may be necessary to perform a so-called heteroanamnesis of other people who know the person and can give suitable information, which, however, generally is more limited than a direct anamnesis.

Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship, such as transitions to physicians that are unfamiliar to the patient.

History taking of issues related to sexual or reproductive medicine may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information. Even if such an issue is on the patient's mind, he or she often doesn't start talking about such an issue without the physician initiating the subject by a specific question about sexual or reproductive health. Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues.^[4] When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level.

Computer-assisted history taking systems have been available since the 1960s.However, their use remains variable across healthcare delivery systems.

One advantage of using computerized systems as an auxiliary or even primary source of medically related information is that patients may be less susceptible to social desirability bias.^[6] For example, patients may be more likely to report that they have engaged in unhealthy lifestyle behaviors. Another advantage of using computerized systems is that they allow easy and high-fidelity portability to a patient's electronic medical record.

One disadvantage of current (2012) medical history systems is that they cannot detect non-verbal communication, which may be useful for elucidating anxieties and treatment plans. Another disadvantage is that people may feel less comfortable communicating with a computer as opposed to a human. In a sexual history-taking setting in Australia using a computer-assisted self-interview, 51% of people were very comfortable with it, 35% were comfortable with it, and 14% were either uncomfortable or very uncomfortable with it.

The evidence for or against computer-assisted history taking systems is sparse. For example, as of 2011, there are no randomized control trials comparing computer-assisted versus traditional oral-and-written family history taking to identifying patients with an elevated risk of developing type 2 diabetes mellitus.

The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and careacross time within one particular health care provider's jurisdiction. The medical record includes a variety of types of "notes" entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.

The terms are used for both the physical folder that exists for each individual patient and for the body of information found therein.

Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites. This concept is supported by US national health administration entities and by AHIMA, the American Health Information Management Association.

A medical record folder being pulled from the records

Because many consider the information in medical records to be sensitive personal information covered by expectations of privacy, manyethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal. Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request.

The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.

The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.

Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.

Auxiliary purpose

In addition, the individual medical record anonymised may serve as a document to educate medical students/resident physicians, to provide data for internal hospital auditing and quality assurance, and to provide data for medical research and development.

A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient. Further information varies with the individual medical history of the patient.

Traditionally, medical records were written on paper and maintained in folders often divided into sections for each type of note (progress note, order, test results), with new information added to each section chronologically. Active records are usually housed at the clinical site, but older records are often archived offsite.

The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for medical research.

Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records.

Medical history

The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease states. It includes several subsets detailed below.

Surgical history

The surgical history is a chronicle of surgery performed for the patient. It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did.

Obstetric history

The obstetric history lists prior pregnancies and their outcomes. It also includes any complications of these pregnancies.

Medications and medical allergies

The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies.

Family history

The family history lists the health status of immediate family members as well as their causes of death (if known).^[8] It may also list diseases common in the family or found only in one sex or the other. It may also include a pedigree chart. It is a valuable asset in predicting some outcomes for the patient.

Social history

The social history is a chronicle of human interactions. It tells of the relationships of the patient, his/her careers and trainings, schooling and religious training. It is helpful for the physician to know what sorts of community support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure to asbestos).

Habits

Various habits which impact health, such as tobacco use, alcohol intake, exercise, and diet are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and sexual orientation.

Immunization history

The history of vaccination is included. Any blood tests proving immunity will also be included in this section.

Growth chart and developmental history

For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child's growth over time. Many diseases and social stresses can affect growth and longitudinal charting and can thus provide a clue to underlying illness. Additionally, a child's behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.

Medical encounters

Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the problem-oriented medical record (POMR), which includes a problem list of diagnoses or a "SOAP" method of documentation for each visit. Each encounter will generally contain the aspects below:

Chief complaint

This is the main problem (traditionally called a complaint) that has brought the patient to see the doctor or other clinician. Information on the nature and duration of the problem will be explored.

History of the present illness

A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention.

Physical examination

The physical examination is the recording of observations of the patient. This includes the vital signs , muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing.

Assessment and plan

The assessment is a written summation of what are the most likely causes of the patient's current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.).

Orders and prescriptions

Written orders by medical providers are included in the medical record. These detail the instructions given to other members of the health care team by the primary providers.

Progress notes

When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They are kept in chronological order and document the sequence of events leading to the current state of health.

