Week 2: Interviewing, The Health History, & Communication Flashcards
AIDET mnemonic
A: Acknowledge
I: Introduce
D: Duration
E: Explain
T: Thank you
Preliminary actions
Actions done before the procedure or interaction
4 phases of the health history
Phase 1: History
Phase 2: Psychosocial assessment
Phase 3: Specialty assessments
Phase 4: Review of systems (ROS)
The collection of the following information is a part of what phase of health history?
- Chief complaint/reasons for seeking care
- Biographical data
- Medication reconciliation
- Vaccinations
- Past medical history
- Family history
Phase 1: History
The collection of the following information is a part of what phase of health history?
- Education and occupation
- Housing and environment
- Self care
- Safety
- Substance use
- Sexual health
Phase 2: Psychosocial assessment
The collection of the following information is a part of what phase of health history?
- Functional assessment
- Cultural assessment
- Spiritual assessment
Phase 3: Specialty assessments
When performing medication reconciliation, don’t forget to ask about…
Supplements and vitamins
When asking about past medical history, don’t forget to ask about…
Allergies
BATHE method
B: Background
- What’s going on?
A: Affect
- How do you feel about that?
T: Trouble
- What troubles you most?
H: Handling
- How are you handling that?
E: Empathy
- That must be very difficult
CAGE-AID questionnaire, purpose
Substance abuse screen
HITS screening tool, purpose
Domestic violence screening tool
Barthel index, purpose
Assesses functional independence by measuring a person’s ability to complete ADLs
FICA assessment tool, purpose
Spirituality assessment tool
When with patient, never allow the patient to…
Fall
3 components of situational awareness
- Perception
- Comprehension
- Projection
ABC’s
Airway
Breathing
Circulation
4 elements of LOC
Orientation, speech, behavior, affect
4 elements of alert and oriented
Time, person, place, situation
Your patient is an 88-year-old man. He states that he has been “hearing whistling” in both his ears. He states that it almost sounds like a song. You need to identify whether he is reliable. What question will you ask?
A. “What is the name of the song?”
B. “Can you tell me where you live and your date of birth?”
C. “What do you mean by whistling?”
D.“ Have you seen an ear, nose, and throat doctor?”
B) Asking questions for which you can verify information can help identify reliability. You can check the patient’s chart to see if the address and date of birth are correct
To ensure a safe patient environment, the patient should be…
Always in the lowest position, side rails up, and call bell within reach
Tell whether the following statement is true or false:
Touch is a personal behavior that means the same thing to all persons.
True
False
False. Touch is a personal behavior that means different things to different people.
Personal communication
Self-talk
Interpersonal communication
Between two or more people
A nurse reassuring oneself of being prepared to speak in front of a peer group is using which of the following types of communication?
Sorry this doesn’t make any sense, I stole it from the slides. Don’t shoot the messenger!
A. Intrapersonal
B. Interpersonal
C. Group
D. Organizational
Told you it doesn’t make sense, like why is intrapersonal on there twice?
A. Intrapersonal communication is self-talk that happens within the individual. Interpersonal communication occurs between two or more people to exchange messages. Group communication includes small-group and organizational group communication.
3 phases of a therapeutic relationship
Phase 1: Orientation
Phase 2: Working
Phase 3: Termination
Which activity generally occurs during the orientation phase of the helping relationship?
A. An agreement or contract about the relationship is established
B. The nurse provides any assistance needed to achieve patient goals
C. The nurse provides patient counseling and teaching
D. The patient and nurse examine the goals of the helping relationship for indications of attainment
A. In the orientation phase, a contract defines the goals of the relationship, frequency, location, length of contact, and duration of the relationship. The nurse provides assistance to achieve patient goals, counseling, and teaching in the working phase. The patient and the nurse examine the goals of the helping relationship for indications of attainment in the terminations phase.
When communicating with a patient with a language barrier, don’t…
Use family members or lay interpreters to translate
SOAP note
S: Subjective
O: Objective
A: Assessment
P: Plan
Progress note, DAR format
D: Data
A: Action
R: Response
PIE note
P = Problem
I = Interventions
E = Evaluations
Problems are identified by # and addressed in the documentation used flow sheets.
No organized care plan
Charting by exception
Only exceptions (abnormal or significant findings) are charted
Normal findings are documented by a check mark or initials on a flow sheet
SBAR
S: Situation
B: Background
A: Assessment
R: Recommendation
Which method of documentation is unique in that it does not develop a separate care plan but instead incorporates the care plan into the progress notes?
A. Source-oriented records
B. Problem-oriented records
C. PIE (problem, intervention, evaluation)
D. Focus charting
C. PIE charting incorporates the care plan into progress notes in which problems are identified by number. In source-oriented records, each health care group keeps data on its own separate form. Problem-oriented records are organized around patient problems rather than around sources of information. Focus charting brings the focus of care back to the patient and the patient’s concerns.
