Health Assessment mid-term: Course Introduction, Interviewing, Health History,
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. What would you like to do?
what standard precautions should we consider and why?
- we should wash our hands and wear gloves when dealing and preventing the transmission of blood and body fluids
- - by not taking this precautions we run the risk of spreading nosicomial infections to patients
health assessment is what?
is a systematic way of collecting data about a client/patient for the purpose of determining client's health status
the nursing process consist of what
- - assessment
- - diagnosis
- - goal setting
- - plan
- - implement
- - evaluate
the nursing process serves for what?
it serves in the clinical process that we use
assessment of a patients involves what three main components?
- - patients interview
- - physical exam
- - lab/diagnostic
patient interview is about collecting what type of data?
its about collecting subjective data
if the patient is unable to speak for themselves during the interview, who would we talk to next to gather information?
we would go to the parent or spouse
physical exams is about collecting what type of information?
- its about collecting subjective and objective information
lab/diagnostic testing is about collecting what type of information?
it is about taking objective information
what is subjective information
what the person says about himself or herself
what is objective information
what you observe through measurement, inspection, palpation, percussion, and auscultation
what are the basic concepts of communication ?
- there is a
- - sender
- - receiver
- - message
- - feedback
- - context
can be where it is actually happening. it is a wellness visit at a nurse practitioner's office or is it a crisis situation in the emergency room
is this a new occurrence or is this a reoccurring issues for the patient?
what is communication
- - it is not just the use of words, it is a dynamic process that includes
- - behaviors
- - verbal and nonverbal
- - intended or perceived
communication: what should we look for in behavior?
watch for the congruence of what their saying and how they are behaving
what is more accurate, the words the patient is saying or their behavior?
the behavior of the patient is more important
what are some personal variables that may affect communication?
- - age
- - gender
- - language
- - preferences
- - experiences
- - personality
- - self concept
- - values, attitude
- - cultural background
- - religious/spiritual beliefs
how can age affect communication?
- the pateints may be older so asking personal questions may make them feel uncomfortable.
- - the patients may perceive you a certain way because of your age
- - be aware of generation differences
how can gender affect communication?
sometimes the opposite sex may not want to give intimate information b/c of the difference in gender
how can language affect communication
a language barrier can prevent you from assessing the patient to the best of your ability
when is comes to communication nurses must have a high what in order to communicate effectively with the patient.
the nurse must have a high EQ (emotional intelligence) b/c sometimes we have to stake a step back and try to understand that the patient may not be lashing out on you b/c of personal reasons but instead b/c that is how they respond to a crisis
communication can be impacted by what?
- - visual (whether they are able to see you)
- - hearing (can they hear you or are having difficulty hearing you?)
- - tactile (extremities missing)
what are some aspects to consider in a message?
- - what is in the mind of the sender?
- - what did the sender chose to send
- - how is the message sent?
- - what is received by the receiver?
- - what does the message bring to mind in the receiver
what are the goals of effective communication?
- - to send CLEAR, HEALPFUL messages to our patients
- - INTERPRET ACCURATELY what our patients are communicating
are the words you speak, vocalizations, the tone of voice
verbal communication includes what two categories?
- - denotation
- - connotation
what is denotation?
it is the concrete definition of a word
what is connotation?
it is the personal interpretation on what means to the person
how should we use vocabulary when communicating to a patient. what words should we avoid using when speaking to them?
- using medical jargon can confuse and lose the patient
- - auscultation
- - CAT scan
- - Stool
- - Void
- - Colon
how can we PACE our communication with the pateints
- speed or rate at which the message is delivered
- - which includes the pauses between important ideas or concepts
- - clarity
- - timing and relevance
- - para-language
therapeutic communication is what?
- - goal focused
- - deliberate
- - has different perspectives
how should social communication be?
- - spontaneous
- - needs both
- - mutual sharing
- - both parties express naturally
- - reciprocal approval
- - terminates spontaneously
how should therapeutic communication be
- - planning
- - needs of the pateints
- - focus on problem solving
- - encourage patient to express feelings, concerns
- - nurse not seeking personal approval
- - nurses terminates
critical elements of communication
- - genuineness
- - respect
- - empathy
during communication, we respect the patient by?