Test results

The results of testing, such as blood tests (e.g., complete blood count) radiology examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized testing (e.g., pulmonary function testing) are included. Often, as in the case of X-rays, a written report of the findings is included in lieu of the actual film.

Other information

Many other items are variably kept within the medical record. Digital images of the patient, flowsheets from operations/intensive care units, informed consent forms, EKG tracings, outputs from medical devices (such as pacemakers), chemotherapy protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments.

Medical records are legal documents that can be used as evidence via a subpoena duces tecum, and are thus subject to the laws of the country/state in which they are produced. As such, there is great variability in rules governing production, ownership, accessibility, and destruction. There is some controversy regarding proof verifying the facts, or absence of facts in the record, apart from the medical record itself

Demographics

Demographics include patient information that is not medical in nature. It is often information to locate the patient, including identifying numbers, addresses, and contact numbers. It may contain information about race and religion as well as workplace and type of occupation. It also contains information regarding the patient's health insurance. It is common to also find emergency contact information located in this section of the medical chart.

Production

In the United States, written records must be marked with the date and time and scribed with indelible pens without use of corrective paper. Errors in the record should be struck out with a single line (so that the initial entry remains legible) and initialed by the author. Orders and notes must be signed by the author. Electronic versions require an electronic signature.

Ownership and keeping of patient's records varies from country to country.

In the United States, the data contained within the medical record belongs to the patient, whereas the physical form the data takes belongs to the entity responsible for maintaining the record per the Health Insurance Portability and Accountability Act. Patients have the right to ensure that the information contained in their record is accurate, and can petition their health care provider to amend factually incorrect information in their records.

In the United Kingdom, ownership of the NHS's medical records has in the past generally been described as belonging to the Secretary of State for Health and this is taken by some to mean copyright also belongs to the authorities.

In Germany ownership of patient's records is not explicitly codified. Hence traditional keeping of patient's records is with the hospitals and the practitioners. There is no comprehensive data set containing all information on one patient in one file defined yet. Since 1995, patients are identified via a health insurance card that includes name and address information as well as an ID assigned by the insurance provider. An upgrade to advanced health insurance cards (Elektronische Gesundheitskarte) that can store additional medical information was planned for 2006. Discussion on the benefit, the associated cost, and on data privacy issues is still ongoing as of 2011. There is no comprehensive data set containing all information on one patient in one file defined yet. Since 1997, patients are idntified via a health insurance card that includes name and address information as well as ID assigned by the insurance provide.

Capacity

When a patient does not have capacity (is not legally able) to make decisions regarding his or her own care, a legal guardian is designated (either through next of kin or by action of a court of law if no kin exists). Legal guardians have the ability to access the medical record in order to make medical decisions on the patient’s behalf. Those without capacity include the comatose, minors (unless emancipated), and patients with incapacitating psychiatric illness or intoxication.

Medical emergency

In the event of a medical emergency involving a non-communicative patient, consent to access medical records is assumed unless written documentation has been previously drafted (such as an advance directive)

Research, auditing, and evaluation

Individuals involved in medical research, financial or management audits, or program evaluation have access to the medical record. They are not allowed access to any identifying information, however.

Risk of death or harm

Information within the record can be shared with authorities without permission when failure to do so would result in death or harm, either to the patient or to others. Information cannot be used, however, to initiate or substantiate a charge unless the previous criteria are met (i.e., information from illicit drug testing cannot be used to bring charges of possession against a patient). This rule was established in the United States Supreme Court case Jaffe v. Redmond

In the United Kingdom, the Data Protection Acts and later the Freedom of Information Act 2000 gave patients or their representatives the right to a copy of their record, except where information breaches confidentiality (e.g., information from another family member or where a patient has asked for information not to be disclosed to third parties) or would be harmful to the patient's wellbeing (e.g., some psychiatric assessments). Also, the legislation gives patients the right to check for any errors in their record and insist that amendments be made if required.

Destruction

In general, entities in possession of medical records are required to maintain those records for a given period. In the United Kingdom, medical records are required for the lifetime of a patient and legally for as long as that complaint action can be brought. Generally in the UK, any recorded information should be kept legally for 7 years, but for medical records additional time must be allowed for any child to reach the age of responsibility (20 years). Medical records are required many years after a patient’s death to investigate illnesses within a community (e.g., industrial or environmental disease or even deaths at the hands of doctors committing murders, as in the Harold Shipman case)

A physical examination, medical examination, or clinical examination (more popularly known as a check-up or medical) is the process by which a medical professional investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosisand devising the treatment plan. This data then becomes part of the medical record.

