Module 2 Flashcards
what is the purpose of a patient interview and who established it as the foundation of nursing practice?
Establish a therapeutic partnership and gather information. Introduced by Hildegard Peplau.
maintains privacy and confidentiality, while the nurse demonstrates professionalism, sensitivity, and nonjudgemental behavior
during therapeutic communication, his information shared verbally or non-verbally?
Both.
What are five dimensions of a patient centered assessment via therapeutic communication
- empathy
- unconditional regard (respect as a unique individual)
- genuine honesty/openness
- caring
- respect (maintains dignity)
Define clear framework in therapeutic communication
CLEAR
Center- pause, focus, connect w/ compassion
Listen - being present
Empathize
Attention
Respect - honor differences
what are you do to prepare for a patient interview
Review the patient’s medical record and ensure a distraction, private environment with good lighting and temperature
during the interview, what should you do?
introduce yourself, explain the purpose, be on the same level as the patient either sitting or standing, reassure confidentiality. The patient remains clothed until the physical assessment begins. Don’t rush, don’t use medical jargon, and use language appropriate for the patients developmental level.
An example of active listening
paying attention, verbal & nonverbal cues while maintaining eye contact
broad opening question example
what can i do for you today
example of clarification
What do you mean when you say, the rash comes and goes?
What’s an example of confrontation?
you said you don’t drink but mention being arrested for a DUI can we discuss this?
What’s an example of empathy
I’m sorry to hear about your pain. How is it affected your life?
What’s an example of of showing respect?
You’ve shown great strength in caring for your children during this difficult time
What’s an example of exploring?
Tell me more about your back pain
what is the example of facilitation?
Using prompts like and then? Or. Mmmmhmm
What’s an example of focusing?
How many stairs can you climb before feeling short of breath?
What’s an example of reflection?
Patient: I might have breast cancer
Nurse: you seem upset. are you angry about missing the mammogram
What’s an example of a transitional statement
now, let’s discuss your family history.
What’s an example of silence?
Allow brief pauses for reflection for about 5 to 10 seconds each
What’s an example of summarizing?
Let me summarize the key points we discussed.
is it OK to record how you feel about the event when documenting?
no. Record observations without bias and should remain objective.
what are some barriers to therapeutic communication from you?
- leading the patient and influencing their responses
- asking too many questions so they get overwhelmed
- not allowing enough time to respond
- using medical jargon
- assuming what the patient means
- using cliches (“you’ll feel better in the morning” which undermines their concerns)
- offering false reassurances
- Asking WHY questions (it can feel accusatory)
- changing the subject abruptly esp. if the discussion is uncomfortable
- giving opinions (only provide information)
- stereotyping (every patient should be treated as an individual)
- patronizing (dearie, sweetie, esp to older adults)
how to communicate with hearing impaired patients
Ensure hearing is functional. Minimize background noise. Speak slowly clearly and face the patient. Use written communication if necessary and AVOID SHOUTING.
how to communicate with visually impaired patients?
Introduce yourself and explain the sequence of an assessment. Describe the environment and physical set up. Ask permission before touching and guide the patient with descriptive cues. Let the patient know when you leave the room.
How to communicate with aphasic patients?
definition: patient can’t communicate through speech or writing.
provide a quiet environment. Speak slowly clearly, and one at a time. Use pictures, writing, or drawing if necessary. Although extra time for responses and avoid rushing.
How to communicate with cognitively impaired patients?
Patient has difficulty with thinking, remembering or understanding.
Use simple focus questions. Repeat is necessary. Maintain eye contact and speak slowly. Gathering information from caregivers or family if necessary.
how to communicate with aggressive patients
Stay calm and empathic and reassuring. Less actively in avoid arguments. Speak softly and maintain a non-threatening posture. Ensure clear exit route.
how to communicate with someone who has a language barrier. Meaning they have a little understanding of English.
Hire trained interpreter instead of family members. Speak directly to the patient and not to the interpreter. Ask simple clear questions. Ensure the patient’s language preferences are respected.
how to speak to a patient with low health literacy?
Use simple language, and avoid medical jargon. Incorporate, pictures, models, or diagrams. Verify understanding by asking patient to explain the information back. A.k.a. teach back method.
what to keep in mind while speaking to a patient with a different culture?
realize that they may have discomfort when discussing private issues. variable physical closeness and touching. preference for the same gender sometimes. allow modesty and realize that direct eye contact may be disrespectful. avoid generalizations.
what are examples of open ended questions?
Encourage patient to express her thoughts and provide detailed answers.
How do you remember to take all of your medication?
Tell me more about how you are feeling?
What brings you in today?
what are examples of closed ended questions?
did you ever try to lose weight weight?
Useful for clarifying details after starting with open ended questions.
Typically a yes, or no answer.
What is full preparation for a patient interview entail?
- Review the patient’s medical record (if available).
- Organize your thoughts and plan how to collect the data.
- Set goals for the interview.
- Assess professional appearance and demeanor.
- Create a comfortable, private environment.
- Wash your hands in front of the patient to follow standard precautions.
- If family members are present, clarify their relationship to the patient and ask for permission for their involvement.
- Document who was present during the interview.
What are three phases of a patient interview?
Intro, working, summarization
What is the introduction phase of an interview?
“Hello Mrs. Mangos, my name is Trisha, and I am a registered nurse. I will be asking you questions about your health before Dr. Brown sees you. This will take about 20–25 minutes. I’ll take some notes as we talk. Are you comfortable?”