- addressing them by name. dont make the assumption that you can call the patient by their first name unless they say so
- - also by your tone of voice
during communication, we show empathy by?
recognizing what the patient is going through and allowing yourself to acknowledge what the patient is going through
what elements should be involved in a patients interview ?
- - it should be based on a trusting relationship
- - privacy
- - confidentiality
- - nonjudgmental
- - document
how should we be in position to the patient during an interview?
- - there is eye contact
- - are at the same level
- - there is a closeness that doesn't invade personal space
what are the three stages of on interview?
- - stage I: introduction
- - stage II: working
- - stage III: closing
stage I - introduction
identify name , role, and purpose/ intentions
stage II - working
collection of patient data
stage III - closing
thanking and acknowledging the person. also summarizing and what the information will be used for
what are some effective verbal interviewing techniques
- - open-ended questions
- - closed questions
- - facilitation
- - silence
- - reflection
- - empathy
- - clarification
- - confrontation
- - interpretation
- - explanation
- - summary
verbal techniques: open-ended questions
- gives patient permission to give you their story in their own word
- - how can I help you?
- - what brings you here today?
verbal techniques: closed questions
- very often yes, no questions
- - are you having pain?
verbal techniques: facilitation
done through para-language - your body position or through the nodding of your head allows the patients to tell you more
verbal techniques: silence
allows patient to process the question and formulate an anwer
verbal techniques: reflection
picking up on a word that he patient said regarding the information and reflect on it allowing the patient to share more information
verbal techniques: interpretation
telling the patient what we understand allows the patients to clarify any misunderstanding
what are some effective nonverbal techniques
- - professional appearance
- - posture
- - gestures and facial expression
- - eye contact
- - voice
- - touch
what are some non-therapeutic techniques
- - requesting an explanation - why?
- - probing
- - offering false reassurance
- - giving false reassurance
- - giving approval/disapproval
- - defending
- - advising
how would you document an unanswered question?
never leave the question blank, write that the patient refused to offer this type of information
in which ways can questions a patient become problematic?
- - posing leading questions
- - interrupting the patient
- - engaging in talkativeness
- - using multiple questions
- - using medical jargon
- - being authorative
what are some tips for using an interpreter
- - use trained medical interpreter - not family or significant other
- - allow time for the patient and interpreter to converse prior to interview
- - request sentence by sentence translation
- - allow extra time
- - use brief questions
- - maintain eye contact with the patient
- - observe patient's nonverbal response
- - use preprinted questions if available
health history serves as what?
as a basis for planning care
health history is what ?
- subjective information of health status including
- - social
- - emotional
- - physical
- - cultural
- - well-being
what are the types of health history's ?
- - complete
- - episodic
- - interval or follow-up
- - emergency
episodic health history
- focuses on the problem the patient has been experiencing
- - focused on the problem on hand
interval or follow-up history
checking if the treatment worked or failed stood the same
- - essential information only
- - are they on any medications? have any allergies?
name the components of a health history
- - biographical information
- - informant
- - reason for seeking health care - "chief complaint"
characteristics of chief complaints include what?
- - location
- - radiation
- - quality
- - quantity
- - associated symptoms
- - aggravating factors
- - alleviating factors
- - setting
- - timing
- - meaning/impact
chief complaint: location
- where is the pain located?
chief complaint: radiation
does the pain move from the main site to other parts of the body?
chief complaint: quality
- whats does the pain feel like?
- - dull
- - burning
- - sharp
- - itchy
chief complaint: quantity (severity)
on a scale of 0-10, jow much pain are you feeling right now?
chief complaint: associated symptoms
are you experiencing any other symptoms?
chief complaint: aggravating and alleviating factors
what makes the pain worse? what makes the pain better?
chief complaint: setting
- Where was the person or what was the person doing when the symptom started?
- - for example: were they shoveling snow?
chief complaint: timing
- onset, duration, frequency
- - when did the symptom first appear?
- - how long did the symptom last?