A Cochrane Collaboration meta-study found that routine annual physicals did not measurably reduce the risk of illness or death, and conversely, could lead to over-diagnosis and over-treatment. The authors concluded that routine physicals were unlikely to do more good than harm.^[1]

A physical examination may be provided under health insurance cover, required of new insurance customers, or stipulated as a condition of employment (in this case, it is called pre employment medical clearance). This is a part of the insurance medicine. In the United States, physicals are also marketed to patients as a one-stop health review, avoiding the inconvenience of attending multiple appointments with different healthcare providers. Comprehensive physical exams of this type are also known as executive physicals, and typically include laboratory tests, chest x-rays, pulmonary function testing, audiograms, full body CAT scanning, EKGs, heart stress tests, vascular age tests, urinalysis, and mammograms or prostate exams depending on gender. The executive physical format was developed from the 1970s by the Mayo Clinic and is now offered by other health providers, including Johns Hopkins University, EliteHealth and Mount Sinai in New York City. Executive physicals are also the primary service of concierge doctors who claim to do a more thorough examination for a cash premium on top of the insurance coverage.

While elective physical exams have become more elaborate, in routine use physical exams have become less complete. This has led to editorials in medical journals about the importance of an adequate physical examination.  In addition to the possibility of identifying signs of illness, it has been described as a ritual that plays a significant role in the doctor-patient relationship. Physicians at Stanford University medical school have introduced a set of 25 key physical examination skills that were felt to be useful.

 

Auscultation of a man in Vietnam

Although providers have varying approaches as to the sequence of body parts, a systematic examination generally starts at the head and finishes at the extremities. After the main organ systems have been investigated by inspection, palpation, percussion, and auscultation, specific tests may follow (such as a neurological investigation, orthopedic examination) or specific tests when a particular disease is suspected (e.g. elicitingTrousseau's sign in hypocalcemia).

With the clues obtained during the history and physical examination the healthcare provider can now formulate a differential diagnosis, a list of potential causes of the symptoms. Specific diagnostic tests (or occasionally empirical therapy) generally confirm the cause, or shed light on other, previously overlooked, causes.

While the format of examination as listed below is largely as taught and expected of students, a specialist will focus on their particular field and the nature of the problem described by the patient. Hence a cardiologist will not in routine practice undertake neurological parts of the examination other than noting that the patient is able to use all four limbs on entering the consultation room and during the consultation become aware of their hearing, eyesight and speech. Likewise an Orthopaedic surgeon will examine the affected joint, but may only briefly check the heart sounds and chest to ensure that there is not likely to be any contraindication to surgery raised by the anaesthetist. A primary care physician will also generally examine the male genitals but may leave the examination of the female genitalia to a gynecologist.

A complete physical examination includes evaluation of general patient appearance and specific organ systems. It is recorded in the medical record in a standard layout which facilitates others later reading the notes. In practice the vital signs of temperature examination, pulse and blood pressure are usually measured first.

Example

Section	Sample text	Comments
General	"Patient in NAD. VS: WNL"	May be split on two lines. "WNL" = "within normal limits".
HEENT:	"NC/AT. PERRLA, EOMI. No cervical LAD, no thyromegaly, no bruit, no pallor,fundus WNL, oropharynxWNL, tympanic membrane WNL, neck supple"	"Neck" is sometimes split out from "Head". "Good dentition" may be noted.
Resp or "Chest"	"Nontender, CTA bilat" Chest expansion test, normal breathing with little effort, absence of wheezing, rhonchi and crackles.	More detailed examinations can include rales, rhonchi, wheezing ("no r/r/w"), and rubs. Other phrases may include "no cyanosis or clubbing" (if section is labeled "Resp" and not "Chest"), "fremitus WNL", and "no dullnes to percussion".
CV or "Heart"	"+S1, +S2, RRR, no m/r/g"	If "CV" is used instead of "heart", peripheral pulses are sometimes included in this section (otherwise, they may be in the extremities section)
Abd	"Soft, nontender, nondistended, absence of pain, no hepatosplenomegaly, NBS"	If lower back pain is involved, then the "Back" may become a primary section. Costovertebral angle tenderness may be included in the abdominal section if there is no back section. More detailed examinations may report "+psoas sign, +Rovsing's sign, +obturator sign". If tenderness was present, it might be reported as "Direct and rebound RLQ tenderness". "NBS" stands for "normal bowel sounds"; alternatives might include "hypoactive BS" or "hyperactive BS".
Ext	"No clubbing, cyanosis, edema"	Checking the fingers for clubbing and cyanosis is sometimes considered part of the pulmonary exam, because it closely involves oxygenation. Examinations of the knee may involve the McMurray test, Lachman test, and drawer test.
Neuro	"A&Ox3, CN II-XII grossly intact, Sensation intact in all four extremities (dull and sharp), DTR 2+ bilat, Romberg negative, cerebellar reflexes WNL, normal gait"	Sensation may be expanded to include dull, sharp, vibration, temperature, and position sense. A mental status exam may be reported at the beginning of the neurologic exam, or under a distinct "Psych" section.

