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What are the 2 concepts of health?
- 1. Biomedical "Medical" Model- focus is the diagnosis and treatment of disease
- - assessment factors (signs and symptoms of disease)
- 2. Holistic Models (e.g. Nursing)- Expanded focus
- - Individuals are considered active participants in their health care
- - Assessment factors (expanded to include culture and values, family and social roles, self care behaviors, environmental stress, developmental tasks, etc. )
What are the levels of Disease Prevention and give an example for each.
Primary Prevention: (promote optimum health prior to the onset of problems)-healthy diet, exercise, immunization, etc.
Secondary Prevention: (early identification and treatment of existing health problems)- PAP smear, mammogram, PPD, etc.
Tertiary Prevention: (rehabilitation and restoration of health)- cardiac rehab, etc.
What is a brief definition of assessment?
A collection of subjective and objective data.
What is subjective data?
statements, symptoms (patient history)
What is objective data?
- the signs, observations
- The methods include:
- 1. Inspection
- 2. Palpation
- 3. Percussion
- 4. Auscultation
- 5. Laboratory and diagnostic test results
- 6. Patient's medical records
What is the Medical Diagnosis?
Assessment data used to diagnose disease
What is the Nursing Diagnosis?
Assessment data (used to diagnose a patient's response to actual or potential health problems)- pain, altered skin integrity, ineffective coping, etc.
Here is an example of the differences between Medical and Nursing Diagnosis.
- Subjective data: "I have shortness of breath (SOB)"
- Objective data: wheezing
- Medical diagnoses: asthma
- - Plan (prescribe drug therapy)
- Nursing diagnoses: impaired gas exchange (the patient's response to illness)
- - Plan: teach methods to improve gas exchange (e.g. smoking cessation, proper use of medications, etc.)
What are the 4 types of data?
- 1. Complete (health history and physical examination)- e.g. 1st appointment in primary care, hospital admission
- 2. Episodic (mini data base concerning one problem)
- - e.g., acute illness [common cold]
(to assess progress)
- 4. Emergency (rapid and focused data collection)
- - e.g. chest pain (do you have a history of heart trouble, MI, PUD, hiatal hernia?)
- - The type of data collection may quickly increase/decrease the level of suspicion for a certain type of problem.
What are the purposes of the Interview?
- 1) Allows for collection of subjective data (e.g. health history, symptoms)
- 2) Assists the patient in identifying areas of concern and perceptions of health status.
- 3) Identifies person's problems and strengths
- 4) Establishes rapport and trust for an ongoing working relationship
- 5) Provides a comfortable bridge to the physical examination
- 6) Provides an opportunity for education
What are the components of the interview?
- 1) Purpose (clarify)- Why are you here?
- - it may not always be apparent.
2) Time (set time limits in the beginning)
- 3) Presence of others (other caregivers, family, friends, translator, etc.)
- - Affects communication (positive or negative effect)
- - May be unable to speak freely about issues (abuse, sexual problems,etc.)
- - May help with information acquisition.
- - interpreter e.g. violates confidentiality; risk of misinterpretation.
- 4) Confidentiality
- - avoid conversations of public places
- - don't discuss patients with friends/family; don't refer to patient by name
- - builds patient trust/decreases litigation
What is verbal and nonverbal communication?
- - tone, words, speed, vocalizations, what you don't say
- - posture, gestures, facial expression, eye contact, body position, location in the room)- sometimes conveys more than verbal communication (SMILE)
What are the internal factors affecting the interview?
- 1) Acceptance of others
- - tolerance for weaknesses
- - convey warmth, caring and acceptance
- - respect for other's health care decisions (may be different from yours)
- 2) empathy (to convey understanding for how the patient feels)
- 3) active listening (give the patient full attention)
What are the external factors affecting the interview?
- 1) Environment
- - attempt to achieve a comfortable setting (temperature, lighting, noise reduction, etc.)
- - control interruptions
- - sit 4-5 ft from pt and slightly to the side (allows pt to avoid eye contact if desired by looking straight ahead)
- - avoid standing (implies haste and superiority)
2) Professional Dress (e.g. good hygiene, keeping clothes and shoes neat and clean, and wearing a name tag)
3) Ensure physical or psychological privacy (private room or pull curtain)
What are the challenges of note taking?
