week 3 Flashcards
steps to having a successful interview
- gather all and accurate data about the patients’ health states…description and chronology of illness
- build rapport and trust-safe space
- share info with patient about their health state
- build rapport for a continuing therapeutic relationship….allows for future opportunities for assessment, diagnoses, planning and treatment
- look to engage in teaching for health promotion and prevention
factors of consider for an interview
- time and place
- intro and explanation
- purpose
- length
- expectation
- presence of others
- confidentiality
- costs
what does a therapeutic nurse-client relationship include?
- verbal and nonverbal communication
- sending and receiving
- positivity, empathy and active listening
- attending to the physical environment-setting privacy and refusing interruptions
-taking notes
what type of electronic clinical documentation is there and why is it used
EHR (electronic health record)
-records health histories and physical examination findings
-can influence interviews in a positive way
- share data easily and reduce redundancy
what are the pros of electronic health record
-advance interviewing practice…refines techniques
- minimize redundancy
- helps to stay focused on patient and shows active listening
con of electronic health records
can be a distraction and interfere with the nurse-client therapeutic relationship
communication techniques
- introducing the interview
- working phases (open and closed ended questions)
- responses: assisting the narrative
- non verbal skills
-closing the interview
10 traps of interviewing
- providing false assurance or false 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
situations where it can be challenging to interview
-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
gathering the health history includes
- biographical data
- reason for seeking care
- current health or history of current illness
- past health
- family history
- review of systems
- functional assessment and activities of daily living (ADLs)
examples of biographical data
- 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)
when documenting the reason for seeking care
- brief statement in the patients words…using quotation marks
-includes health maintenance, health promotion or wellness needs
-symptom
-sign
what is a symptom
subjective sensation
what is a sign
-objective abnormality
- detectable on physical examination or lab reports
characteristics of a symptom
- location
- character or quality
- quantity or severity
- timing (onset, duration, frequency)
- setting
- aggravating or relieving factors
- associated factors
- patient’s perception
PQRSTU
what does PQRSTU stand for
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
examples of what would be part of past health
- childhood illnesses
- accidents or injuries
- serious or chronic illnesses
- hospitalizations
- operations
- obstetrical history
- immunizations
- most recent examination date
- allergies
- current meds
examples of whats in family history
- 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)
cultural and social considerations-very important to get health history for new immigrants
- 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)
examples of possible functional assessment and ALDs
- 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
questions to ask to gage a persons perception of health
-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
for the health history for children what are the developmental considerations
-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
developmental consideration: past history examples
- prenatal status, labour and delivery, postnatal status
- childhood illnesses, serious accidents or injuries
- serious chronic illnesses, operations or hospitalization, immunizations, allergies, medications
developmental considerations: children example
-developmental history
- nutritional history
- family history
- review of systems
- functional assessments, including ADLs