Depending upon the chief complaint, additional sections may be included. For example, hearing may be evaluated with a specific Weber test and Rinne test, or it may be more briefly addressed in a cranial nerve exam. To give another example, a neurological related complaint might be evaluated with a specific test, such as the Romberg maneuver.

The primary vital signs are:

·         Temperature recording

·         Blood pressure

·         Pulse

·         Respiratory rate

A meta-study performed for the Nordic Cochrane Centre found that general health checks did not reduce the risk of death from cancer, heart disease, or any other cause, and could not be proved to affect the patient's likelihood of being admitted to the hospital, becoming disabled, missing work, or needing additional office visits. The study found no effect on the risk of illness, but did find evidence suggesting that patients subject to routine physicals were diagnosed with hypertension and other chronic conditions at a higher rate than those who were not. Its authors noted that studies often failed to consider or report possible harmful outcomes (such as unwarranted anxiety or unnecessary follow-up procedures), and concluded that routine health checks were "unlikely to be beneficial."

The general medical examination is a common form of preventive medicine involving visits to a general practitioner by asymptomatic adults on a regular basis. This is generally yearly or less frequently. It is known under several other names, such as the periodic health evaluation, annual physical, comprehensive medical exam, general health check, or preventive health examination.

The term is generally not meant to include visits for the purpose of newborn checks, Pap smears for cervical cancer, or regular visits for people with certain chronic medical disorders (for example,diabetes).^[1] The general medical examination generally involves a medical history, a (brief or complete) physical examination and sometimes laboratory tests. Some more advanced tests include ultrasound and mammography.

Although annual medical examinations are a routine practice in several countries, it is poorly supported by scientific evidence in the majority of the population. A 2012 Cochrane review did not find any benefit with respect to the risk of death or poor outcomes related to disease in those who received them. People who undergo yearly medical exams however are more likely to be diagnosed with medical problems.

Some notable health organisations recommend against annual examinations. The American Cancer Society recommends a cancer-related health check-up annually in men and women older than 40, and every three years for those older than 20.

A systematic review of studies until September 2006 concluded that the examination does result in better delivery of some other screening interventions (such as Pap smears, cholesterolscreening, and faecal occult blood tests) and less patient worry. Evidence supports several of these individual screening interventions.The effects of annual check-ups on overall costs, patient disability and mortality, disease detection, and intermediate end points such a blood pressure or cholesterol, are inconclusiveA recent study found that the examination is associated with increased participation in cancer screening.

The lack of good evidence contrasts with population surveys showing that the general public is fond of these examinations, especially when they are free of charge. Despite guidelines recommending against routine annual examinations, many family physicians perform them. A fee-for-service healthcare system has been suggested to promote this practice. An alternative would be to tailor the screening interval to the age, sex, medical conditions and risk factors of each patient. This means choosing between a wide variety of tests.

The arguments for and against are similar for many other screening interventions. The possible advantages include detection and subsequent prevention or early treatment for conditions such ashigh blood pressure, alcohol abuse, smoking, unhealthy diet, obesity and various cancers. Moreover, they could improve the patient-physician relationship and decrease patient anxiety. New York doctor finds that more and more private insurance companies and even Medicare include annual physical in their coverage. Some employers require a mandatory health checkup before hiring a candidate. Most surgeons will ask a patient for his or her recent general medical examination results in order to proceed with the surgery.  Disadvantages cited include the time and money that could be saved by a more targeted screening (health economics argument), a possible increased anxiety over health risks (medicalisation), overdiagnosis and harm resulting from unnecessary testing to detect or confirm medical problems.