- 1) impedes eye contact
- 2) attention shifting
- 3) interrupts patient's narrative flow
- 4) impedes observation of nonverbal behavior
- 5) can be threatening
What are some components for beginning the interview?
(Always introduce yourself and your title)- explain your role.
- Address patient by surname (Mr./Mrs./Ms.)- unless permission given to use 1st name
- - Open ended questions
- - requires narrative responses
- - used to begin interview
- - allows for description, leads to more info
- - Close ended questions
- - requires 1-2 word answers or yes/no responses
- - used to fill in omitted info or to get specific facts
- - ask only one question at a time
What are nine communication techniques?
- 1) Facilitation (encourages patient to say more)- "uh huh" or "go on"
- 2) Silence (gives the patient time to think, helps him/her focus)
- 3) Reflection: (echoes the response; help patient elaborate)- ...you're telling me that it hurts when you cough
- 4) Empathy (shows understanding and acceptance)- "I can understand why your test results would upset you"
- 5) Clarification (describe what you mean by "upset stomach")
- 6) Confrontation: (use this technique if the history is inconsistent)
- - inconsistency may occur in one visit or over time
- - situation: obese male over 300 lbs
- - "before you told me that you rode your bike 10 miles/day, now you say you ride 25 miles/day"
- 7) Interpretation: (links events and associations; your impression of what patient has said)- "It seems as though every time you have a deadline to meet at work, you develop stomach pain"
- 8) Explanation (providing objective info)
- 9) Summary(final review of what the patient has said; surveys what we perceive the health problems/concerns to be)
What are 10 communication traps to avoid?
- 1) Providing False Assurance (may lead to disappointment and lack of trust)- "I'm sure you will be all right"
- 2) Giving Advice- Don't shift accountability for decision making from the patient to you.
- - present patient with the facts and allow him/her to make an informed decision.
- 3) Using Authority "Your doctor knows best"
- 4) Avoiding Difficult Topics- Don't avoid discussion (allow the pt to discuss fears/dying etc.)
- 5) Engaging in Distancing: e.g. saying "the breast" instead of "your breast"
- 6) Using Professional Jargon (use language at the patient's level of understanding)
- 7) Using Leading or Biased Questions (you may not get honest or objective response)- You don't smoke do you?
- 8) Talking Too Much (you can't learn for yourself)
- 9) Interrupting (breaks pt train of thought)- may miss important info
- 10) Asking "Why" questions may put the pt on the defensive; too challenging; implies blame)
- - "why did you wait so long to bring your child to the hospital?"
- - It is better to teach regarding future behavior
What are the seven characteristics of non-verbal behavior?
- 1) Physical appearance (ill/well, student/professional, well groomed/poor hygiene, etc.)
- 2) Posture (relaxed/tense)
- 3) Gesture(agreement/anger/pain)
- 4) Facial expression (alert/relaxed/anxious)
- 5) Eye-contact (shy/withdrawn/depressed)
- 6) Voice (anxious/hearing impaired/sarcasm)
- 7) Touch
What are nine special considerations affecting the interview?
- 1) Hearing impaired- raising your voice increases the pitch and makes hearing worse
- 2) Acutely ill
- 3) Substance abuse
- 4) Personal questions (redirect conversation to the pt) [not obligated to divulge personal info]
- 5) Sexually aggressive (don't tolerate; confront) "your behavior makes me uncomfortable"
- 6) Crying (allow expression of emotions; don't change the subject)
- 7) Anger (deal with this emotion before going on with the interview)
- 8) Those who threaten violence-be sure that you are safe and don't hesitate to seek assistance from others around you
- 9) anxious
What are four cross-cultural considerations
- 1) eye-to-eye contact
- 2) hand shaking
- 3) touch (may or may not be acceptable to the pt)
- 4) personal space and interview distance
What are the three distance zones and their feet and when are they used?
- 1) Social Distance: 4-12 feet, Interview range
- 2) Personal Distance: 1.5-4 feet, Distance for most physical assessment
- 3) Intimate Zone: 0-1.5 feet, Some physical assessment (e.g. HEENT exam)