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health assessment > week 3 > Flashcards

week 3 Flashcards

1
Q

steps to having a successful interview

A
  1. gather all and accurate data about the patients’ health states…description and chronology of illness
  2. build rapport and trust-safe space
  3. share info with patient about their health state
  4. build rapport for a continuing therapeutic relationship….allows for future opportunities for assessment, diagnoses, planning and treatment
  5. look to engage in teaching for health promotion and prevention
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2
Q

factors of consider for an interview

A
  • time and place
  • intro and explanation
  • purpose
  • length
  • expectation
  • presence of others
  • confidentiality
  • costs
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3
Q

what does a therapeutic nurse-client relationship include?

A
  • verbal and nonverbal communication
  • sending and receiving
  • positivity, empathy and active listening
  • attending to the physical environment-setting privacy and refusing interruptions
    -taking notes
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4
Q

what type of electronic clinical documentation is there and why is it used

A

EHR (electronic health record)
-records health histories and physical examination findings
-can influence interviews in a positive way
- share data easily and reduce redundancy

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5
Q

what are the pros of electronic health record

A

-advance interviewing practice…refines techniques
- minimize redundancy
- helps to stay focused on patient and shows active listening

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6
Q

con of electronic health records

A

can be a distraction and interfere with the nurse-client therapeutic relationship

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7
Q

communication techniques

A
  • introducing the interview
  • working phases (open and closed ended questions)
  • responses: assisting the narrative
  • non verbal skills
    -closing the interview
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8
Q

10 traps of interviewing

A
  1. providing false assurance or false reassurance
  2. giving unwanted advice
  3. using authority
  4. using avoidance language
  5. engaging in distancing
  6. using professional jargon
  7. using leading or biased questions
  8. talking too much
  9. interrupting
  10. using “why” questions
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9
Q

situations where it can be challenging to interview

A

-hearing impaired patients
- acutely ill patients
- under the influence
- personal questions asked of the clinician
- dealing with sexual advances
- crying patients
- angry patients
- those who threaten violence
-anxious patients

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10
Q

gathering the health history includes

A
  1. biographical data
  2. reason for seeking care
  3. current health or history of current illness
  4. past health
  5. family history
  6. review of systems
  7. functional assessment and activities of daily living (ADLs)
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11
Q

examples of biographical data

A
  • name
  • address and phone number
  • age and birth date
  • birthplace
  • gender
  • marital status
  • ethnocultural background
  • occupation (usual and present)
  • source of info (primary language and authorized representative)
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12
Q

when documenting the reason for seeking care

A
  • brief statement in the patients words…using quotation marks
    -includes health maintenance, health promotion or wellness needs
    -symptom
    -sign
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13
Q

what is a symptom

A

subjective sensation

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14
Q

what is a sign

A

-objective abnormality
- detectable on physical examination or lab reports

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15
Q

characteristics of a symptom

A
  • location
  • character or quality
  • quantity or severity
  • timing (onset, duration, frequency)
  • setting
  • aggravating or relieving factors
  • associated factors
  • patient’s perception
    PQRSTU
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16
Q

what does PQRSTU stand for

A

P: provocative or palliative
Q: quality or quantity
R: region or radiation
S: severity (scale of 1-10)
T: timing
U: understanding patient’s perception

17
Q

examples of what would be part of past health

A
  • childhood illnesses
  • accidents or injuries
  • serious or chronic illnesses
  • hospitalizations
  • operations
  • obstetrical history
  • immunizations
  • most recent examination date
  • allergies
  • current meds
18
Q

examples of whats in family history

A
  • age and health or cause of death of blood relatives
  • health of close family members
  • family history of various conditions ex. heart diseases, high blood pressure, diabetes, mental health issues
  • genogram (family tree)
19
Q

cultural and social considerations-very important to get health history for new immigrants

A
  • when they arrived in canada and from where
  • refugee or immigrant status
  • effect of historical events in country of origin for older patients
  • spiritual resources and religion
  • past health (immunization in country of origin)
  • health perception
  • nutrition (taboo foods/combinations)
20
Q

examples of possible functional assessment and ALDs

A
  • self concept, self esteem
  • activity and mobility
  • sleep and rest
  • nutrition and elimination
  • interpersonal relationships and resources
  • spiritual resources
  • coping and stress management
  • smoking history
  • alcohol
  • substance use
  • environmental hazards
  • intimate partner violence
  • occupational health
21
Q

questions to ask to gage a persons perception of health

A

-what does it mean to you to be healthy
- how do you define health
- how do you view your situation now
- what are your concerns
- what do you think will happen in the future
- what are your health goals
- what do you expect from your health acre providers

22
Q

for the health history for children what are the developmental considerations

A

-developmental assessment tools
- biographical data-including other children
- source of history and reason for seeking care
- current health or history of current illness, including parents intuitive sense of a problem and coping ability

23
Q

developmental consideration: past history examples

A
  • prenatal status, labour and delivery, postnatal status
  • childhood illnesses, serious accidents or injuries
  • serious chronic illnesses, operations or hospitalization, immunizations, allergies, medications
24
Q

developmental considerations: children example

A

-developmental history
- nutritional history
- family history
- review of systems
- functional assessments, including ADLs

25
Q

developmental considerations for adolescents

A

HEEADSSS
Home environment
Education and employment
Eating
Activities, peer related
Drug (substance) use
Sexuality
Suicide or depression
Safety from injury and violence

26
Q

Types of therapeutic communication techniques

A

listening
broad opening
restating
clarification
reflection
informing
focusing
silence

27
Q

what does listening show to a patient

A

-nonverbally shows your interest and acceptance to a patient

28
Q

what does broad openings show a patient (therapeutic communication techniques)

A

-shows acceptance and valuing patient’s initiative

29
Q

what does restating show a patient (therapeutic communication techniques)

A

-shows you are listening and validates, reinforces or calls attention to something important that ahs been said

30
Q

what does clarification show a patient (therapeutic communication techniques)

A
  • clarifies patient’s feelings, ideas and perceptions and provide an explicit correlation between them and patient’s actions
31
Q

what does reflection show a patient (therapeutic communication techniques)

A

validates your understanding of what patient is saying and signifies empathy, interest and respect

32
Q

what does informing show a patient (therapeutic communication techniques)

A

helpful for patient education about relevant aspects of patients well-being and self-care

33
Q

what does focusing show a patient (therapeutic communication techniques)

A

allows patient to discuss central issues related to problem and keeps communication process goal directed

34
Q

what does silence show a patient (therapeutic communication techniques)

A

allows the patient to have time to think and gain insights, slows the pace of interaction, encourages patient to initiate conversation while i show support, understanding and acceptance

35
Q

essential quality of effective communication

A

establish and understand the purpose of a patient interaction

36
Q

what do communication skills provide

A

-info
- comfort
- promote understanding
- clarify misinformation
- help to develop plans of care
- promote interprofessional collaboration
- facilitates wellness through patient teaching

health assessment (4 decks)

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