Health Assessment Chapter 3

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Health Assessment Chapter 3
2012-05-28 02:07:35
Health history

Interviewing to obtain a health history
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  1. Phases of an Interview
    • Introduction Phase
    • Discussion Phase
    • Summary Phase
  2. Introduction Phase of an Interview
    • Nurse introduces self to client
    • Nurse describes the purpose of the interview
    • Nurse describes the process of the interview so client knows how long interview will take and what to expect
  3. Discussion Phase of an Interview
    • Nurse facilitates discussion
    • Discussion is client centered
    • Nurse uses various communication techniques to collect data
  4. Summary Phase of an Interview
    • Summarization of data
    • Allows for clarification of data
    • Provides validation to the client that the nurse understands problems.
  5. The Physical Setting of an Interview
    • Private
    • Quiet
    • Comfortable (temperature, personal space, street clothes)
    • Free from Distraction
  6. Professional Nursing Behavior
    • Good Personal Hygiene : clean hair, nails, and modest dress
    • Professional yet warm demeanor
    • Make every attempt to understand client's POV
    • Avoid being careless with words
    • Avoid extremes of reaction-- startle, surprise, laughter, grimacing-- as clients provide information
  7. Asking Questions
    • Speak Clearly
    • Define words clients may not understand (but don't use a lot of technical language)
    • Use language that is familiar, even slang
    • Encourage specificity in answers
    • Ask one question at a time
    • Be attentive to client's emotional responses and follow up if necessary
    • Use permission giving with sensitive questions
    • Be concise and specific when answering client questions
  8. Directive questions
    lead clients to focus on one set of thoughts; this type of question is most often used in reviewing systems or in evaluating functional status.
  9. Techniques that Enhance Data Collection
    • Active Listening
    • Facilitation: "Go oh", "Uh-huh", "Then?"
    • Clarification: "What do you mean by that?"
    • Restatement
    • Reflection: repeating a phrase or sentence the client just said.
    • Confrontation: used when there are inconsistencies between what the client says and what your observations or other data show; use tone that communicates confusion or misunderstand
    • Interpretation: when you want to share with clients conclusions you have drawn from data they have given
    • Summary: condenses and orders data obtained during the interview to help clarify a sequence of events.
  10. Techniques that Diminish Data Collection
    • Using medical terminology
    • Expressing value judgements
    • Interrupting the client
    • Behaving authoritarian or paternalistic
    • Using "Why" questions
  11. Managing Awkward Moments During an Interview
    • Answering personal questions: brief and direct
    • Silence: do not break silence-- clients may need the silence to reflect or to gather courage. May indicated client isn't ready to discuss or approach needs to be evaluated.
    • Displays of Emotion: let patient cry if they need too; acknowledge anger and discuss approach for talking to person or apologize yourself if need be.
  12. Components of a Comprehensive Health History
    • Biographical Data
    • Reason for seeking care
    • History of present illness
    • Present health status
    • Past Health History
    • Family History
    • Personal and psychosocial history
    • Review of systems
  13. Symptom Analysis used when taking history of present illness
    • Onset: when did the symptoms begin?
    • Location: Where are the symptoms?
    • Duration: How long do the symptoms last
    • Characteristics: Describe the characteristics of the symptom
    • Aggravating and Alleviating Factors: What affects the symptoms?
    • Related Symptoms: What other symptoms are present?
    • Treatment: describe self treatment tried before seeking care.
    • Severity: Describe the severity of the symptom (number, extent, size, amount, rank 0-10)
  14. Biographic Data
    • Name
    • Gender
    • Address and Telephone Number
    • Birth Date
    • Birthplace (especially if in a foreign country)
    • Race/Ethnicity
    • Religion
    • Marital Status
    • Occupation
    • Contact person
    • Source of Data