TOPIC 2 Flashcards
what is the purpose of a complete health history?
to collect subjective data and to get a complete picture of a person’s past and present health
what is involved in a complete health history of a well person?
lifestyle, exercise, diet, substance use, risk reduction, health promotion
affirm what they are doing right
what is involved in a complete health history of an ill person?
information about the health problem
what is the health history sequence?
- Biographic data
- Source of history
- Reason for seeking care
- Present health or history of present illness
- Past history
- Family history
- Review of systems
- Functional assessment or activities of daily living (ADLs)
biographical data
Name
Address and phone number
Age and birth date
Birthplace
Sex
Marital status
Race
Ethnic origin
Occupation: usual and present
source of history
Record who furnishes the information, judge how reliable the informant seems and how willing, note any special circumstances
(how reliable is the person providing the information?)
reason for seeking care
Brief, spontaneous statement in the person’s own words that describes the reason for the visit
symptom
subjective sensation person feels from disorder
o What person says is reason for seeking care is recorded and enclosed in “quotation marks” to indicate person’s exact words
sign
objective abnormality that can be detected on physical examination or in laboratory reports
Present Health or History of Present Illness (HPI)
Location (where is the pain)
Character or quality (burning, sharp, dull)
Quantity or severity (using pain scale)
Timing (when did the symptoms appear)
Setting (where/what were you doing when symptoms started)
Aggravating or relieving factors (What makes pain better or worse)
Associated factors (review symptoms related to that body system)
Patient’s perception
HPI and PQRST
mnemonic for pain and symptom
P/P: Provocative or palliative
Q/Q: Quality or quantity
R/R: Region or radiation
S: Severity scale: 1 to 10
T: Timing or onset
U: Understand patient’s perception of problem
Past Health History
-Childhood illnesses (Which ones, how old?)
Accidents or injuries (When, what kinds, lasting effects?)
-Serious or chronic illnesses (HTN, DM, CKD, Lungs… how long, how managed?)
-Hospitalizations
-Operations (When, what, recovery?)
-Obstetric history
-Immunizations
-Last examination date
-Allergies (Note both allergen and reaction)
-Current medications (Med Rec. Prescription and OTC meds and Herbal)
Family Health History
a record of any illnesses or medical conditions that have afflicted members of a person’s family
Functional Assessment
screens the safety of independent living, the need for home health services, and quality of life, THIS INCLUDES ADLs
for a health history on new immigrants what should be included
o Biographical data
o Spiritual resource and religion: assess if certain procedures cannot be done
o Past health: what immunizations, if any
o Health perception
o How does person describe health and illness
o How does person see problems he or she is now experiencing
o Nutrition: taboo foods or food combinations
when assessing an older adult what additional questions/ comments be said?
are ADLs affected by normal aging process or by the effects of chronic illness/disability?
what are they doing to help themselves stay well?
affirm things they are going right and note health strengths
The Older Adult: Past Health History
General health in past 5 years
Accidents or injuries, serious or chronic illnesses, hospitalizations, operations
Last examination
Obstetric status
The Older Adult: Medication Profile
-Current medications (prescription, OTC, herbal)
-consider the individual may be taking a lot of drugs from many different doctors and they may not know they name or what it is used for
-drug adherence
Polypharmacy
use of multiple medications
The Older Adult: Family History
- Not as useful in predicting which familial diseases person may contract, because most of those will have occurred at an earlier age
- describes persons existing social network
CAGE test
used to assess alcohol consumption
-Have you ever thought you should CUT down your drinking?
-Have you ever been ANNOYED by criticism of your drinking?
-Have you ever felt GUILTY about your drinking?
