ch3 Flashcards
1
Q
What is the interview and what is the goal?
A
The interview is a meeting between you and the patient. Goal is to record a complete health history. It is the most important part of data collection.The health hx is a bridge to the physical examination
2
Q
What are the components of a successful interview?
A
- Gather complete and accurate data about the persons health state, including the description and chronology of any symptoms.
- Establish rapport and trust so person feels accepted and free to share all data
- Teach person about health state so that they can participate in identifying problems
- Build rapport for continuing therapeutic relationship. Rapport facilitates future diagnoses, planning, and treatment.
- Begin teaching for health promotion and disease prevention
3
Q
Why should you consider the interview to be a “contract between you and the patient?
A
Because a contract consists of spoken or unspoken rules for behavior. The contract concerns what the person needs and expects from health care and what you have to offer as the professional. Mutual goal is optimal health for the patient
4
Q
What are the terms of the “contract” between the nurse and the patient?
A
- Time and place of interview and succeeding physical examination
- Introduction of self and brief explanation of your role
- the purpose of interview
- how long it will take
- expectation of participation for each person
- Presence of any other people (patients family, another health profess., students)
- Confidentiality and to what extent it may be limited
- any costs that the patient must pay
5
Q
Why is communication between the patient and interviewer so important?
A
- Communication is the vehicle that carries you and the patient through the interview
- Communication is exchanging info so that each person clearly understands each other. If you have not conveyed meaning, then no communication has occured
- Communication is all behavior, both conscious and unconscious and verbal and non verbal. All behaviors has meaning
6
Q
What are the four processes of communication?
A
- Sending
- Receiving
- Internal factors
- External factors
7
Q
What is “sending” in the process of communication?
A
Verbal (we are aware) and non-verbal communication (we are usually unaware). Non-verbal is less conscious so it is more reflective of your true feelings so be aware of messages you are sending.
8
Q
What is “receiving” in the process of communication?
A
- Words and messages must be interpreted in a “specific context” to have meaning. We have a specific context in mind when we send words.
- the receiver attaches meaning to our words depending on their past experiences, culture, self-concept, and physical and emotional state.
- problem occurs when the contexts do not coincide. There needs to be mutual understanding between sender and reciever to have successful communication.
9
Q
Why is there a greater risk for misunderstanding in the health care setting than in a social setting?
A
The patients frame of reference is narrowed and focused on illness. The health problem emotionally charges your professional relationship and intensifies the communication because the person depends on you to help them feel better.
10
Q
What are the internal factors that influence communication?
A
Internal factors are those particular to the examiner, what the examiner brings to the interview.
- Liking others
- Empathy
- The ability to listen
11
Q
Describe the internal factor, “liking others”.
A
- a general optimistic view of people, and assumption of their strenghts and tolerance for their weaknesses. Patient must feel accepted unconditionally.
- Must respect other people
- Respect their own control over their health
- Goal is to not make patients dependent on you, but help them increase responsibility for themselves. Patients must apply health care resources to their own lives.
12
Q
Describe the internal factor “empathy”.
A
Viewing the world from the other persons inner frame of reference while remaining yourself.
- recognizing and accepting the other persons feelings without criticism,
- Understand WITH the person, how she or he perceives the world. Do NOT become lost in the other person at the expense of your own self.
13
Q
Describe the internal factor “ability to listen”
A
- Listening is not a passive role. It is active and demanding.
- Active listening is the route to understanding.
- Let patient talk from his or her own outline and timeline.
- Listen to the way they tell a story (difficulty with language, impaired memory, tone, and what they are leaving out)
14
Q
What are the External Factors involved in communication?
A
The physical setting.
- Ensure privacy
- Refuse interruptions
- Physical Environment
- Dress
- Note-taking
- Tape and video recording
- Electronic health recording
15
Q
How does a nurse ensure privacy?
A
- Aim for geopraphic privacy (a private room in an office, hospital, home). This may involve asking an ambulatory room mate to step out of the room.
- if geographic privacy is not available, psychological privacy by curtains is ok, as long as the person feels sure no one can hear the convo or interrupt.
