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NURSING: 1st QUARTER > History and Interviewing > Flashcards

History and Interviewing Flashcards

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1
Q

What are the goals of history an interviewing?

A

Lead pt to maximum wellness
Discover info leading to diagnosis and management
Provide information about diagnosis
Share info with health care management
Education and prevention

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2
Q

Privileged Communication

A

Protects physicians, APNs or dentists from disclosing information against a patient on trial

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3
Q

Pitfalls in taking Hx

A

not appreciating cultural differences
judgmental
making medical model the only paradigm
bias and lack of personal awareness
medical jargon
failing to check for pt understanding

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4
Q

Patient Level Barriers

A

Lack of Assertiveness
Trust
Fund of Knowledge - Lack of understanding about dx

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5
Q

Provider Level Barriers

A

Lack of Cultural Competence
Stereotyping
Intersection of Patient and Provider Barriers

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6
Q

Ethical Context Respect and Flexibility

A

Autonomy
Beneficence
Utilitarinaism
Nonmaleficience
Fairness of Justice
Deontological

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7
Q

Factors that Enhance Communication

A

Courtesy
Comfort
Connection
Confirmation
Confidentiality
Patient Centered

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8
Q

Leading Questions

A

“Have you been taking your meds?”

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9
Q

Techniques to Enhance Communication

A

Facilitate - encourage to say more
Reflect - Repeat back
Clarify
Empathize
Confront - Address disturbing behavior
Interpret - Repeat back

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10
Q

Communication Tensions

A

Curiosity about you
Anxiety
Silence
Depression
Crying
Physical intimacy
Seduction
Anger
Avoidance of full story
Financial Considerations - Can they afford meds

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11
Q

Structure of Hx

A

Identifiers: name, date, time, age, gender, race, occupation, and referral source
Chief Complaint
History of present illness (HPI)
Past medical history (PMH)
Family history
Personal and social history (SH)
Review of Systems(ROS)

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12
Q

Building the History

A

Avoid medical jargon
Take notes sparingly
Avoid leading questions
Start with general concerns, then move to specific descriptions
Clarify responses (where, when, what, how, and why)
Verify and summarize

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13
Q

Goal of screening

A

Find out if a problem exists

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14
Q

CAGE Questionnaire

A

Cutting down
Annoyance by criticism
Guilty Feeling
Eye-opener

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15
Q

TACE Questionnaire

A

how many drinks does it TAKE to feel high?
ANNOYANCE by criticism
have you felt you ought to CUT down on drinking
do you take EYE-OPENER drinks in morning for hangovers

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16
Q

CRAFFT Questionnnaire

A

More so for adolescents
have you driven or ridden a CAR driven by someone under the influence?
do you ever take drugs to RELAX, feel better or fit in?
do you ever take drugs when you’re ALONE?
do you FORGET the things you did when using drugs?
do you have a FAMILY member or FRIEND tell you to cut down?
have you ever gotten into TROUBLE from using?

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17
Q

Three questions to detect partner violence

A

Have you been hit, kicked, punched or otherwise hurt by someone in the past year?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is making you feel unsafe now?

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18
Q

HITS questionnaire

A

Hurt you physically?
Insult or talk down to you?
Threaten you with physical harm?
Scream or curse at you?

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19
Q

FICA Questionnaire

A

Faith - spiritual heritage? writings important to you?
Importance - beliefs influence how you handle stress?
Community - belong to a spiritual community?
Address - do religious beliefs affect health decisions?

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20
Q

Gender neutral questions

A

Tell me about your living situation
Are you sexually active? In what way?

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21
Q

Different types of health history

A

Brief
Complete Inventory
Interim (see pt 6mo.-1yr)
PE (physical examination)

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22
Q

OLD CARTS for HPI

A

Onset
Location
Duration
Character - Stabbing or dull?
Aggravating/associated factors
Relieving factors
Temporal factors - continuous in the morning?
Severity

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23
Q

Chief Complaint

A

Note all significant complaints
What symptoms brought you here?
How long has problem been present?
Note age, gender, marital status, occupation and previous hospital admissions

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24
Q

HPI

A

Chronology of events
Health state before present problem
First symptoms
Exposure to infection or toxic agents
Typical attack
Illness impact on lifestyle
Stability of problem
Immediate reason for visit
Review of involved systems
Medications list
Complementary or alternative therapies
Chronology review
Problem list

25
Q

PMH

A

General health
Childhood illnesses
Major adult illnesses
Hospitalizations
Serious injuries
Accidents
Disability
Immunizations
Past medication
Blood transfusions
Allergies
Recent Screening Tests
Emotional Health

26
Q

Social History

A

Socioeconomic status
Access to care
Occupation
Living conditions
Drugs
Smoking
Intimate Partner Violence
Spiritual
Sexual hx
Military hx
Living or traveling abroad
Home Conditions
Safety - guns, seat belts or helmets

27
Q

Obstetric Hx

A

GTPAL - gravida, term, preterm, abortions, living

28
Q

Menstrual hx

A

age of menarche, frequency, duration, amount of flow, pain or other problems, LMP (last menstrual period) , LNMP (last normal menstrual period)