It is commonly performed in the United States and the United Kingdom, whereas the practice varies among mainland European countries.

The roots of the periodic medical examination are not entirely clear. They seem to have been advocated since the 1920s. Some authors point to pleads from the 19th and early 20th century for the early detection of diseases like tuberculosis, and periodic school health examinations. The advent of medical insurance and related commercial influences seems to have promoted the examination, whereas this practice has been subject to controversy in the age of evidence-based medicine. Several studies have been performed before current evidence-based recommendation for screening were formulated, limiting the applicability of these studies to current-day practice.

Erikson’s Stages of Psychosocial Development

Like Piaget, Erik Erikson (1902-1994) maintained that children develop in a predetermined order. Instead of focusing on cognitive development, however, he was interested in how children socialize and how this affects their sense of self. Erikson’s Theory of Psychosocial Development has eight distinct stage, each with two possible outcomes. According to the theory, successful completion of each stage results in a healthy personality and successful interactions with others. Failure to successfully complete a stage can result in a reduced ability to complete further stages and therefore a more unhealthy personality and sense of self. These stages, however, can be resolved successfully at a later time.

Trust Versus Mistrust. From ages birth to one year, children begin to learn the ability to trust others based upon the consistency of their caregiver(s). If trust develops successfully, the child gains confidence and security in the world around him and is able to feel secure even when threatened. Unsuccessful completion of this stage can result in an inability to trust, and therefore an sense of fear about the inconsistent world. It may result in anxiety, heightened insecurities, and an over feeling of mistrust in the world around them.

Autonomy vs. Shame and Doubt. Between the ages of one and three, children begin to assert their independence, by walking away from their mother, picking which toy to play with, and making choices about what they like to wear, to eat, etc. If children in this stage are encouraged and supported in their increased independence, they become more confident and secure in their own ability to survive in the world. If children are criticized, overly controlled, or not given the opportunity to assert themselves, they begin to feel inadequate in their ability to survive, and may then become overly dependent upon others, lack self-esteem, and feel a sense of shame or doubt in their own abilities.

Initiative vs. Guilt. Around age three and continuing to age six, children assert themselves more frequently. They begin to plan activities, make up games, and initiate activities with others. If given this opportunity, children develop a sense of initiative, and feel secure in their ability to lead others and make decisions. Conversely, if this tendency is squelched, either through criticism or control, children develop a sense of guilt. They may feel like a nuisance to others and will therefore remain followers, lacking in self-initiative.

Industry vs. Inferiority. From age six years to puberty, children begin to develop a sense of pride in their accomplishments. They initiate projects, see them through to completion, and feel good about what they have achieved. During this time, teachers play an increased role in the child’s development. If children are encouraged and reinforced for their initiative, they begin to feel industrious and feel confident in their ability to achieve goals. If this initiative is not encouraged, if it is restricted by parents or teacher, then the child begins to feel inferior, doubting his own abilities and therefore may not reach his potential.

Identity vs. Role Confusion. During adolescence, the transition from childhood to adulthood is most important. Children are becoming more independent, and begin to look at the future in terms of career, relationships, families, housing, etc. During this period, they explore possibilities and begin to form their own identity based upon the outcome of their explorations. This sense of who they are can be hindered, which results in a sense of confusion ("I don’t know what I want to be when I grow up") about themselves and their role in the world.

Intimacy vs. Isolation. Occurring in Young adulthood, we begin to share ourselves more intimately with others. We explore relationships leading toward longer term commitments with someone other than a family member. Successful completion can lead to comfortable relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression.

Generativity vs. Stagnation. During middle adulthood, we establish our careers, settle down within a relationship, begin our own families and develop a sense of being a part of the bigger picture. We give back to society through raising our children, being productive at work, and becoming involved in community activities and organizations. By failing to achieve these objectives, we become stagnant and feel unproductive.

 

Ego Integrity vs. Despair. As we grow older and become senior citizens, we tend to slow down our productivity, and explore life as a retired person. It is during this time that we contemplate our accomplishments and are able to develop integrity if we see ourselves as leading a successful life. If we see our lives as unproductive, feel guilt about our pasts, or feel that we did not accomplish our life goals, we become dissatisfied with life and develop despair, often leading to depression and hopelessness.