-Do you drink in the morning, an EYE opener?
functional assessment of the older adult
-Requires knowledge of normal aging changes and effects of chronic diseases, heredity, and lifestyle
-Multiple disciplines may participate in assessment
what does a comprehensive geriatric assessment incorporate?
physical examination, mental status, functional status, social and economic status, pain, and examination of physical environment for safety concerns
functional ability
the ability of a person to perform activities necessary to live in modern society; may include driving, using the telephone, or performing personal tasks such as bathing and toileting
functional status
a person’s actual performance of activities and tasks associated with current life roles (ability to perform self care)
Functional assessment includes what three overarching domains
o Activities of daily living (ADLs)
o Instrumental activities of daily living (IADLs)
o Mobility
what are the Two approaches to functional assessment
o Individual’s self-report about his or her ability to perform tasks
o Observing his or her ability to perform tasks
ADLs
activities of daily living Þ measure tasks necessary for self-care
-Eating
-Bathing
-Grooming (washing, combing hair, shaving, cleaning teeth, dressing)
-Toileting
-Walking (Including propelling a wheelchair & Using stairs
-Transferring, such as bed to chair
Katz Index of ADL
Assessment of level of independent functioning and type of assistance required in six areas of ADL.
what activities are assessed in Katz index of ADL?
bathing
dressing
toileting
transferring from bed to chair
continence
feeding
IADLs
instrumental activities of daily living: Goal of measuring functional abilities necessary for independent community living
IADLs include…
shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, using transportation
AADLs
Advanced Activities of Daily Living: Activities older adults perform as family member, member of society and community, including occupational and recreational activities
Occupational therapists often perform what assessment of AADLs
up and go test
assessment of cognition includes what domains?
o Attention
o Memory
o Orientation
o Language
o Visuospatial skills
o Higher cognitive functions
what three disorders are commonly attributes to altered cognition in older adults?
dementia
delirium
depression
dementia
slow onset difficulty with word finding, naming objects, memory
delirium
Acute changes in cognition and attention
depression
Memory problems
informal vs formal support
Informal support:
o family, close long-time friends, usually provided free of charge
o tasks such as shopping, bathing, feeding, and paying bills
Formal supports:
o social welfare, social service, health care delivery agencies such as home health care
what is one of the most important factors in a discharge plan of an older adult from an acute care hospital?
presence of a care giver
all caregivers should be screened for…
caregiver burden
Cultural and Subcultural identifications
help define an individual and influences beliefs about health, illness, coping mechanisms, wellness behaviors
what is KEY in cultural competence?
self-awareness and knowledge of ones own culture
Culturally sensitive
Caregivers possess basic knowledge and understanding
Culturally appropriate
Caregivers apply knowledge to improve health outcomes
Culturally competent
implies that the caregivers understand and attend to the total context of the individual’s situation,
Caregivers apply a universal concept of understanding to all contextual aspects of care
cultural care
Provision of health care across cultural boundaries in consideration of context
health
Balance Within one’s being: physical, mental, spiritual
illness
Loss of a person’s balance Within one’s being: physical, mental, spiritual
Title VI of Civil Rights Act of 1964
Services cannot be denied to people of limited English proficiency
o Health care facilities may have established interpreters who can assist with therapeutic communication
Patients who have limited English proficiency (LEP) are..
at risk for poor health care outcomes due to language barrier
Four basic concepts of culture
learned, shared, adapted, dynamic
Race and ethnicity
Self-identification and social group
Religion and spirituality
Organized system of beliefs versus individual’s unique experience
Acculturation
the adoption of the behavior patterns of the surrounding culture
acculturative stress
stress resulting from the need to change and adapt a person’s ways to the majority culture
ethnicity
Describes a group united by Common geographic origin, Migratory status, Religion, Race, Language, Shared values, traditions, or symbols, Food preferences
Religion
an organized system of beliefs about the cause, nature, and purpose of the universe, as well as the attendance of regular services. It is a shared experience of spirituality and practices.
Spirituality
a broader term that refers to a connection to something larger than oneself and belief in transcendence
what are the diseases causation theories?