29
Q

Family Hx

A

Blood relatives with similar illness
Blood relatives with hx of major disease
Determine if any cancers have been multiple, bilateral, occuring more than once and occuring at a young age (less than 50 y/o)
Note age and outcome of illnesses
Ethnic and racial background
Note the age and health of spouse or patients parents

30
Q

ROS

A

General constitutional symptoms,
Skin, hair and nails
Head and neck
Lymph nodes
Chest and lungs
Breasts
Heart and blood vessels
Peripheral vascular
Hematologic
GI
Diet
Endocrine
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Concluding questions

31
Q

General Constitutional Symptoms

A

Fever, chills, malaise, fatigability, night sweats, sleep patterns,
Weight - average, preferred, present, change

32
Q

Skin, hair and nails

A

rash, eruption, itching
pigmentation
excessive sweating
abnormal nail or hair growth

33
Q

Head and Neck: General

A

Headaches, dizziness, syncope, head injuries, Loss of Conciousness

34
Q

Head and Neck: Eyes

A

Acuity, blurring, diplopia, photophobia, pain, vision changes, glaucoma, trauma

35
Q

Head and Neck: Ears

A

Hearing loss, pain, discharge, tinnitus, vertigo

36
Q

Head and Neck: Nose

A

Sense of smell, colds, obstruction, epistaxis, postnasal discharge, sinus pain

37
Q

Head and Neck: Throat and Mouth

A

Hoarseness or change in voice, sore throats, bleeding gum, tooth abscesses, extractions, soreness or ulcers of tongue/mucosa, taste changes

38
Q

Lymph Nodes

A

Enlargement, tenderness, suppuration (pus forming)

39
Q

Chest and Lunga

A

Pain, dyspnea, cyanosis, wheezing, cough, sputum, hemoptysis, night sweats, exposure to TB, last chest radiograph

40
Q

Breasts

A

Development, pain, tenderness, discharge, lumps, galactorrhea, mammograms (screening and diagnostic), self-awareness, self-examination

41
Q

Heart and Blood Vessels

A

Chest pain, palpitations, dyspnea, orthopnea, edema, claudication, hypertension, previous MI, exercise tolerance, date of last ECG, other cardiac tests

42
Q

Peripheral Vascular

A

Claudication - frequency, severity
Tendency to bruise or bleed
Thromboses
Thrombophlebitis

43
Q

Hematologic

A

Anemia, blood cell abnormalities, past transfusions

44
Q

GI

A

Appetite, digestion, food intolerance, dysphagia, heartburn, N/V/D, hematemesis, regularity of bowels, constipation, change in stools, hemorrhoids, jaundice, previous imaging studies

45
Q

Diet

A

Appetite, likes and dislikes, diet restrictions, cultural constraints, vitamins and other supplements, caffeine, dietary recall

46
Q

Endocrine: General

A

Thyroid enlargement or tenderness, heat/cold intolerance, weight change, diabetes, polydipsia, polyuria, changes in facial or body hair, increased hat or glove size, skin striae

47
Q

Endocrine: Female

A

Menses, discharge, itching, lasp pap smear, libido, intercourse, birth control, infertility, pregnancy, menopause

48
Q

Endocrine: Male

A

Puberty onset, erections, emissions, testicular pain, libido, infertility

49
Q

Genitourinary

A

STIs, dysuria, pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, dribbling, loss in force of stream, passage of stone, edema of face, stress incontinence, hernias

50
Q

Musculoskeletal

A

Joint stiffness, pain, restriction of motion, swelling, redness, heat, bony deformity

51
Q

Neurologic

A

Syncope, seizures, weakness or paralysis, abnormalities of sensation or coordination, tremors, loss of memory

52
Q

Psychiatric

A

Depression, mood changes, difficulty concentrating, nervousness, tension, SI, irritability, sleep disturbances

53
Q

Concluding Questions

A

Is there anything else you think would be important for me to know?
What problem concerns you most?

54
Q

Considerations for Children

A

Mother’s gestational history, pregnancy, and birth
Child’s neonatal period, feeding, and development
Child’s school adjustment, habits and home life
Review systems for child-specific conditions

55
Q

HEEADSSS

A

For adolescents
Home environment
Education
Eating
Activities, affect, ambitious, anger
Drugs
Sexuality
Suicide/depression
Safety

56
Q

PACES

A

For adolescents
Parents, peers
Accidents (alcohol/drugs)
Cigarettes
Emotional issues
School, sexuality

57
Q

Considerations for Pregnant Women

A

Current pregnancy and obstetric hx
exposure to environmental/occupational hazards
family genetic conditions/congenital
personal and social issues of pregnancy and parenting
Reproductive, CV, endocrine, resp. focus
Risk factors that threaten mother and fetus

58
Q

Older Adults

A

Watch age-related changes like sensory loss, visual impairment, cognitive impairment, or memory loss
Draw on persons cumulative lifetime experience

59
Q

Health history of older adults

A

Multiple overlapping health problems
Chronic symptoms
Complete drug assessment
Assessment of functional capacity

NURSING: 1st QUARTER (9 decks)

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