Interview and Health Student Flashcards
Collection of Data
about an individuals health through objective and subjective data
what is objective data?
something that is “seen” or “heard” : it can be measured
Ex: A rash
101 temp
What is subjective data?
something that the patient “says”
- gather information
-establish rapport
-assist in understanding health status
- build relationship for future care
steps of the Nursing process
- Assessment: Collect data, review clinical record, physical examination, health history , document replant data
- diagnosis: compare clinical findings with normal and abnormal variations, interpret data (Make hypothesis & test hypothesis), validate diagnosis
- Outcome identification: identify expected outcomes, indivuilaize to the person, develop a timeline, establish realistic and measurable outcomes
- Planning: establish priorities, develop outcomes, set timelines for outcomes, document plan of care
- Implementation: implement in a safe and timely manner, collaborate with colleagues, coordinate care delivery, use evidence-based interventions
-Evaluation: progress towards outcomes, include patient and significant others, disseminate results to patient and family
Collecting four types of patient data
(1) Complete Total database: complete health history and full physical exam
(2) Episodic or Problem focused database: used for a limited or short term problem
(3) follow up database: evaluating an identified problem on a regular interval
(4) emergency database: urgent collection of crucial information
What is holistic health
- you consider the whole person (body, mind, & spirit)
Assessment factors based on Holistic Health Model
- patterns of coping
- ADLs
-emotional status - biophysical status
- growth and development
- cultural, religious, socioeconomic
- resources
- environment
-health goals - perception of health status
- interaction patterns
Interview purpose
- to gain an understanding of the patients beliefs, corners, and perception of their individual health state
- allows for the compilation of subjective data and awareness of objective data (physical appearance, posture, ability to carry on a conversation , and demeanor)
Developing a relationship and effective communication with the patient (5 c’s)
- comfort
-confirmation - confidentiality
- courtesy
-connection
Active or attentive listening
- Be present
(what is being said or avoided) - tone of voice
- eye contact (use cultural awareness)
Prepare the Interview Setting
- establish privacy
- temperature
- good lighting
-reduce noise & distractions - face to face
- therapeutic distance
- professional dress
- try to avoid excessive note-taking
- minimize interruptions
- equal status seating
Conduct the Interview
- Introduce yourself
- then give the purpose of the interview
-Collect your information ( open-ended questions leave the person free to answer in any way/ let the person person express themselves fully
(closed or direct questions for specific information )
Therapeutic Communication Techniques (9)
(1) Facilitation- encourages client to say more Ex: nodding yes
(2) Silence- Provides you with a chance to observe a client and note nonverbal cues Ex: Counting silently 1 to 10
(3) reflection: Echoes clients words by repeating part of what person has just said
(4) empathy: allows person to feel accepted and strengthens rapport
(5) Clarification: summarizes person’s words, simplify the statement, and ensure that you are on the right track
(6) Confrontation: focusing client’s behavior on an observed behavior, action, or feeling Ex: you look sad. or You sound angry
(7) interpretation: Links events, makes an associations, and implies cause
(8) explanation: informing person
(9) Summary: condenses fats and validates what was discussed during the interview
Positive Nonverbal Behaviors (8)
- Professional appearance - the way someone grooms themselves can let a healthcare provider diagnose a person
- Open posturing- willing to participate in communication
- Facilitating gestures
- Eye Contact
- Moderate Tone of Voice
- Appropriate Touch
- Moderate Rate of Speech
Ten Traps of Interviewing
- Provding false assurance or reassurance
- giving unwanted advice
- using authority
- using avoidance language
- engaging in distancing
- Using professional jargon
- Using leading or biased questions
- talking too much
- interrupting
- Using why questions
Interviewing the parent or caregiver of a child or children
- focus on both individuals so as to encourage participation
-obtain information and relevant data
-address by name to help foster engagement
interviewing an older adult
- address respectfully
-use therapeutic touch to provide empathy
-developmental task of finding purpose and evaluating existence
Patients with special needs
- crying
-anger - threat of violence
- anxiety
- personal questions
- sexually aggressive
- under the influence
- actually ill
- hearing- impaired
Closing the Interview
- now new topics introduce
- summary provided as final statement
Approaching sensitive issues
- provide privacy
- do not waffle
- do not apologize for asking questions
- do not preach
- do not use medical jargon
- do not push too hard
Sensitive Issues
- alcohol and drug use
- intimate partner violence (child abuse should be considered if this is detected)
-spirituality - sexuality and gender identity
Health Literacy
is the degree to which individuals have the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions
assessing for low health literacy
- how confident do you feel in filling out medical forms by yourself?
use the nutrition label and ask patient to interpret the information
Techniques to improve health literacy
- oral teaching ( provide simple, easy instructions, use conversational structure rather than medical jargon)
- written materials (use 12 point font , avoiding all caps )
- teach back ( encourages verification of understanding )
SBAR (define)
S- situation; provide a brief description of location, clinical diagnosis
B- background; provide history as it directly relates to patient’s current health status
A- assessment; states assessment findings obtained with interpretation of data
E- recommendation or request; state what you need or want for the patient in terms of medical treatment and or assistance
Purpose of Health History
- collect subjective data to combine with objective data from physical exam and lab studies to form the database
-provides a complete picture of patients past and present health status
-
Components of the Health History
- Biographic data
- Source of the history
- reason for seeking care
- history present illness (HPI)
- past medical history (PMH)
- family history (FH)
- review of systems ( ROS)
- functional assessment (FA)
HPI
- location
-character of quality
-timing
-setting
-associated factors
-patient perception - severity of quantity
- aggravating or relieving factors
PMH
- childhood illnesses
- accidents or injuries
- serious or chronic illnesses
- hospitalization
- operations
-obstetric history - immunizations
-most recent exam - allergies
- current medications
- last menstrual period
FH
- provides age and health or cause of death of relatives
- highlights diseases or conditions that an individual may be at risk for as a result of genetics
- Pedigree or genogram used as standardized
tool to organize data - Ability based on results to seek early screening,
make possible lifestyle adjustments, and/or
undergo periodic surveillance
ROS
purpose
subjective data - told to the nurse by the patient
- evaluate each body system
- evaluate health promotion practices
Systems Approach
- sexual health
-male/ female genital
-endocrine
-hematologic
-neurologic - skin and hair
- head
-respiratory - cardiovascular
-gastrointestinal - general overall health state
- peripheral vascular
-urinary
Functional assessment
- social and self care
- ADLs
-IADLs
Health history Infant or child
- the source of history
- CC in parents words
- PI
- PMH ( prenatal care, labor & delivery, postnatal)
-Developmental history (growth, developmental milestones) - functional assessment
-nutritional history
Health History Older adults
- medications
-emotional status
-sleep pattern
-bowel habits - home safety
- forces on ADLs and IADLs
Reason for Seeking care or chief complaint (CC)
- use the patients own words
- avoid medical terms
-ask about symptoms
symptoms
suggest disease or dysfunction described in the history
signs
found on examination, when abnormal structure or function suggests the presence of disease
ACEs
Childhood experiences, both positive and negative, have a tremendous
impact on future violence victimization and perpetration, and lifelong
health and opportunity.
ACEs can be prevented.
Adverse Childhood Experiences are
Common
Household Dysfunction:
Substance Abuse 27%
Parental Separation/Divorce 23%
Mental Illness 17%
Battered Mother 13%
Criminal Behavior 6%
Abuse:
Psychological 11%
Physical 28%
Sexual 21%
Neglect:
Emotional 15%
Physical 10%