16
Q
How does a nurse refuse interruptions?
A
- inform support staff of the interview and ask that they not interrupt
- Discourage other health prof. from interrupting you with their need for access to patient.
17
Q
Describe the appropriate components of the physical environment
A
- comfortable temp
- suffiecent lighting. Avoid facing patient directly toward a strong light
- reduce noise because multiple stimuli is confusing. Turn off TV and other equipment
- Remove distracting objects, clutter, stacks of mail, food, etc.
- Place distance between you and the patient at 4-5 ft. If farther, than you may seem a loof.
- Arrange equal-status seating
- Arrange face to face position when interviewing the hospital bedridden patient. they should not have to stare at ceiling.
18
Q
How do you arrange equal status seating?
A
- both comfortably seated at eye level
- Avoid facing patient across a desk, table, etc. because it feels like a barrier
- Place chairs 90 degrees is good bc patient can face you or look straight ahead from time to time.
- THE MOST IMPORTANT THING IS TO AVOID STANDING- standing communicates haste, and assumes superiority. If you sit, the patient feels some control in the setting
19
Q
Why should you keep note-taking to a minimum? What are the disadvantages?
A
- Some note taking may be unavoidable. Note taking should be secondary to dialogue. Note taking disadvantages :
1. breaking eye contact too often
2. shifts attention away from person and diminishes their sense of importance
3. Can interrupt patients narrative flow
4. Impedes your observation of their non verbal behavior
5. threatening to patient during the discussion of sensitive issues (alcohol intake, number of sexual partners, drug history)
20
Q
When recording in the electronic health record system (EHR), what should you do>
A
- Only type data into computer after the interview is done
- Ask the person if you can go ahead and type some of the info into the computer record
- turn the monitor so the patient can see it
- computer entry may ease some sections of the history (family history, past health occurrences), but some components such as patient narrative, emotional issues, and complex health problems can only be addressed through reciprocal communication and the patient centered interview.
21
Q
What is the technique to introduce the interview to the patient?
A
- Keep the beginning short
- Address patient using surname
- introduce self and role
- give reason for interview
- Ask open ended question and let them proceed. Rapport is built best by letting him or her describe their concern early. Not through social visiting.
22
Q
What is the working phase?
A
The phase of data gathering. Involves asking the patient questions and responding. Use open-ended and closed questions.
23
Q
What is the purpose of open ended questions?
A
Open ended questions ask for narrative info. They state the topic to be discussed but only in general terms. They are unbiased and let the person answer in any way they want. Key to interview= When they answer, with a brief response, respond back asking “anything else?” or “tell me more about it” and look interested. Use them:
- to begin interview
- to introduce a new section of questions
- whenever person introducses new topic
24
Q
What is the purpose of closed or direct questions?
A
Ask specific info. Elicit a short or two-word answer.
- use after persons opening narrative to fill in any details he or she left out.
- use when you need spedific facts
- help speed up the interview
- dont over use closed questions. Follow guidelines:
1. Ask one at a time. Avoid bombarding with long lists.
2. Choose language the person understands.
25
What are the 9 types of verbal responses when assisting the patients narrative?
The first 5 involve your reactions to the facts or feelings the person as communicated.
1. Facilitaion: encourage patient to go on, "mmhmm, go on..", "uh-huh...ok continue.." also called general leads. Maintaining eye contact and leaning forward also facilitate.
2. Silence: Leave patient time to organize thoughts, and what they wish to say.
3. Reflection: Echo patients words. Focuses on a specific phrase, and helps person communicate in their own way. Helps express feeling behind a persons words, and helps them to elaborate.
4. Empathy: a response that recognizes feeling and puts it into words. It names the feeling and allows the expression of it, and accepts the feeling.
5. Clarification: Used when patients word choice is ambiguous or confusing. Summarizes a persons words, and simplifies them. Ask them if you are on the right track.
