Health Assessment #1 - The Nursing Process (2)

Question 1

The interview

• This allows us to gather the ______ data.
• The beginning of the assessment. Allows a rapport with the client.

Answer 1

• This allows us to gather the subjective data.
• The beginning of the assessment. Allows a rapport with the client.

Question 2

The Process of Communication

• Sending
  
  • Verbal communication
  • ______ : Your body language, gestures, facial expression, eye contact, foot tapping, touch. More reflecting of your true feelings.
• Receiving
  
  • Try to interpret what the patient is telling you correctly.
  • Understand that they are scared, anxious, and physically ill.
• Internal Factors
  
  • Liking others
  • ______
  • View the world from the other person’s view. Accept others without criticism.
  • Ability to listen
  • Listening requires ______.
• External Factors
  
  • ______ (what do they do)
    
    • Find a private room, make sure they feel safe with you.
  • ______
    
    • Ask your coworkers to not disturb you unless there is an emergency. The clients will lose your trust if there are too many interruptions.
  • ______
    
    • Appropriate room temp, sufficient lighting
    • Reduce noise, turn off tv, radio, etc.
    • Place distance, at least 4-5 feet (twice arms length)
    • Arrange equal-status seating (should be at eye level)
    • be face-to-face
  • Your dress
    
    • Should be appropriate
  • Note taking
    
    • Sometimes unavoidable, but try to avoid it.

Answer 2

The Process of Communication

• Sending
  
  • Verbal communication
  • Nonverbal communication : Your body language, gestures, facial expression, eye contact, foot tapping, touch. More reflecting of your true feelings.
• Receiving
  
  • Try to interpret what the patient is telling you correctly.
  • Understand that they are scared, anxious, and physically ill.
• Internal Factors
  
  • Liking others
  • Express empathy
  • View the world from the other person’s view. Accept others without criticism.
  • Ability to listen
  • Listening requires complete attention.
• External Factors
  
  • Ensure privacy (what do they do)
    
    • Find a private room, make sure they feel safe with you.
  • Refuse the interruption
    
    • Ask your coworkers to not disturb you unless there is an emergency. The clients will lose your trust if there are too many interruptions.
  • The physical environment
    
    • Appropriate room temp, sufficient lighting
    • Reduce noise, turn off tv, radio, etc.
    • Place distance, at least 4-5 feet (twice arms length)
    • Arrange equal-status seating (should be at eye level)
    • be face-to-face
  • Your dress
    
    • Should be appropriate
  • Note taking
    
    • Sometimes unavoidable, but try to avoid it.

Question 3

Ten traps of interviewing

Question 4

Effective Communication

Use effective responses:

______ : “mm-hmmm” “go on”

Answer 4

Fascilitation : “mm-hmmm” “go on”

Question 5

Effective Communication

Use effective responses:

______ : Shows attentive/active listening

Answer 5

Providing Silence : Shows attentive/active listening

Question 6

Effective Communication

Use effective responses:

______ : echoes patient’s words

Answer 6

Reflection : echoes patient’s words

Question 7

Culture

Question 8

The Complete Health History

1. Biographic data
2. Their reason for seeking care
3. Health history of present pain (OLD CART)
4. Past health
5. Family history
6. Review of systems
7. Functioning assessment
8. Their perception of health

Answer 8

preview of next few slides

Question 9

The Complete Health History - Health History of Present Pain

OLD CART

• An explanation of the symptoms from when they started to now
• Ask these questions:
  
  • ______ : where is the pain?
  • ______ : sharp or dull? Use the 10-point scale
  • ______ : how many times a day? Does it get worse as the day progresses?
  • ______ : when did the symptoms first start? How long do they last?
  • ______ : What were you doing or where were you when the symptoms started?
  • ______ : What makes it worse? What makes it better?
  • ______ : is this symptom related to any other factors?
  • ______ : how does it affect your daily activities?

Answer 9

• Ask these questions:
  
  • Location : where is the pain?
  • Quality of pain : sharp or dull? Use the 10-point scale
  • Quantity of pain : how many times a day? Does it get worse as the day progresses?
  • Timing : when did the symptoms first start? How long do they last?
  • Setting : What were you doing or where were you when the symptoms started?
  • Relieves / Aggravating : What makes it worse? What makes it better?
  • Associative factors : is this symptom related to any other factors?
  • Perception : how does it affect your daily activities?

Question 10

Mental Status Assessment

Definition: A person’s emotional and cognitive function.

What are the 4 components of a mental status assessment?

Answer 10

(A, B, C, T)

1. Appearance
2. Behavior
3. Cognition
   
   1. New learning = 4 words test (tests person’s ability to lay down new memories. Should get 3 out of 4 if under 60
4. Thought processes
   
   1. Supplemental Mental Status Exam (MMSE) Cognition only

Question 11

Describe the method for alcohol assessment (CAGE test)

Answer 11

Do you think you can cut down on your drinking?

Have you ever been annoyed by a friend’s criticism?

Have you ever felt guilty about your drinking?

Do you ever drink an eye-opener to relieve shakes in the morning?

Question 12

Mental Status Assessment

Answer 12

A-B-C-T

Appearance

Behavior

Cognition

Thought processes