- - was it steady(constant)? or did it come and go(intermittent)?
chief complaint: meaning/impact
- how it affect daily activities
- - how has this affect you?
- - is there anything you can't do now that you could before?
- P: provokes/palliative
- Q: quality/quantity
- R: region and radiation
- S: severity
- T: timing
- U: understanding patient's perception
- C: character - how does it look, feel, sound, smell
- O: onset
- L: location - where, ? radiation
- D: duration
- S: severity
- P: pattern - what makes it worse/better
- A: associated manifestations
- M:what meaning does this have to you
components of a past history
- - medical history
- - surgical history
- - psych/mental health history
- - medications: prescribed, over the counter
- - communicable diseases
- - allergies
- - injuries/accidents
- - childhood diseases
- - immunization history
components of a family health history
- - identify genetic patterns
- - immediate blood relative
- - genogram
components of social history
- - alcohol use: type, amount, frequency, CAGE
- - drug use: type, amount, frequency
- - tobacco use: pack yr history
- - sexual practices
- - travel history: military history
- - education
- - roles and responsibilities (any support at home?)
- - domestic violence
- C: Have you ever thought you should Cut down your drinking?
- A: Have you ever been Annoyed by criticism of your drinking?
- G: Have you ever felt Guilty about your drinking?
- E: Do you drink in the morning? (i.e., an Eye opener?)
violence (domestic) leads to what
chronic health problems
should domestic violence screening be done with every patient?
yes, every patient
components of health maintenance
- - sleep
- - diet
- - exercise (FIT)
- - stress management
- - safety devices
- - health check-ups: traditional and alternative
- F: frequency of exercise
- I: intensity of exercise
- T: how many time a week
what is Review of Systems
- subjective responses to series of body system questions
- - this is not the physical assessment
- - ask questions such as: do you have these symptoms? (helps guide physical exam)
what is the purpose of a physical assessment?
- - screening of general well-being
- - validation of complaints that caused the patient to seek health care
- - monitoring of current health problems
- - formulation of diagnosis and treatments
types of assessment techniques
- - inspection (I)
- - palpation (P)
- - percussion (P)
- - auscultation (A)
- you usually follow the order IPPA, expect for the abdomen which is IAPP
- inspecting the
- - sense of smell
- - sense of sight
- is the ac of touching the patient in a therapeutic manner. it includes
- - light palpation
- - moderate palpation
- - deep palpation
- - superficial, delicate, gentle
- - uses finger pads or the back of your hand
provides information on skin texture, moisture, temperature, superficial pulsations and tenderness
- - superficial, delicate, gentle
- - uses finger pads
- - depress 1 cm below surface
provides information on skin texture, moisture, masses, fluid, muscle guarding pulsations, and tenderness
provides information about the position of organs, masses, their size, shape, mobility and consistency
- - uses hands
- - depress 4 to 5 cm below skin surface
- - most commonly used for assessing abdominal and reproductive structures
- - wash hands before and after the exam
- - waer gloves if indicated
- - warm hands
- - fingernails short and clean
- - inform the patient when, where, and how the touch will occur
- - striking one object against another to cause vibrations that produce sound
- - analyze sounds by intensity, duration, pitch
- - any part of the body can be percussed
- - most commonly used for abdomen and thorax
percussion: quality of sounds include?
- - flatness
- - dullness
- - resonance
- - hyperresonance
- - tympany
When no air is present, over thigh muscles, bone, or over tumor
fluid filled areas, Relatively dense organ, as liver or spleen
over norma/healthyl lung tissue
- - Normal over child's lung
- - Abnormal in the adult, over lungs with increased amount of air (over inflated lungs), as in emphysema
Over air-filled viscus (e.g., the stomach, the intestine)
- - immediate or direct
- - mediate or indirect
- - direct fist
- - indirect fist
- - clean earpieces
- - point earpieces towards the nose
- - quiet room
- - diaphragm - with pressure
- - bell - without pressure
the diaphragm picks up what type of sounds?
high pitched sound
the bell picks up what type of sounds?
- picks up low pitched sounds
- - you don't want to press on the skin, only lightly place it
What would you like to do?
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