General Survey & Interview Flashcards
What is a care partner?
Family and friends involved in care
- Can be informal or formal caregivers
- Care partners is a more inclusive term that acknowledges the energy, work, and importance of their role
What is the difference between objective and subjective data?
Objective - reported by a healthcare professional
- measured/observed through your senses
Subjective - reported by a client
What is clinical judgement?
An interpretation or conclusion about a persons needs, concerns, or health problems, and the decision to take action (or not), use or modify standard approaches, or improvise new ones (as deemed appropriate by the patients response)
What is critical thinking?
A process where people use a logical process to gather information and take purposeful action based on their evaluation
- necessary for problem-solving and decision-making
1st Step in Tanner’s Model: Noticing
- Looks beyond the clinical condition of the client to recognize/respond to emotional and social needs
- The ability to ‘notice’ becomes important when clients are unable to communicate their needs
- Part of the physical exam that describes the client’s mental state and behaviours of the client being seen
Components of the General Survey
A - appearance and behaviour
S - speech
E - emotion
P - perception
T - thought process
I - insight
C - cognition
4 Phases of the Interview Process
- Pre-interactive
- Orientation
- Working
- Termination
What is involved in the pre-interactive process?
- Review existing health record/ chart for an overview of the client’s reason for seeking care
WHY - Conveys interest
- Allows you to follow-up on missing data (clarify and validate client information)
- Assist you to plan your care
Environmental Barriers to Communication
Workload
Time constraints
Nursing shortages
Poor teamwork andcollaboration between teammembers
Equipment (if client has hearing aids, make sure they work)
Distractions (Noise)
Lack of privacy
Why is self reflection important in the pre-interaction phase?
- it is important for recognizing your emotional state and minimizing unintentional miscommunication with clients (ie. What is occupying your thoughts?)
- Useful for connecting with clients and authentically being in the moment as they respond
5 components in the orientation interactive process?
- Introduce yourself - name & credentials
- Verify client - ask for client name, birth date, how they want to be addressed, and cross-reference with records
- Explain/identify the purpose of the encounter and your role
- Discuss privacy and confidentiality
- Obtain consent
Working phase:
3 Types of Interview Questions
- Closed-ended
- Q’s you ask when you are seeking precise information
- Short, do not facilitate dialogue
Ex. “Do you smoke?”
- Short, do not facilitate dialogue
- Q’s you ask when you are seeking precise information
- Open-ended
- Invite the client to share descriptive answers, open up about their experience
- ”What was going on in your life when you started feeling stressed?”
- Probing
- Used to gather additional subjective data
- Used to clarify a client’s response or resolve discrepancies - Can be open or close-ended
- Avoid “Why” or “How come” (can make the client feel defensive) - Ex. “Tell me more”
“How did that affect you”
- Used to gather additional subjective data
What is the difference in communicating across the lifespan?
Infants
- Baby talk
Young Children
- Children enjoy receiving compliments and encouragement
Older Children
- Should offer the opportunity to speak with you privately
Adolescents
- Emotional and cognitive capacity will vary
- Often feel self conscious and have a fear of being judged
Older Adults
- Avoid making assumptions about their sensory or cognitive capacity
- Usually come with care partners
- do not infantalize them
What is the purpose of the termination phase?
- Ensure you have understood everything necessary to best care for the client
- Ensure client has shared what is important to them & any additional information
- Ensure client knows what the next steps are for their care
What is involved in the termination phase?
- Provide a summary of the collected data, reflecting what the client said
- Follow with a few questions (“Did I capture what you said accurately?” “Is there anything else you would like to share with me?” )
- Discuss next steps related to care
- Thank them for sharing their information