Freud’s Stages of Psychosexual Development

Sigmund Freud (1856-1939) is probably the most well known theorist when it comes to the development of personality. Freud’s Stages of Psychosexual Developmentare, like other stage theories, completed in a predetermined sequence and can result in either successful completion or a healthy personality or can result in failure, leading to an unhealthy personality. This theory is probably the most well known as well as the most controversial, as Freud believed that we develop through stages based upon a particular erogenous zone. During each stage, an unsuccessful completion means that a child becomes fixated on that particular erogenous zone and either over– or under-indulges once he or she becomes an adult.

Oral Stage (Birth to 18 months). During the oral stage, the child if focused on oral pleasures (sucking). Too much or too little gratification can result in an Oral Fixation or Oral Personality which is evidenced by a preoccupation with oral activities. This type of personality may have a stronger tendency to smoke, drink alcohol, over eat, or bite his or her nails. Personality wise, these individuals may become overly dependent upon others, gullible, and perpetual followers. On the other hand, they may also fight these urges and develop pessimism and aggression toward others.

Anal Stage (18 months to three years). The child’s focus of pleasure in this stage is on eliminating and retaining feces. Through society’s pressure, mainly via parents, the child has to learn to control anal stimulation. In terms of personality, after effects of an anal fixation during this stage can result in an obsession with cleanliness, perfection, and control (anal retentive). On the opposite end of the spectrum, they may become messy and disorganized (anal expulsive).

Phallic Stage (ages three to six). The pleasure zone switches to the genitals. Freud believed that during this stage boy develop unconscious sexual desires for their mother. Because of this, he becomes rivals with his father and sees him as competition for the mother’s affection. During this time, boys also develop a fear that their father will punish them for these feelings, such as by castrating them. This group of feelings is known as Oedipus Complex ( after the Greek Mythology figure who accidentally killed his father and married his mother).

Later it was added that girls go through a similar situation, developing unconscious sexual attraction to their father. Although Freud Strongly disagreed with this, it has been termed the Electra Complex by more recent psychoanalysts.

According to Freud, out of fear of castration and due to the strong competition of his father, boys eventually decide to identify with him rather than fight him. By identifying with his father, the boy develops masculine characteristics and identifies himself as a male, and represses his sexual feelings toward his mother. A fixation at this stage could result in sexual deviancies (both overindulging and avoidance) and weak or confused sexual identity according to psychoanalysts.

 

Latency Stage (age six to puberty). It’s during this stage that sexual urges remain repressed and children interact and play mostly with same sex peers.

 

Genital Stage (puberty on). The final stage of psychosexual development begins at the start of puberty when sexual urges are once again awakened. Through the lessons learned during the previous stages, adolescents direct their sexual urges onto opposite sex peers, with the primary focus of pleasure is the genitals.

Freud's Structural and Topographical Models of Personality

 

Sigmund Freud's Theory is quite complex and although his writings on psychosexual development set the groundwork for how our personalities developed, it was only one of five parts to his overall theory of personality.  He also believed that different driving forces develop during these stages which play an important role in how we interact with the world.

 

Structural Model (id, ego, superego)

 

According to Freud, we are born with our Id.  The id is an important part of our personality because as newborns, it allows us to get our basic needs met.  Freud believed that the id is based on our pleasure principle.  In other words, the id wants whatever feels good at the time, with no consideration for the reality of the situation.  When a child is hungry, the id wants food, and therefore the child cries.  When the child needs to be changed, the id cries.  When the child is uncomfortable, in pain, too hot, too cold, or just wants attention, the id speaks up until his or her needs are met.

 

The id doesn't care about reality, about the needs of anyone else, only its own satisfaction.  If you think about it, babies are not real considerate of their parents' wishes.  They have no care for time, whether their parents are sleeping, relaxing, eating dinner, or bathing.  When the id wants something, nothing else is important.

 

Within the next three years, as the child interacts more and more with the world, the second part of the personality begins to develop.  Freud called this part theEgo.  The ego is based on the reality principle.  The ego understands that other people have needs and desires and that sometimes being impulsive or selfish can hurt us in the long run.  Its the ego's job to meet the needs of the id, while taking into consideration the reality of the situation.  

 

By the age of five, or the end of the phallic stage of development, the Superego develops.  The Superego is the moral part of us and develops due to the moral and ethical restraints placed on us by our caregivers.  Many equate the superego with the conscience as it dictates our belief of right and wrong.