6-9 are from your perspective, and these responses include your own thoughts and feelings. Only used when merited by the situation:
6. Confrontation: You have observed a certain action, feeling, or statement and now you focus patients attention on it. Give honest feedback about what you see and feel. May focus on a discrepancy (You said is doesn't hurt, but when i touch here, you grimace), their affect ("you sound angry"), or confront them when they are inconsistent.
7. Interpretation: No based on direct observation like confrontation, but is based on inference, or conclusion. Links events, makes associations, implies cause ("it seems every time you feel stomach pain, you have some kind of stress in your life"). Also helps person understand feelings related to the verbal message.
8. explanation: Inform the person by sharing factual and objective info. "the reason you cant drink or eat before blood test is because the food will change the results", or "your dinner comes at 5:30"
9. Summary: Final review of what the patient has said. It is a type of validation, because the person can agree with is or correct it. Both should participate.
26
What is an example of facilitation?
"uh-huh, please continue..", "tell me more...", nodding "yes", hand gesturing to 'go on', leaning forward in increasing interest
27
What is an example of reflection?
Patient: I'm here because of my water. It was cutting off.
Response: "it was cutting off?"
Patient: "yes, yesterday it took me 30 min to pass my water. Finally I got a tiny stream, but then it just closed off"
OR
Patient: "its hard staying flat on my back in the hospital with this pregnancy. I have two little ones at home. Im so worried they arent getting the care they need"
Response: "you feel worried and anxious about your children?"
28
What is an example of empathy?
Patient: This is just great. I have my own business, and direct 20 employees and here I am having to call on you for every little thing
Response: It must be hard- one day having so much control ,and now feeling dependent on someone else.
29
what is an example of clarification?
Response: "so now that i understand, this pain occurs when you...... is that correct??"
30
What is an example of confrontation?
"earlier you said you were laying off the alcohol, and now you just said you had a few drinks after work."
OR
" You look sad.."
OR
" You say it doesnt hurt, but when i touch there, you grimace"
31
What is an example of Interpretation?
Patient: I have decided that I dont want any more treatments. But I cant seem to tell my doctor that. Every time she comes in, I tighten up and cant say anything
Response: Could it be that you are afraid of her reaction?
*you risk of making a wrong inference, but if so, the person will correct it and it can prompt further discussion of the topic
32
What is an example of explanation?
"your dinner comes at 5:00"
"You cant eat before the blood test because it could affect the results"
33
What are the 10 traps of interviewing?
1. Providing False Assurance or Reassurance
2. Giving unwanted Advice
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using "why" questions
34
Why is giving false reassurance a problem?
It only relieves your anxiety, and gives you a false sense of having provided comfort. For the patient, is closes off communication and trivializes her anxiety while denying further talk of it.
35
How can you avoid giving false reassurance?
Acknowledge the feeling of the patient, and open the door for more communication.
Dont say: "Dont worry! I am sure youll be alright!'
Instead say: "You are really worried about the lump arent you? It must be really hard to wait for biopsy results"
*genuine reassurance does exist and can be shown by letting patient know you are there for them and that you are listening and have hope for them.
36
Why is unwanted advice a problem?
You are not the patient. By giving an advice response that is unwanted (such as, "if i were you, I would...) you are shifting the accountability for decision making from the patient to yourself.
37
How can you avoid giving unwanted advice?
When asked for advice, respond by
1. asking the person to weight the pros and cons of the choice
2. ask them what concerns they have
3. ask them what is holding them back.
* involve the patient in the problem solving process.
38
What is an example of using avoidance language?
Using a euphemism such as "passed on" to avoid reality or to hide real feelings. Avoidance language involves avoiding the real issue, in attempt to make fearful topics more comfortable but it does not. It actually suppressed the fear, making it more fearful.
*use direct language to deal with frightening topics
39
What is "distancing" and why is it a problem?
Distancing is using interpersonal speech to put a space between the threat and the self.
"there is a lump in THE left breast", using "the" instead of "your" or "my", the woman or patient can deny any association with her diseased breast and protect herself from it. It is used to soften reality but communicated to person that you are afraid of the procedure. *Use blunt and specific terms.
