Lecture 1: Vitals and Patient History Flashcards
1
Q
2 Assessments for Data Collection
A
- History: Subjective Data - What the person says (open to interpretation, how they perceive the information)
- Physical Examination: Objective Data - What the health care provider observes (What people can see/hear, using senses to perceive data)
2
Q
Types of Clinical Reasoning Models
A
- Diagnostic Reasoning (Clustering data, reasoning your way through)
- Nursing Process (Pull together our thoughts)
- Critical Thinking
3
Q
4 Steps of Diagnostic Reasoning
A
- Attending to cues (ex: listening to the lungs, writing what you see, gathering data)
- Formulating hypotheses
- Gathering data
- Evaluating hypotheses + data
4
Q
6 Parts of the Nursing Process
A
- Assessment (Focus subjective + objective data cluster data to move to nursing diagnoses
- Diagnosis (How they are adapting, what is happening)
- Outcome Identification (Exert themselves without wheezing, how do you overcome this?)
- Planning (Planning ways to help them achieve their goals)
- Implementation (Teach and show them)
- Evaluation (Did it work?)
5
Q
Levels of Clinical Judgement (4)
A
- Novice
- Competent
- Proficient
- Expert
6
Q
Examples of our Clinical Thinking Skills
A
- Identifying assumptions
- Identifying an organized and comprehensive approach
- Validation
- Distinguishing normal from abnormal
- Making inferences
- Clustering related cues
(We have to identify assumptions based on our experiences, is it a gut feeling, or fact based) - Distinguishing relevant from irrelevant
- Recognizing inconsistencies
- Identifying patterns
- Identifying missing information
- Promoting health
- Diagnosing actual and potential (risk) problems
- Setting priorities
- Identifying patient-centered expected outcomes
- Determining specific interventions
- Evaluating and revising thinking
- Determining a comprehensive plan
7
Q
Evidence Informed Assessment
A
Evidence:
- What “counts” as evidence
- Assessment skills are foundational to EIP
- Importance of questioning tradition in assessment when no compelling research evidence exists to support it
Evidence Model:
- Evidence from research and evidence-informed theories
- Physical examination and assessment of patient
- Clinical expertise
- Patient preferences and values
8
Q
Guidelines for Clinical Practice
A
- Work to build trust
- Engage through listening
- Convey respect for differences
- Pay attention to social and economic contexts of patients and families lives
- Be knowledgeable about the social and economic policies in Canada that influence provision of healthcare provincially and nationally
9
Q
The Interview Process
A
- Subjective Data: What the patient says about himself or herself
- Results of a successful interview: Gather complete accurate data, establish trust, teach patient about their health, build rapport for a continuing therapeutic relationship, look for opportunities to engage in teaching
10
Q
The Contract
A
- The interview as a contract between patient and examiner
Factors to consider: - Time/place
- Intro and explanation
- Purpose
- Length
- Expectations
- Presence of others
- Confidentiality
- Costs
11
Q
The Process of Communication
A
- Sending
- Receiving
- Attending to power differentials
- Communication Skills
- Unconditional positive regard
- Empathy and active listening
12
Q
Describe a Proper Physical Setting
A
- Ensure privacy
- Refuse interruptions
- Attention to the physical environment
- Dress
- Taking notes
- Electronic clinical documentation
- Audio recording
13
Q
Challenges of Note Taking
A
- Impedes eye contact
- Shifts attention away from patient
- Interrupts patients narrative flow
- Impedes observation of nonverbal behaviour
- Can be threatening during discussion of sensitive issues
14
Q
Communication Techniques
A
- Introducing the interview
- The working phase: open ended and closed ended questions
Responses: assisting the narrative - Facilitation
- Silence
- Empathy
- Clarification
- Confrontation
- Interpretation
- Explanation
- Summary
Nonverbal skills - Eye contact, physical appearance,etc
- Closing the interview
15
Q
10 traps for interviewing
A
- Providing false assurance or false 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
16
Q
Interviewing in Challenging Situations
A
- Hearing-impaired patients
- Acutely ill patients
- Patients under the influence of alcohol or drugs
- Personal questions asked of the clinician
- Dealing with sexual advances
- Patients who are crying
- Angry patients
- Patients who threaten violence
- Anxious patients
17
Q
Cultural and Social Considerations
A
- Communicating across cultures
- Perspectives on professional interactions
- Etiquette
- Space and distance
- Considerations related to gender
- Considerations related to sexual orientation
18
Q
Overcoming Communication Barriers
A
- Differing perceptions of the roles of patient, family, and healthcare professional
- Need for reflective nursing practice and awareness of expectations of conformity and obedience
- Influence of past experiences and inequity in shaping responses in health care settings
- Use of interpreters who are trained is ideal
- Children are inappropriate interpreters
- Awareness of potential for violation of confidentiality when a relative, friend, or visitor is used for interpretation
