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health assessment > Ch 2: Health History And Interview > Flashcards

Ch 2: Health History And Interview Flashcards

1
Q

What is the purpose of a health history

A

To provide description of patients symptoms and how they developed

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2
Q

What does a complete health history identify

A

Potential/underlying disease states

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3
Q

What is another commonly used word for health history?

what are very broad components of a health history

A

An interview

Review of past history and a review of systems where the patient disclose his private information during open communication

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4
Q

Describe the communication process and relationship

A

The communication process is used in caring relationships with patients focused on patient emotion

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5
Q

What are two essential components (people) of the communication process

A

Verbal and nonverbal communication between a sender and a receiver (decoder)

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6
Q

What are the two types of therapeutic communication and describe them

A

1. Caring : respect, valuing patient, non-judge mental

  1. Empathy: putting yourself in their shoes , compassion, sensitivity
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7
Q

 What is therapeutic communication used for

A

To create a relationship with the patient of trust and rapport

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8
Q

What is nonverbal communication considered as almost more important than verbal communication

A

It is most accurate a demonstrating feelings

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9
Q

List the important components of nonverbal communication

A
  • Physical appearance/ facial expression
    : (1st impression)

-Posture
: crossing arms closed communication

  • Gestures/ eye contact
    : gestures should be purposeful and iContact must be maintained at patient level such as a CHAIR (do not stand over them as it signals a power position)
  • Tone and use of touch
    : speak at a moderate tone, always ask permission for touch
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10
Q

Why is it essential to always ask permission for touch

A

It may not always be culturally appropriate so clarify with patient
As well as eye contact

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11
Q

 Why is nonverbal communication and physical appearance vital

A

Nonverbal communication and physical appearance is vital so the line of communication stays open between patient and nurse

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12
Q

How is verbal communication developed

A

Is learned by practice and repetition

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13
Q

What are appropriate speech patterns for verbal communication

Normal hearing v hearing problems

A

Nurses speak in a moderate tone that is not too fast as the patient will lose trust in a barrier will be formed

                         V

Project voice for those with hearing problems, speak slower

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14
Q

What are key components you can use for a patient with limited English

A
  • USE SIMPLE CLEAR LANG AT NORM VOLUME*
  • Use simple 1 to 2 word phrases
  • Use pauses
  • Use a normal volume
  • let patient speak so you can get an understanding
  • facilitate trust, respect and caring
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15
Q

Do’s and don’ts of a complete language barrier

A

DO: get a hospital interpreter
- is standard of care

DONT: don’t use family

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16
Q

If there is a complete language barrier why is it important to not use family

A

You may violate HIPPA

medical terms may not be known

family member may give incomplete information

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17
Q

How would you actively listen to a patient

A

Use both verbal and nonverbal actions to focus on a patient and their perspective

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18
Q

How can you actively listen that helps a patient heal?

A

Let’s patient Talk about difficult feelings, concerns, anxieties, and fears

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19
Q

What is a good skill to use in patients who’s emotions cannot be diffused such as anger

A

Redirect patient to the purpose of your communication

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20
Q

What are other techniques of communication (list 4)

A
  1. Restatement
  2. Reflection
  3. Elaboration (facilitation) 
  4. Silence
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21
Q

Define restatement

A

RESTATE = Elaborate

Restatement is the repeating of what the patient said FOR ELABORATION

22
Q

Define reflection and give an example of how you as a nurse can state it

A

Reflection is summarizing the main themes said by your patient

Ex: “you sound very scared” and boom communication is open

23
Q

Define elaboration (facilitation) and how would you tell the patient to elaborate

A

Get patient to more completely describe the issues

done by showing interesting conversation

“Go on” “how would you describe that”

24
Q

How to silence aid in communication

A

Silence shows both caring and thinking

25
Q

Define empathy

A

Putting yourself in your patients shoes

Compassion

26
Q

What is focusing and how would you get a patient to focus

A

Focusing= redirecting

Keeping conversation on track

“ we were talking about”

27
Q

How would you ask a patient to clarify

A

” tell me what you mean by”

28
Q

What is summarizing and when is it used

A

Summarizing is reviewing and condensing information stating the most important things

Done at the end of the closing phase of an interview

29
Q

Give examples of non-therapeutic responses (greatest ones)

A
  • False reassurance: A casual response the diminishes the patients concerns
    We truly don’t know