40
Why shouldnt you use professional jargon?
It sounds exclusionary and paternalistic. Adjust your vocabulary to the person but avoid sounding condescending
41
Why should you avoid asking leading questions or biased questions?
They imply that one answer is correct or better than the other. Patient may feel guilty and answer to please you.
42
Why should you not "talk too much"?
Helpfulness is NOT associated with verbal productivity.
| Listen more than you talk.
43
How can you avoid interrupting?
Aim for a moment of silence between the persons statements and your next response.\- Pathway should be two people talking and two people listening.
44
Why should you not use "why?"?
It condemns, and blames the patient, and puts person on the defensive.
- "why did you take so much medication?" or "why did you wait so long to come in to the hospital?"- these place blame and only elicit an excuse.
- instead say "I see the pain started early in the day, what was happening between this morning and the time you came into the E.D.?"
45
What are the non-verbal modes of communication
1. Physical appearance: Professional
2. Posture: note patients position and changes in position (suddenly tense=discomfort with new topic). You should sit, and not stand. Relaxed, open posture
3. Gestures: nodding, facilitating gestures.
4. Facial Expression: animation, interest. Use appropriate smiling. Not bored, distracted, disgusted, disbelief
5. Eye contact: Easy eye gaze to person
6. Voice: moderate tone, moderate rate of speech. (anxious= loud, fast) (long unexpected pause with an easy question= question honesty of answer) (unusually frequent and long pauses with slow speech, breathy voice= depression)
7. Touch: Influeced by age, gender, culture, past experience, current, setting. Do not use touch unless you know them well.
46
How should you close the interview?
- End it gracefully
- do not be abrupt. or awkward.
- ask " is there anything else you would like to mention?" " are there any more questions you would like to ask?", "is there anything else you think I should ask about?"
- give summary: final statment of what you and the patient agree the health state to be. Include positive health aspects, and health problems identified, and plans for action, and explanation of the following physical examination.
47
How can you provide quality care to hearing-impaired individuals?
- Ask them their preferred way to communicate. Signing, lip reading, writing?
- Complete health history requires a sign language interpreter (family is fine but be aware that they may edit)
- If they prefer lip reading, face them directly and ensure good lighting
- Do not exaggerate lip movements because it disorts the reception of hearing aids
- speak slow and supplement yout voice with hand gestures
- non-verbal communication (they only understand about 50% of speech when relying on their vision)
- many nod "yes" to be cooperative but do not understand
- Written communication is good in sections like past health history, or review of systems.
48
How do you interview acutely ill people?
- Emergency situation demands your prompt action. Need to combine interview with physical exam skills to determine life saving actions.
- try to interview them as much as possible. Subjective data is crucial to finding out cause
- Abbreviate questioning
- ID main area of distress
- for a very weak patient, first attend to their comfort. Then find out what history is most relevant, and explore the first concern the person mentions.
- Make very clear statements
- Used closed and directed questions earlier. be direct and precise
49
How do you interview people under influence of street drugs or alcohol?
- simple direct questions
- Manner questions in non-threatening way
- Avoid any confrontation methods
- Top priority is to find out time of persons last drink or drug and how much, name of drug. This helps assess withdraw patterns
- once sober, assess for extent of problem, and meaning of problem.
50
What should you do if you are asked personal questions?
- dont need to respond to every question.
- You can supply brief info that you feel in appropriate.
- try redirecting your response back to the persons frame of reference
51
How do you respond to sexually agressive people?
- make it clear that you are a health professional and that you accept the person but you must remain professional and can not tolerate sexual advances
- Set boundaries by saying "I am uncomfortable when you talk to me like that, please dont"
- To further open communication suggest that "Maybe the way you are feeling relates to your illness or being in the hospital?"
52
How do you respond to a crying patient?
- if patient starts crying, dont go on to a new topic. Let them express their feelings
- Offer tissue and wait until they can talk.
- if they look as though they are going to cry, do not move on to a new subject. State "you look sad"
53
How do you respond to an angry patient?
