obtaining a health history Flashcards
what to do in therapeutic communication
- nurses engage in therapeutic communication to set their own opinion judgments aside to listen to their patients fully
- encourage the nurse patient relationship
- active listening
- reflection = repeating what the PT said
- empathy
- non judgement
what do you not do to communicate with your patients
- change the subject
- share personal opinions as it limits convos between pt and nurse
- don’t be dismissive
what are the 2 main components to a health assessment?
- health history (subjective data)
- physical exam (objective data)
what makes a physical space safe for communication? what room do you want your pt in?
- private, quiet, comfortable room without distractions
what are the 4 phases of an interview
- Orientation phase = PT reaches out and needs help
- Identification phase = establishing mutual, respectful relationship
- Exploitation phase = nurse educations the PT on change
- Resolution / termination phase = the relationship is over, they are changing their behavior, healed
what are the different types of questions for interviewing a pt about their health?
- Open - ended questions
- Restating = changing the way you are asking their question, or what their saying
- Reflection = reflect on what they said
- Facilitation = tell me more things while I chart for ex
- Clarification = clarifying what they say
- Affirmations = affirming what their saying
- Active listening
- Confrontation = we need to confront them on misleading information
- Interpretation & summarization = summarizing and restating to make sure we understand what the PT said
when documenting present illness what should I as a nurse include?
- chief complaint or present problem
- brief statement regarding purpose for visit
- recorded in direct quotes from patient
- multiple reasons: list & prioritize
- symptomology = onset, location, duration, ect
what are the components of a health history?
- biological data: if they’re married
- reason for seeking care
- history of present illness
- present health status
- past medical history
- family history
- personal and psychosocial history
- review of the body systems
Ask PT about present health status, like:
- health conditions: chronic or not and how it affects their daily lives
Ask PT about present health status, like allergies:
- food, environmental, and medications
- what does the reaction look like?
Ask PT about present health status, like medications:
- name, route, why they take the medication
when asking about past health history, what should we ask about?
- Childhood diseases
- Immunizations (are they UTD = up to date)
- Blood transfusions (when, why, what kind)
- Major illnesses (when)
- Surgeries (where, when)
- Injuries (ex: they were in an accident and that effects life later)
- Hospitalizations (when, why, how long)
- Childbirths (how many times the person was pregnant, any losses, how many live births)
when nurses ask about family history what are they asking about?
- 3 generations of blood relative diseases
- genetically linked diseases
when nurses ask about psychosocial history they are asking about?
- Personal status (how do they feel about themselves, are they married)
- Family and social relationships (is there someone here that can take care of you?)
- Education level (how educated they are determines how we interact with them based on vocab, ect)
- Finances (can they pay for their care)
Roles and relationships - Ethnicity and culture (is there a certain practice that they want us to follow, ect)
- Environment / safety issues at home?
- Access to care? (do they have good access to care, how long does it take)
- Health promotion activities
- Spirituality
- Mental health (PHQ 9, starts asking mental health questions)
- Use of alcohol, tobacco, illicit drug use, have PT be specific about what and how much of it
- Diet / nutrition (access to these foods as well)
- Functional ability (can they walk, do they use an advice, ADL’s)