 

In a healthy person, according to Freud, the ego is the strongest so that it can satisfy the needs of the id, not upset the superego, and still take into consideration the reality of every situation.  Not an easy job by any means, but if the id gets too strong, impulses and self gratification take over the person's life.  If the superego becomes to strong, the person would be driven by rigid morals, would be judgmental and unbending in his or her interactions with the world.  You'll learn how the ego maintains control as you continue to read.

 

Topographical Model

 

Freud believed that the majority of what we experience in our lives, the underlying emotions, beliefs, feelings, and impulses are not available to us at a conscious level.  He believed that most of what drives us is buried in our unconscious.  If you remember the Oedipus and Electra Complex, they were both pushed down into the unconscious, out of our awareness due to the extreme anxiety they caused.  While buried there, however, they continue to impact us dramatically according to Freud.

 

The role of the unconscious is only one part of the model.  Freud also believed that everything we are aware of is stored in our conscious.  Our conscious makes up a very small part of who we are.  In other words, at any given time, we are only aware of a very small part of what makes up our personality; most of what we are is buried and inaccessible.

 

The final part is the preconscious or subconscious.  This is the part of us that we can access if prompted, but is not in our active conscious.  Its right below the surface, but still buried somewhat unless we search for it.  Information such as our telephone number, some childhood memories, or the name of your best childhood friend is stored in the preconscious.

 

Because the unconscious is so large, and because we are only aware of the very small conscious at any given time, this theory has been likened to an iceberg, where the vast majority is buried beneath the water's surface.  The water, by the way, would represent everything that we are not aware of, have not experienced, and that has not been integrated into our personalities, referred to as the nonconscious.

 

 

Ego Defense Mechanisms

 

We stated earlier that the ego's job was to satisfy the id's impulses, not offend the moralistic character of the superego, while still taking into consideration the reality of the situation.  We also stated that this was not an easy job.  Think of the id as the 'devil on your shoulder' and the superego as the 'angel of your shoulder.'  We don't want either one to get too strong so we talk to both of them, hear their perspective and then make a decision.  This decision is the ego talking, the one looking for that healthy balance.

 

Before we can talk more about this, we need to understand what drives the id, ego, and superego.  According to Freud, we only have two drives; sex and aggression.  In other words, everything we do is motivated by one of these two drives.

 

Sex, also called Eros or the Life force, represents our drive to live, prosper, and produce offspring.  Aggression, also called Thanatos or our Death force, represents our need to stay alive and stave off threats to our existence, our power, and our prosperity.

 

Now the ego has a difficult time satisfying both the id and the superego, but it doesn't have to do so without help.  The ego has some tools it can use in its job as the mediator, tools that help defend the ego.  These are called Ego Defense Mechanisms or Defenses.  When the ego has a difficult time making both the id and the superego happy, it will employ one or more of these defenses:

 

 

 

Ego defenses are not necessarily unhealthy as you can see by the examples above.  In face, the lack of these defenses, or the inability to use them effectively can often lead to problems in life.  However, we sometimes employ the defenses at the wrong time or overuse them, which can be equally destructive.

Kohlberg’s Stages of Moral Development

Although it has been questioned as to whether it applied equally to different genders and different cultures, Kohlberg’s (1973) stages of moral development is the most widely cited. It breaks our development of morality into three levels, each of which is divided further into two stages:

Preconventional Level (up to age nine):

     ~Self Focused Morality~

1. Morality is defined as obeying rules and avoiding negative consequences. Children in this stage see rules set, typically by parents, as defining moral law.

2. That which satisfies the child’s needs is seen as good and moral.

Conventional Level (age nine to adolescence):

     ~Other Focused Morality~

3. Children begin to understand what is expected of them by their parents, teacher, etc. Morality is seen as achieving these expectations.

4. Fulfilling obligations as well as following expectations are seen as moral law for children in this stage.

Postconventional Level (adulthood):

     ~Higher Focused Morality~ 

5. As adults, we begin to understand that people have different opinions about morality and that rules and laws vary from group to group and culture to culture. Morality is seen as upholding the values of your group or culture.

 

6. Understanding your own personal beliefs allow adults to judge themselves and others based upon higher levels of morality. In this stage what is right and wrong is based upon the circumstances surrounding an action. Basics of morality are the foundation with independent thought playing an important role.