- ask about the anger, and feelings of anxiety or helplessness
- deal with angry feelings before moving to something else
- If you are angry due to an unrelated incident, tell the patient so they do not think your anger was caused by them.
54
When interviewing a patient with LEP, what is important for the nurse to do?
- interpreter who is NOT family or friend
- Carefully document that patient and family fully understand what is happening to them, diagnosis, implcations of the diagnosis, what procedures are going to be done, what they mean, what meds will be taken and when, and the prognosis
55
what is the cultural perspective of southeast asians on health care? What about asian americans?
- Southeast asians expect those in authority to be directive and detached.
- Asian americans expect HCP to intuitively know what is wrong with them. HCP may loose credibility when asking "what brings you here?"
56
What is the concern with Asians and American indians and their emphasis on social harmony?
- They may not fully express their concern or feelings in order to maintain social harmony
- reserved behavior that suggests they agree with you, or nodding and smiling, may only reflect their value of harmony, and does not always mean they agree.
57
How can you distinguish between socially compliant responses and genuine responses?
validate your assumptions and invite the person to respond frankly to your suggestions, or give them permission to disagree with you.
58
How might Appalachians respond to the interview?
- they expect close interpersonal relationships with HCP.
- May evaluate your effectiveness by your interpersonal skills over your competencies.
- may dislike the impersonal style of healthcare institutions.
59
Which cultures need to feel comfortable before entering into the intimate aspects of health history and physical exam? How can you accomplish this?
American indians
Hispanic
Middle Eastern
African cultures
*They expect a personal or social conversation before. They place a high value on interpersonal relationships.
*Use a conversational tone of voice and inquire about their family members and their health
60
True or False: Most Asian women use their husbands last name after marriage
False- most asian women do not use husbands name.
| - most asian children are given fathers last name.
61
How should you shake an asians hand?
Do not shake vigorously, or too firm.
62
How do you address a central or south american?
Two surnames that represent fathers last name and mothers last name.
63
How do you address arabs?
- fathers first name is used as middle name, and last name is the family name. Some prefer to be addressed as Abu (father of...) or Um (mother of...).
- formality is emphasized, so always use Mr. Mrs. Dr. Ms.
- kiss on the cheek and handshake for same gender
- no touching when man and woman are introduced
64
American Indians
- Most tend to our norms
- najavo tribe elders may be addressed as "grandmother" or grandfather
- some american indians and alaska natives have surnames such as Running Deer, Flying Eagle, etc.
- Always extend gentle non aggressive handshake when introduced to american indian patient.
65
Intimate Zone (0-1.5 ft)
- visual distortion
| - best for assessing breath and other body odor
66
Personal distance (1.5-4 ft)
- Perceives as an extension of the self similar to bubble
- voice is moderate
- body odor inapparent
- no visual distortion
- Much of physical assessment occurs here
67
Social Distance ( 4-12ft)
- interpersonal business transactions
- perceptual info much less detailed
- much of the interview occurs here
68
Public Distance ( 12ft+)
- interaction with others impersonal
- speakers voice must be projected
- subtle facial expressions imperceptible
69
Cultural considerations on Gender
- Arab americans: adult male never alone with a female, except his wife. He will generally be accompanied by one or more other males when interacting with females.
- Ask person about culturally significant relevant aspects at the beginning of the interview.
- Offer to have 3rd person present.
- not unusual for a female to refuse exam by a male and vice versa.
- ensure they are draped at all times, closed curtains, and doors.
- always knock and announce self
70
Which cultures consider direct eye contact impolite or aggressive?
```
Asian
American Indian
Indochinese
Arab
Appalachian
```
71
An American Indian patient is staring at the floor, what does this most likely mean?
American indians stare at the floor during conversations to indicate that they are listening intently to the speaker
72
How do hispanics convey respect with eye contact?
with a downward cast of the eyes
73
Eye contact in muslim-arab women, and hasidic jews
Muslim- arab women: no eye contact with men to convey modesty
Jews: no eye contact with females
74
What cultures are most concerned with inter-generder touch during exams?
Arabs and Latinos.
