Health History I Flashcards
What is the purpose of history taking?
- gather subjective data from the patient/care partners to create a plan to maximize health
- to learn more about symptoms and patient perceptions
- to examine and further investigate
- to create treatment strategies
- to establish rapport and a therapeutic relationship
- simultaneously perform a general survey
Types of Objective and Subjective Data
Objective (from nurse themself)- physical assessment, diagnostic testing (ie. blood pressure, heart rate)
Subjective (from patient, family, care partners)- feelings, perceptions, desires, ideals, values, symptoms, personal info
What can a nurse do if they suspect the person is unreliable to collect info from?
- Always document WHO is giving the information so you can cross reference for discrepancies
- identify the sources (previous records) to confirm their history
- when the client is unable to provide info, the nurse may obtain it through a secondary source
What are clues that a person is not able to provide RELIABLE history?
- Ie. A patient in a manic episode or having delusions is not a reliable source
- Ie. A patient having negative connotations regarding a certain condition/symptom due to religion/personal beliefs, so they may not report the condition entirely
How do nurses build rapport?
- explain why info is being collected
- use silence
- communicate understanding (empathy)
- provide positive regard
- care for the unique patient (concerns)
- therapeutic touch (if appropriate)
- active listening (listen w/out judgement)
Examples of what to say when building rapport?
- “That sounds like a very difficult time”
- “I am here to listen and support you, Feel free to ask me any q’s abt your care”
- “You are not alone in this. We will wor together toward you recovery”
What is the purpose of unconditional positive regard?
- accepting another person without judgement (just bc they are a human)
- necessary to minimize the influence of guilt or shame while discussing taboo subjects
- caring for the client as a seperate person with permission to have their own feelings/experiences
Who 1st described unconditional positive regard?
Carl Rogers - Humanistic Psychologist
what is the difference between ‘hearing’ and ‘listening’?
Hearing - passive; process of perceiving sound
Listening - active; hearing with an intention to understand
What is Presencing?
Deliberately focused attention, receptivity to the other person, and persistent awareness of the other
- encourages patents to be active contributors of their care
Active listening is a dynamic process involving:
1) hearing a clients message
2) decode its meaning
3) provide feedback to the client regarding the nurse’s understanding of the message
What is the goal of active listening?
To see of the words and behaviours match. If not, you need to find out what the essence (real meaning) is.
Which characteristics are most important to listening?
- empathy
- silence
- attention to verbal and non-verbal communication
- ability to be nonjudgemental and accepting
How to use silence effectively?
- respect clients silence without breaking the mood
- should only last bw 10-15 seconds
- long silences can be uncomfortable
- allows the client and nurse to reflect (esp useful when discussion is emotional)
What are the 2 parts of empathy?
1) Pre-verbal: mental process where the nurse shifts from their world into the clients
2)Verbal: accurately and specifically reflect your understanding
What is the difference between empathy, sympathy, and compassion?
Empathy - feeling WITH someone
- feeling with people
- a vulnerable choice
- affectionate response that understands a patients suffering through emotional resonance
Sympathy - feeling FOR someone
- drives disconnection
- distracts from the actual problem
- involves a pity-based response
- superficial acknowledgement of suffering
- not necessarily bad; used in specific situations
- can be a coping strategy for situational suffering
Compassion
- action-based
- seeks to address the patients’ suffering through understanding AND action
What is the similarity between empathy and compassion?
- they share attributes of acknowledging, understanding, and emotionally resonating with a person who is suffering
What is the difference between natural and clinical empathy?
Natural Empathy
- instinctive trait
- intrinsic ability to understand others’ feelings
Clinical Empathy
- a skill that is consciously and deliberately employed to achieve a therapeutic intervention and establish a helping relationship
Verbal aspects of empathy?
- reflect to the client what you understand of their feelings and reactions
- be accurate; do not exaggerate
- dont just repeat what the client said
- be specific
Non-Verbal aspects of empathy?
- genuineness
- warmth
- empathy is not feeling sorry for - it is value free
What are things you should NOT say in an interview? (non-therapeutic)
- asking personal questions
- giving opinions
- generalizing/ stereotyping
- giving defensive responses
- arguing
- providing false reassurance
- asking “why” questions
What are the 8 Communication Pitfalls?
1) Why Q’s - client may feel judges blamed, or get defensive
2) Leading Q’s - anticipate the answer when little is known
- if you give options to the client to answer, they will often just pick 1 of the options
3) Negative Phrasing - avoid asking a question in a format that downplays, minimizes, or negates the clients experience
4) Unfamiliar Language - (ie. medical technology, jargon)
5) Irrelevant or poorly times Q’s - impacts the flow of conversation
6) Too many Q’s - clients may feel that they are being interrogated
7) Inaccurate or false reassurance - client may distrust the nurse and discount the info given by the them
8) Defensiveness - justify an action that they know is insensitive, inappropriate, wrong, or covers up an error
Why should we not use, ‘but’ statements?
- Using “but” in statement’s negates everything you said before that
- Ie. “you are making great progress, but I know you can improve”
- Instead, use “and”
You should talk _______ the client, NOT _______ them.
Talk WITH the client, not ABOUT them.
- encourage client to tell their story
- give the client a voice and JOIN in with yours