Introduce yourself, explain your role, and establish rapport and trust.
State the purpose of the interview, expected duration, and note-taking.
Ensure the patient is comfortable and address them respectfully (use Mr., Mrs., Ms., or Dr., unless told otherwise).
What is the working phase of an interview?
- Collect information using a combination of open- and closed-ended questions.
- Encourage self-reporting and be attentive to nonverbal communication.
- Identify patient problems and goals.
- Allow the patient to ask questions.
What is the summarization phase of an interview?
- Summarize the patient’s report to confirm accuracy and shared understanding.
- Clarify any remaining concerns or questions.
- Validate goals with the patient.
What is the health history?
A patient provides critical pertinent information.
Includes ROS as a subcategory. ROS goes over all 11 body systems and asks them about symptoms they are having in each. This info is subjective.
What are three types of health histories?
- Comprehensive
- Focused
- Follow up
What is a comprehensive health history and when do you perform one?
- Reviews the whole patient and all body systems.
- Common during annual physical exams or first-time visits
- Example: Head-to-toe review of systems.
What is a focused/problem based health history and when do you perform one?
- Addresses a specific problem or symptom. For example, shortness of breath. This would cause the encounter to focus on respiratory system and other systems that could cause shortness of breath.
- Common in urgent care or emergency settings.
- Example: A patient with breathing difficulty focuses on the respiratory and cardiac systems.
What is a follow up history and when do you do one?
- Reviews new data since the last visit.
- Example: Evaluating treatment effectiveness for heart palpitations during a follow-up appointment.
Explain a primary source of data?
Information comes from the patient being assessed. most reliable.
Explain a secondary source of data?
- Family members, significant others, or medical records.
- Used when the patient cannot communicate due to sensory deficits, physical limitations, or cognitive disabilities.
- Example: “Patient is unreliable; report by patient’s son.”
How do you determine if the patient is reliable historian? aka info is accurate
if the patient provides accurate info, they should be able to tell you answers that you yourself can confirm.
Verify with confirmable questions (e.g., “What is your date of birth?” Where are you? What season is it? Who is the president”).
For unreliable sources, rely on secondary sources and document appropriately.
Do you document subjective or objective data?
Both
objective data is physically observable.
subjective data is told by pt.
What is an overview of health history
key purposes of the Health History
* Create a database of past and current medical history, including:
* Chronic conditions, surgeries, hospitalizations.
* Document family health history.
* Identify psychosocial influences on health.
* Assess self-care and health promotion practices.
* Recognize patient strengths and weaknesses.
* Determine educational and discharge needs.
* Plan case management or referrals as necessary.
At the very beginning of the health history, what do you establish?
Reason for being here
Reason for being here overview
also called chief compliant (CC) or presenting problem.
Either an annual physical, some condition, or a main symptom they complain about.
Always begin with an open ended question. Later will ask focused questions.
On average it takes a patient three minutes to tell you what they want to say.
What is an HPI?
A history of present illness. It usually includes only pertinent information. An HPI should tell you everything important you should know to understand a patient’s situation.
Common mneumonics for this is OLDCARTS and LMNOPQRSTUV. You only have to pick one or the other.
I prefer OLDCARTS because it flows the best with conversation
OLDCARTS?
- Onset: When did the symptom begin?
- Location: Where is the symptom felt? Does it radiate?
- Duration: Is it constant or intermittent? How long does it last?
- Characteristics: Describe the sensation or appearance.
- Aggravating/Alleviating Factors: What makes it better or worse?
- Related Symptoms: Are other symptoms present (e.g., nausea)?
- Treatment: What treatments have been tried? Were they effective?
- Severity: Rate the intensity (1 to 10) or impact on daily life.
LMNOPQRST?
- Location: “Can you point to where it hurts?”
- Mechanism: “What do you think caused the problem?”
- New: “Is this a new issue for you?”
- Onset: “When did the symptoms begin?”
- Palliative/Provocative: “What makes it better or worse?”
- Quality: “How would you describe the sensation (e.g., sharp, dull)?”
- Radiation: “Does the symptom spread anywhere else?”
- Severity: “On a scale of 1–10, how intense is the symptom?”
- Timing: “Does it occur at specific times or is it constant?”
- Unusual Symptoms: “Have you noticed anything unusual?”
- Valid: “Do the symptoms feel real to you?”
- Work: “Have these symptoms affected your daily activities or work?”
Example of a pertinent positive?
Located in the HPI.
Patient complains of coughing, wheezing, shortness of breath, pinpoint chest pain, nausea, and vomiting.
Example of a pertinent negative?
Located in the HPI?
Denies rhinorrhea, facial pain, trouble with swallowing, malaise, body aches, fever, fatigue, weight loss.
Summary of some key points (just read this)
- Holistic Approach: The health history integrates physical, psychological, social, and cultural dimensions of health.
- Patient-Centered Communication: Build rapport, ensure confidentiality, and adapt to the patient’s needs.
- Systematic Inquiry: Use mnemonics like OLDCARTS to gather detailed symptom information.
- Documentation: Accurately record subjective data, including pertinent positives and negatives, and verify source reliability.
What is done in biographical data?
- assess patient as a reliable source.
- Name, address, date of birth (DOB), birthplace.
- Age, gender, race, religion.
- Primary and secondary languages.
- Marital status and occupation.
- Health insurance.
- Allergies (drug, environmental, food).
- Reaction Documentation: Include type of reaction (e.g., “Pollen—watery eyes”).
- Emergency contact information.