-Sympathy: having pity on patient, feeling what patient feels

-unwanted advice:
It’s best to refer to provider and family

-biased questions
Hold judgment, guide patient to acceptable response

-Interrupting: listen to patient> speaking

30
Q

What is a very essential non-therapeutic way to ask a question and why

A

Asking why questions

they are often accusatory and close communication

31
Q

What is non-professional involvement and some examples (2)

A

Non-professional involvement is crossing boundaries / relationships with patients

  1. Social media: Out of hospital
  2. Violation of sexual boundaries
32
Q

How would you describe intercultural communication

A

Intercultural communication is what we learn from culture on how to be healthy and or Ill

33
Q

What is proper communication etiquette when under inter-cultural communication circumstances

A

Show respect and be sensitive to patient by asking how they want to be addressed

34
Q

What are issues that can ride with limited English during intercultural communication

A

There can be a decrease in quality of care that can be fixed with a hospital interpreter

DO NOT USE FAMILY

35
Q

How do you address gender and sexual orientation issues

A

Address patient as what they identify but clearly state they must be treated as their biological aspects

36
Q

What are phases of the interview process and give brief description + post interview

A

1.Pre-interaction phase
:preparing for interview by looking at medical records, demographic data (pt info)

  1. Beginning phase
    : introduction, stating purpose, opening line of communication
  2. Working phase
    : gathering of data through direct and open ended questions as well as chart
  3. Closing phase
    : “reflecting” summarizing and stating the most important issues

Post interview
“ is there anything else you need to tell me”
And think patient

37
Q

Expand on the pre-interaction phase

A

The preinteraction phase is preparing for the interview where you gather patient information (demographic data), medical records

!!! Is used to determine historian (PT) reliability!!!

38
Q

Elaborate on the beginning phase

A

The beginning phase is where you introduce yourself, address the patient, say the purpose of the interview, and establish an open line of communication

39
Q

Elaborate on the working phase

A

The working phase is the gathering of the bulk of data asking both closed, direct questions (Y/N) and open ended questions

Avoiding “why” questions

Information can come from the primary source (pt) or the secondary source (fam, doc, emt)

40
Q

Elaborate on the closing phase and mention the post interview 

A

The closing phase is essentially reflecting: summarizing the main ideas about 2 to 3 important issues of the interview

You are obligated to report any information by law (I.E: abuse)

POST INTERVIEW
“ is there anything else you need to tell me”
Thank the patient

41
Q

What is the nurses main Focus of the interview

4 things

A
  • gather info
  • assess patient status
  • risk behaviors
  • strengths
42
Q

Differentiate primary and secondary data sources

A

Primary : AKA historian is pt

Secondary: fam, doc, emt

43
Q

What is an important action to do during the pre-interaction phase in regards to the historian and the historians information

A

Determine the historians reliability between the information you get pre-interaction and during the interview

44
Q

What are you obtaining as you get a patient’s history

A

Your obtaining the patients database

45
Q

Give initial components of health history

A

• Demographic data : id pt and history

  • any illnesses (adult and childhood)
  • surg, immunizations, injury, transfusions
  • med lists and reasons (including herbal)
  • Reason for seeking care
  • history of present illness
O-nset
L-ocation
D-uration 
C-haracteristic
A-ggregating/ alleviating
R-adiations
T-iming 
S-everity
46
Q

Define genogram

A

GENE- ogram

Shows family health patterns and genetic genes

47
Q

Define functional health assessment

A

Assess patient strengths and needed improvements such as in activities of daily living

48
Q

What is the purpose of the review of systems and are you physically touching the patient

A

Purpose: to identify current and past health of systems where we touch base on systems and assess all areas

No touching

49
Q

What area of the health assessment is done until the end of the interview and why

A

The psychosocial and lifestyle factors are done at the end of the interview because trust must be established first

50
Q

What is discussed during the psychosocial and lifestyle factors

A

Any social, cultural, spiritual assessments
-coping and stress tolerance

A mental health assessment
-self-medicating is assessed 

Human violence assessment
-look for possible abuse such as different color bruising

Sexual history and orientation
-establish a need for education

51
Q

What are a few special situation’s in interviews and their solutions

A

Low levels of consciousness/ cognitive impairments
-Establish other sources, direct questions

Anger
- Avoid becoming defensive DO NOT YELL

Mental illness
-have patient focus (redirect) away from distractions to interview

health assessment (20 decks)

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