Chapter 26 Flashcards
What does data collection refer to during a interview?
Obtaining subjective and objective information from clients.
During which portion of the health assessment does Subjective data come from?
Health History
During which portion of the health assessment does Objective data come from?
Physical examination and diagnostic tests
What are two interviewing techniques?
Standardized formats and therapeutic techniques
Definition of Standardized format technique?
Framework for obtaining physical, developmental, emotional, intellectual, social, and spiritual information (dimensions) of a client.
Definition of Therapeutic techniques (not methods)?
A health assessment that fosters communication and promotes an optimal health assessment/data collection experience.
What does therapeutic communication include?
Introduction
What does the client want to be called?
Is the client comfortable? Interpretive services?
Reduce Environmental noise
State purpose of the interview
Obtain health Hx, General survey, & Vitals prior to PE
Note body language
Avoid - Jargon, Advice, False reassurance
Summarize
What are the health history components?
Demographics Source of Hx Chief complaint (CC) Hx of present Illness (HPI) Past Health Hx (PHx) and current Health Status Family History Psychosocial History Health promotion behaviors
Methods to practice therapeutic communication techniques?
Active Listening
Open-ended questions - want pt to tell own story
Close-ended questions - used to clarify information
Clarifying (expand on clients statements)
Back channeling (active listening phrases - “go on” or “tell me more”.
Summarizing
Is it appropriate to feel or listen through clothing?
No - will obscure findings
Additional guidelines for older pts
Allot time for the elderly to move/change position
Allot time for possible extensive Hx
Observe if pt is getting tired
Realize the loss of independence is difficult for pt
Sensory aids available
What is the order for look, feeling, listening during exam? And What is the exception?
IPal-PerA (IPPA)
- Inspect
- Palpate
- Percuss
- Auscultate
Exception = Abdomen (IAPer-Pal or IAPP) - avoid altering bowel sounds
When should a tender area be palpated - First or last?
Last
When is deep palpation performed?
During abdominal examination
What sensation is the dorsal surface of the hand most sensitive to?
Temperature
What sensation is the palmar surface of the hand and base of fingers most sensitive to?
Vibration
What sensation is the fingertips most sensitive to?
Pulsation Position Texture Turgor Size Consistency
What are the fingers and thumb useful for?
Grasping an organ or mass
During percussion, what might quieter sounds indicate?
Denser tissue
Describe is direct percussion?
Involves striking the body directly
Describe is indirect percussion?
Involves striking your flat hand or finger covering body part you are trying to exam
Describe is fist percussion?
Involves lightly tapping areas over kidney, liver, or gallbladder with a fist to elicit tenderness
How are auscultation sounds described?
Amplitude/intensity (Loud or soft)
Pitch/Frequency (high or low)
Quality (What it sounds like)
What side of a stethoscope is intended for high pitch sounds?
Diaphragm
What sounds should be higher in pitch?
Expected heart, bowel, and lung sounds
What sounds should be lower in pitch?
Unexpected heart sounds or bruits
What side of a stethoscope is intended for low pitch sounds?
Bell
How is the Bell or Diaphragm of a stethoscope used?
The Diagraph should be placed firmly
The Bell should be lightly placed
What is a general survey?
A written summary of overall health.
What is included in a general survey?
Physical appearance Body Structure Mobility Behavior Vital Signs
