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Health History
Interview techniques
| Question | Answer |
|---|---|
| What is subjective data | Information from the patient/ what the patient tells you |
| What is objective data | Information you gather about the patient/ what you see |
| What are the 4 different types of assessments | Initial comprehensive assessment, partial/ongoing/time-lapsed assessment, focused/problem oriented assessment, emergency assessment |
| Describe an initial comprehensive assessment | Basic head to toe assessment of the patient, goiing through entire body |
| Describe a partial or ongoing assessment | A reassessment of what you already know (I.e. Blood pressure is high, medicate patient & reasses to see if change occurred) |
| Describe a focused/ problem oriented assessment | Focus on the problem at hand. (I.e. Blood pressure just increased, why did it increase? * does not have to be the issue the patient initially came for |
| Describe the emergency assessment | A quick judgement assessment (I.e CPR for someone not breathing) |
| What are the 5 phases of the nursing process | Assess, diagnose, plan, implement, evaluate |
| Phases of the interview | Introductory, working, summary& closing |
| What is involved in the introductory phase of interview | Introduce yourself & state your position, explain purpose of interview, discuss the types of questions that will be asked, explain the reason for taking notes, assure the client all info is confidential, ensure patient is comfortable, develop trust |
| What does the working phase of the interview entail | Gathering data about the patient such as: biographic data, reasons for seeking care, history of present health concern/past health history&family health history, review of body system,lifestyle & health practices, identify problem& develop a plan |
| What does the summary and closing phase of the interview entail | summarize and reiterate info obtained during the interview, validate problems and goals with the client, identify and discuss possible plans of resolution, make sure to inquire about any other questions/concerns the patient may have |
| What are some key points to remember when interviewing a client | set the environment, have your pans in order, use techniques like clockwork, use open ended questions, include close ended questions, review at end of assessment |
| What happens when a patient complains about pain during an interview | C.O.L.D.S.P.A |
| What does C.O.L.D.S.P.A stand for? | Character (Describe pain), Onset (When did it begin), Location (Where), Duration (How long does it last/How long has it been going on), Severity (How severe is it 1-10), Pattern (What makes pain better or worse), Associated factors (What else hurts) |
| What is the 5th Vital sign | Pain |
| Collection of objective data is what? | Anything you can see, smell, hear, feel such as: physical characteristics, body functions, appearance, behavior, measurements, results of lab tests |
| What are some assessment techniques used to gather objective data | inspect, palpate, percuss, auscultate |
| What is involved in the inspection technique | you are looking, listening, and smelling. You are observing the size, shape, color, symmetry, location and any abnormalities |
| What is a palpation | A gentle touch; palpate for moisture, temperature, texture, turgor, tenderness, lumps |
| What is a percussion | Involves tapping the skin with your fingertips to vibrate underlying tissues or organs; typically on the back or stomach; listen for sounds *The thicker or firmer the tissue the quieter the sound is |
| What does it mean to auscultate | To listen; listen to sounds our body makes and determining if those sounds are normal or not |
| What is considered to be groundwork | Infection control- use standard precaution during entire exam environment- privacy, adequate lighting, fall precaution equipment- make sure they're properly cleaned and working; be prepared |
| What are some key points on preparing your patient | If possible start with an empty bladder, make sure the patient is properly positioned, always give a thorough explanation of what you will be doing to alleviate anxiety, assess each age group appropriately (if patient is too young explain to parent) |
Created by:
amandamarie194
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