biomedical
naturalistic
magicoreligious
biomedical
-Assumes all events have a cause and effect
-Views the body as a machine
-Life can be divided into parts
-Endorses germ theory
Naturalistic
Forces of nature must be kept in balance
-Embraces idea of opposing categories or forces
-Yin and yang, hot and cold
Magicoreligious
-Supernatural powers predominate in area of health and illness
-Examples include voodoo, witchcraft, and faith healing
Families: Culture affects choices parents make for children regarding the following…
o Presumed cause of illness
o First treatment tried
o Acceptability of treatments offered by clinicians
Older patients; culture is likely to do the following…
o Define their family responsibilities
o Affect their view and knowledge of health care systems used by dominant culture
Transcultural expression of pain
-Expectations, manifestations, and management of pain are all embedded in a cultural context
-Pain has been found to be a highly personal experience, depending on cultural learning, the meaning of the situation, and other factors unique to the person
-Silent suffering has been identified as the most valued response to pain by health care professionals
what are the steps to cultural competence
- Understand one’s own heritage-based values, beliefs, attitudes, and practices
- Identify meaning of “health” to patient
- Understand how health care system works
- Acquire knowledge about social backgrounds of patients
- Become familiar with languages, interpretive services, and community resources available to nurses and patients
what is the first step of a therapeutic relationship
the interview
what is information is gained in an interview?
-subjective data collection
-Patient perception of health
what is the first and most important part of data collection?
the interview
What is the interview contract?
it concerns the clients needs and expectations from healthcare and what you as the clinician can offer
what are the interview contract terms?
-Time and place of interview and physical examination
-Introduction of and explanation of health care provider’s role
-Purpose of interview
-How long it will take
-Expectation of participation for each person
-Presence of others (family, etc.)
-Confidentiality and to what extent it may be limited
-Any costs that the patient must pay
what are the elements of the interview process?
Nonverbal skills
Physical appearance
Posture
Gestures
Facial expression
Eye contact
Voice
Touch
Closing the interview
internal factors of communication
- Liking others
- Empathy
- Ability to listen
external factors of communication
- ensure privacy
- refuse interruptions
- physical environment
- dress
- note taking
- tape and video recording
what are the challenges of note-taking?
-Breaks eye contact too often
-shifts attention away from person, diminishing his or her sense of importance
-Interrupts patient’s narrative flow
-Impedes observation of patient’s nonverbal behavior
-May be threatening to patient’s discussion of sensitive issues
what is an open ended question and when do you use it?
allows the person to answer freely in any way
o To begin interview
o To introduce a new section of questions
o Whenever the patient introduces a new topic
what is a close ended question and when do you use it?
elicits a yes or no response
o After opening narrative to fill in details person may have left out
o When you need many specific facts about past health problems or during review of systems
o To move the interview along
what types of verbal responses assist the narrative from the clients perspective?
facilitation
silent attentiveness
reflection
empathy
clarification
what types of verbal responses assistantships the narrative from the examiners perspective?
confrontation
interpretation
explanation
summary
facilitation
-Encourages patients to say more
-Shows you are interested and will listen further
Silent attentiveness
-Gives patient time to think and organize what to say without interruption from you
-Gives you a chance to observe person unobtrusively and note nonverbal cues
reflection
-Echoes patient’s words
-Repeats what person has just said
-focuses further attention on a specific phrase
-Helps person continue in his or her own way
empathy
recognizes feelings and puts it into words
-names the feeling and allows expression of it
-patient feels accepted and can deal with feeling openly
clarification
summarize person’s words and to simplify them
-use when persons words are ambiguous or confusing
confrontation
when you have observed a certain action, feeling or statement and now FOCUS THE PERSONS ATTENTION ON IT AND GIVE HONEST FEEDBACK ABOUT WHAT YOU SEE FOR FEEL
-reference shifts from patients perspective to yours
interpretation
based on you inference or conclusion
explanation
you inform the patient, you share factual and objective information
summary
final review of what examiner understands patient has said; condenses facts and presents a survey of how the examiner perceives the health problem or need
what are the five types of nonverbal behaviors?
vocal cues
action cues
object cues
personal space
touch
vocal cues
pitch & tone
quality of voice
moaning, crying, and groaning
action cues
posture, facial expression, and gestures
object cues
clothing, jewelry, and hairstyles
personal space
the physical space individuals maintain between themselves and others
touch
use of personal space and action
be respectful of culture
What are the ten traps of interviewing?
- Providing 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
what techniques are used to improve health literacy?
verbal teaching
written materials based on standard education levels
teach back or sue of return demonstration
health literacy
a person’s capacity to learn about and understand basic health information and services, and to use these resources to promote one’s health and wellness
