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Health assessment Exam 1

Terms in this set (110)

communicating techniques
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1. introducing the interview: intro short and formal, use last name
2. the working phase: data gathering phase, combo of open ended and close ended
3. open ended questions: asks for narrative information. use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic
4. closed or direct questions: ask for specific information, yes or no, past medical history, or during review of systems
5. verbal responses - assisting the narrative: role is to encourage free expression while keeping the person focused. your responses help the teller amplify the story.
6. ten traps of interviewing: nonproductive verbal and non verbal messages. avoid them.
7. nonverbal clues: physical appearance, posture, gesture, facial express, ...
8. closing the interview: should end gracefully "is there anything else you would like to mention?" final opportunity for self expression. no new topics should be introduced. give a summary of the interview
interviewing the patient, best practices
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1. gather: gather complete and accurate data about the persons health state including description and chronology of any symptoms
2. establish: est trust to foster acceptance and allow for data sharing
3. teach: teach the person about their individual health state
4. build: build rapport to continue therapeutic relationship
5. discuss: discuss health promotion and disease prevention
interviewing purpose
Interviewing is the best chance to gain an understanding of the patient's beliefs, their concerns and their perception of their own individual health state. This information can vary greatly between patients. Interviewing also allows for the compilation of subjective and objective data. You can also distinguish factors such as a patient's orientation, physical appearance, posture, conversational abilities, and overall demeanor. It is an opportunity for observation and gathering information.
Process of Communication: External Factors
Ensure privacy—aim for "geographic" privacy but ensure "psychological" privacy
Avoid interruptions—minimize and/or refuse
Physical environment—"equal status" seating
Dress—appearance and comfort
Note-taking—keep to a minimum, offer "focused" attention
health history database
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...
complete database
complete health history and full physical exam
-must screen for pathology
Focused database
used for a limited or short-term problem; concerns mainly one problem, one cue complex, or one body system
Follow-up database
The status of any identified problems should be evaluated at regular and appropriate intervals.
-used in all settings, short term and chronic health problems
-what change has occurred, is the problem getting worse or better, which coping strategies are used?
Emergency database
This is an urgent, rapid collection of crucial information and often is compiled concurrently with lifesaving measures.
-assess ABC, LOC, and disability
-once pt is stable a complete assessment can be taken
Purpose of health history
1. Collect subjective data to combine with objective data from physical exam and lab studies to form the database.
2. Provides a complete picture of patient's past and present health status
3. Can be used as a screening tool for detection of abnormalities
4. Printed or electronic format that is available for review, validation, and updates
5. Sequence may vary in terms of obtained information.
6. Focus may differ in terms of clinical practice setting and/or nature of complaint.
Health History Sequence
1. Biographical data
2. Source of history
3. Reason for seeking care
4. Present health or history of present illness
5. Past health
6. Family history
7. Review of systems
8. Functional assessment including activities of daily living (ADLs)
Biographical Data
1. Name, Address and phone number
2. Age, birth date, Birthplace
3. gender (identification) and relationship status
4. Race and ethnic origin
5. Occupation: usual and present
6. primary language
Source of History
1. Record who furnishes information, usually the person, although source may be relative or friend
2. Judge reliability of informant and how willing he or she is to communicate
A reliable person always gives same answers when questions are rephrased or are repeated later in interview
3. Note any special circumstances, such as use of interpreter
Reason for seeking care
Brief, spontaneous statement in the person's own words that describes the reason for the visit
ex: chief complaint: HA lasting for 7 days
worsening cough and SOB
history of present illness/documentation
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-a chronologic record of the reason for seeking care, from the time the symptom first started until now
-isolate each reason for care identified by the person and say for example, "please tell me about your headache, from the time it started until the time you came to the hospital"
-use mnemonic PQRSTU
U: understand patients perception of problem: what do you think it means
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