Ch 2: Health History And Interview Flashcards
What is the purpose of a health history
To provide description of patients symptoms and how they developed
What does a complete health history identify
Potential/underlying disease states
What is another commonly used word for health history?
what are very broad components of a health history
An interview
Review of past history and a review of systems where the patient disclose his private information during open communication
Describe the communication process and relationship
The communication process is used in caring relationships with patients focused on patient emotion
What are two essential components (people) of the communication process
Verbal and nonverbal communication between a sender and a receiver (decoder)
What are the two types of therapeutic communication and describe them
1. Caring : respect, valuing patient, non-judge mental
- Empathy: putting yourself in their shoes , compassion, sensitivity
 What is therapeutic communication used for
To create a relationship with the patient of trust and rapport
What is nonverbal communication considered as almost more important than verbal communication
It is most accurate a demonstrating feelings
List the important components of nonverbal communication
- 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
Why is it essential to always ask permission for touch
It may not always be culturally appropriate so clarify with patient
As well as eye contact
 Why is nonverbal communication and physical appearance vital
Nonverbal communication and physical appearance is vital so the line of communication stays open between patient and nurse
How is verbal communication developed
Is learned by practice and repetition
What are appropriate speech patterns for verbal communication
Normal hearing v hearing problems
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
What are key components you can use for a patient with limited English
- 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
Do’s and don’ts of a complete language barrier
DO: get a hospital interpreter
- is standard of care
DONT: don’t use family
If there is a complete language barrier why is it important to not use family
You may violate HIPPA
medical terms may not be known
family member may give incomplete information
How would you actively listen to a patient
Use both verbal and nonverbal actions to focus on a patient and their perspective
How can you actively listen that helps a patient heal?
Let’s patient Talk about difficult feelings, concerns, anxieties, and fears
What is a good skill to use in patients who’s emotions cannot be diffused such as anger
Redirect patient to the purpose of your communication
What are other techniques of communication (list 4)
- Restatement
- Reflection
- Elaboration (facilitation) 
- Silence
Define restatement
RESTATE = Elaborate
Restatement is the repeating of what the patient said FOR ELABORATION
Define reflection and give an example of how you as a nurse can state it
Reflection is summarizing the main themes said by your patient
Ex: “you sound very scared” and boom communication is open
Define elaboration (facilitation) and how would you tell the patient to elaborate
Get patient to more completely describe the issues
done by showing interesting conversation
“Go on” “how would you describe that”
How to silence aid in communication
Silence shows both caring and thinking
Define empathy
Putting yourself in your patients shoes
Compassion
What is focusing and how would you get a patient to focus
Focusing= redirecting
Keeping conversation on track
“ we were talking about”
How would you ask a patient to clarify
” tell me what you mean by”
What is summarizing and when is it used
Summarizing is reviewing and condensing information stating the most important things
Done at the end of the closing phase of an interview
Give examples of non-therapeutic responses (greatest ones)
- 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
What is a very essential non-therapeutic way to ask a question and why
Asking why questions
they are often accusatory and close communication
What is non-professional involvement and some examples (2)
Non-professional involvement is crossing boundaries / relationships with patients
- Social media: Out of hospital
- Violation of sexual boundaries
How would you describe intercultural communication
Intercultural communication is what we learn from culture on how to be healthy and or Ill
What is proper communication etiquette when under inter-cultural communication circumstances
Show respect and be sensitive to patient by asking how they want to be addressed
What are issues that can ride with limited English during intercultural communication
There can be a decrease in quality of care that can be fixed with a hospital interpreter
DO NOT USE FAMILY
How do you address gender and sexual orientation issues
Address patient as what they identify but clearly state they must be treated as their biological aspects
What are phases of the interview process and give brief description + post interview
1.Pre-interaction phase
:preparing for interview by looking at medical records, demographic data (pt info)
- Beginning phase
: introduction, stating purpose, opening line of communication - Working phase
: gathering of data through direct and open ended questions as well as chart - Closing phase
: “reflecting” summarizing and stating the most important issues
Post interview
“ is there anything else you need to tell me”
And think patient
Expand on the pre-interaction phase
The preinteraction phase is preparing for the interview where you gather patient information (demographic data), medical records
!!! Is used to determine historian (PT) reliability!!!
Elaborate on the beginning phase
The beginning phase is where you introduce yourself, address the patient, say the purpose of the interview, and establish an open line of communication
Elaborate on the working phase
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)
Elaborate on the closing phase and mention the post interview 
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
What is the nurses main Focus of the interview
4 things
- gather info
- assess patient status
- risk behaviors
- strengths
Differentiate primary and secondary data sources
Primary : AKA historian is pt
Secondary: fam, doc, emt
What is an important action to do during the pre-interaction phase in regards to the historian and the historians information
Determine the historians reliability between the information you get pre-interaction and during the interview
What are you obtaining as you get a patient’s history
Your obtaining the patients database
Give initial components of health history
• 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
Define genogram
GENE- ogram
Shows family health patterns and genetic genes
Define functional health assessment
Assess patient strengths and needed improvements such as in activities of daily living
What is the purpose of the review of systems and are you physically touching the patient
Purpose: to identify current and past health of systems where we touch base on systems and assess all areas
No touching
What area of the health assessment is done until the end of the interview and why
The psychosocial and lifestyle factors are done at the end of the interview because trust must be established first
What is discussed during the psychosocial and lifestyle factors
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
What are a few special situation’s in interviews and their solutions
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
