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Health Assess. Ch. 4
Interviewing to Obtain a Health History
| Question | Answer |
|---|---|
| What are the 2 primary components of health assessment? | Health History and Physical Examination |
| What is the nurse's role in an interview? | To facilitate discussion in order to collect and record data. |
| What are important aspects to learn about a patient? | 1. The patient's health concerns 2. Social, economic and cultural factors that influence health and response to illness. |
| What are the phases of an interview? | Introduction, Discussion, and Summary |
| What occurs in the Introduction phase? | The nurse introduces herself to the client, describes the purpose of the interview, and describes the process of the interview so that client knows how long it will take. |
| What occurs in the Discussion phase? | The nurse facilitates the discussion, which is client centered, and uses various communication techniques to collect data. |
| What occurs in the Summary phase? | Summarization of data, allows for clarificaton of data, and provides validation to the client that the nurse understands problems. |
| How is therapeutic communication established? | By establishing rapport and gaining the client's trust. |
| Why is the physical setting of an interview so important? | It has a great effect on the information that you'll receive, needs to be private, quit, comfortable, and free from environmental distractions. Privacy is essential. |
| What is professional nursing behavior? | A good first impression, a warm demeanor, the patient feels understood, actively listen and show genuine interest, treat people with respect, and watch your nonverbal behavior. |
| What are client-related variables? | Age and physical, mental, and emotional status |
| What is the Art of Asking Questions? | Obtain information and listen carefully to responses, speak clearly and in a language your patient can understand. Define words and use slang when necessary. Encourage specificity and ask one question at a time, while being attentive. |
| Name types of questions to ask. | Open-ended questions to being the interview (how...describe...tell me a little more). Closed ended questions get more detail. Directive questions are important too. |
| What are the techniques that enhance data collection? | Active listening, facilitation, clarification, restatement, reflection, confrontation, interpretation, summary |
| What are the techniques that diminish data collection? | Using medical terminology, expressing value judgements, interrupting, being authoritative or paternalistic, and using "why" questions. |
| How do you manage awkward moments? | Answer personal questions, silence, displays of emotion. |
| Name challenges to the interview. | Manage the overly talktive patient, others in the room, language barrier, and cultural differences. |
| How much data do you collect? | It is dependent on settling and the purpose of the visit. Whether it is comprehensive and focused, episodic or follow-up. The nurse determines what data i sirrelevant or important. |
| What are the components of health history? | Biographic data, reason for seeking health care, history for present illness (HPI)/present health status, past medical history(PMH)/past health status, family history, personal and psychosocial history, and reviw of symptoms (ROS). |
| What is biographical data? | Name, gender, address & phone number, date of birth (DOB), birthplace, race/ethnicity, marital status, occupation, contact person, source of data. |
| What are the reasons a client seeks health care? | Also referred to as chief complaint (CC) or presenting problem, it is a brief statment of the client's purpose for requesting the services of a health care provider. |
| How should you record the clien't reason for seeking health care? | In direct quotes. |
| Name the steps to systematic analysis. | OLDCARTS-Onset, Location, Duration, Characteristics, Aggravating or Alleviating Factors, Related Symptoms, Treatment, Severity. |
| Asks the question "When did the symptoms begin?" | Onset |
| Asks "Where are the symptoms?" | Location |
| Asks "How long do the symptoms last? | Duration |
| Tells the patient to describe what the symptoms feel and look like. | Characteristics |
| Asks "What affects the symptoms?" | Aggravating and Alleviating Factors |
| Asks "What other symptoms are present?" | Related Symptoms |
| Tells patient to describe the self-treatment attempted before medical attention was sought. | Treatment |
| Tells patient to describe the severity of the symptoms. | Patient rates pain on a scale from 1-10, 10 being the most severe. Severity |
| What topics should be covered when focusing on past health history/past medical history (PMH)? | Childhood illnesses, surgeries, hopitalizations, accidents or injuries, chronic illnesses, medications, allergies, immunizations, last exam (physical, dental, vision, hearing), obstetric history (females), and pregnancy history (children). |
| Whom are included in a family history? | Blood relatives (biologic parents, aunts, uncles, and siblings), spouse, and children. |
| What aspects make up the personal and psychosocial history? | Personal status, family and social relationships, diet/nutrition, functional ability, mental health, personal habits, health promotion activities, and the environment. |
| An outline used during health assessments in order to assure the nurse covers all body systems; be sure to move from the tip of the head to the tip of the toes. | Review of Systems (ROS) read p. 46-47 |
| Term during the first 27 days of life. | Neonate or newborn |
| Term describing the time from 1-12 months of age. | Infancy |
| Term describing 1 year through adolescence. | Childhood |
Created by:
shanhaup
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