HA Exam 5 Study Guide

Which is a guideline you should follow in working with a non-English-speaking patient and an interpreter?

Have interpreter speak to patient before health interview begins

Successful communication requires...

mutual understanding by sender & receiver

Biographic Data

name, address, phone number, age, birthdate, gender, marital status, race, ethic origin, occupation, primary language

One of your new patients is Miss Tarpoy. She is 83 years old and has come to the cancer clinic for a 1-year follow-up check. Which statement is acceptable to use when updating her history?

"Hello. You look well. How do you feel?"

Mr. Littlefield is a 42-year-old man who comes to the clinic for a follow-up visit after treatment of a recurrent left leg pain. When gathering information to update his history, the nurse uses both open- and closed-ended questions and statements. Which is an example of a closed-ended question or statement that might have been used?

"On a scale of 1 to 10, how would you rate your pain?"

Mrs. Murdock is a 46-year-old female who comes to the office for an initial evaluation of recurrent dizziness with position change. Which is an example of an open-ended question/statement that might be used while taking her history?

"Tell me about your dizziness."

Mr. Tucker is a 68-year-old patient who is recovering from his right total knee replacement surgery. You overhear the nurse assigned to Mr. Tucker as she assesses him, and realize that this nurse is using leading questions/statements. Which is a leading question/statement that you might have overheard?

"You are upset about the pain in your knee, right?"

Process of Communication: *Sending*

*"How you send the message"* Communication is *behavior, conscious & unconscious, verbal and nonverbal* *All behavior has meaning* *Body Language* - way you look & hold yourself

Formal Operations Stage

*12+ yrs* -abstract thinking; futuristic; takes broader, more theoretical perspective -language near adult like skills

Competency nurse

*2 to 3 years post graduation *Ability to see actions in context of arching goals or daily plans for pts

Preoperational stage

*2-6yrs* -begin use of symbolic thinking -imaginative play -masters reversibility *lang. develop.: -*Symbolic:* use of structured grammar & lang., pronouns; >10,000 words by 6 yr

Concrete Operations Stage

*7-11 yrs* -logical thinking -masters use of numbers & concrete ideas such as classification & conservation -masters passive tense by 7 yrs & complex grammatical skills by 10 yrs

Negative Nonverbal Communication

*Appearance objectionable to pt *standing; sitting behind desk; far way; turned away *tense posture; slouched in chair *critical or distracting gestures: pointing finger, clenched fist, looking at watch *bland expression, yawning, tight mouth *frowning, lip biting *shifting, avoiding eye contact, focusing on notes *strident, high-pitch tone; rate too slow/fast *too frequent or inappropriate touch

Positive Nonverbal Communication

*Appropriate professional appearance *Equal-status seating *close proximity to pt *relaxed, open posture; leaning slightly foward *facial animation, interested *appropriate smiling & eye contact *moderate tone & rate of speech *appropriate touch

Sensorimotor Stage

*Birth - 2 yr* -infant learns by manipulating objects -at birth reflexive communication, then thru 6 stages to reach actual thinking *language develop.: -*Presymbolic:* communication nonverbal; 4 words by 12 mths; >200 words & short sentences by 2 yr

External Factors

*Ensure privacy* -be careful who you speak in front of *Refuse interruptions* *Physical Environment* -room temp comfortable -quiet room -remove distractions -place distance 4-5 ft from pt -equal-status seating (comfortable & eye level) -avoid standing bc it assumes superiority & communicates haste *Dress* -pt remain in reg. clothes, gown may make pt feel exposed & uncomfortable *Note taking* -may be unavoidable -Cant rely on memory for details -breaks eye contact -shifts attention away from pt -impedes observation -threatening to pt -keep at a minimum *Tape & Video Record -dont let become a barrier b/w pt; really look at policies

Summary Response

*Final review of what pt said; condenses facts & presents your view of health problem *type of validation that pt can agree w/ or correct; both you & pt should participate *end of interview, signals termination of interview is near

Confrontation Response

*Frame of reference shifts from pt's perspective to yours *focus on inconsistency in pt's narrative -observed a certain action, feeling, or statement & now focus pt's attention on it -give honest feedback about what you see/feel

Verbal Responses

*NINE different types: first 5 involve YOUR *reactions* to facts or feelings pt communicated: -your responses focus on pt frame of reference, yours doesnt enter into response 1.) facilitation 2.) silence 3.) reflection 4.) empathy 5.) clarification last 4 responses YOU express *own* feelings & thoughts: 6.) confrontation 7.) interpretation 8.) explanation 9.) summary *in first 5 responses pt leads convo, last 4 responses you lead

Nonverbal Skills

*Physical appearance* *Posture* *Gestures* *Facial expression* *Eye contact* *Voice* *Touch* *Closing interview gracefully not abrupt*

Empathy Response

*Recognizes feeling & puts into words *Names feeling & allows expression of it -Pt feels accepted & can deal w feeling openly

Tools for Determining Health Literacy:

*Test of Functional Health Literacy (TOFHLA):* -used for research -measures reading comprehension & numeracy -uses actual pt instructions & forms -about 22 min long *Rapid Estimate of Adult Literacy in Medicine (REALM)*: -clinical setting -reads 66 med terms aloud -score based on # if words read & pronounced correctly -2-3 min long *Newest Vital Sign (NVS)* -assesses numeracy & comprehension -uses nutrition label that pt must read/interpret -6 questions related to label -3 min long

Clarification Response

*Use when pt words are ambiguous or confusing -Used to summarize pts words & simplify to make clearer *You are asking for agreement, & pt can then confirm or deny your understanding

Open-Ended Questions

*asks for narrative (story-like) response -unbiased, states topic to be discussed but only in general terms -ex. "Tell me how can I help you?" ; "What brings you to the hospital?" *eye contact & listen as pt answers; lean forward & look interested

Closed (Direct) Questions

*asks for specific info *Elicit short, one-or-two word answers, a yes or no answer, or forced choice *Used to: -to fill in details pt may have left out -When need specific facts about past health problems, or during review of systems -To move interview along 1.)ask only one direct question at a time 2.) choose language pt understands

Silent Attentiveness Response

*communicates pt has time to think; interruption can make pt lose thought *gives chance to observe nonverbal cues of pt -sitting quietly (dont fidget) -counting silently 1-10

Working Phase of Interview

*data gathering phase *verbal skills include you questions & response to pt -open & closed questions

Explanation Response

*inform pt; share factual & objective info offering reasons for requirements or actions

Internal Factors

*liking others *empathy -feeling *with* pt instead of feeling *like* pt *ability to listen -active listening *Self awareness -understanding personal bias, prejudices, & stereotypes

Interpretation Response

*links events, makes associations, & implies cause *not based on direct observations but inference or conclusion *interpretation may be incorrect but helps promote convo *helps pt understand own feelings in relation to verbal message

Interview Goals

*record complete health hx *identify problems so you know what to assess, guides physical exam *mutual goal is optimal health for pt

Reflection Response

*repeating what pt just said; can help pt elaborate on specific problem/phrase

Piagets Stage of Cognitive Development

*sensorimotor* *preoperational* *concrete operational* *formal operational*

Low Health Literacy Associated With:

-low medication compliance -more emergency department visits -increased readmission rates -inability to recall info after visit -inability to manage chronic illness

Process of Communication

Awareness of internal and external factors and their influence allows you to maximize communicating skill -Internal & External factors

Communication of Infants (Birth-12 mon)

-uses coos, gurgles, facial expressions, & cries to indicate needs -nonverbal primary method -as infant gets older, develops stranger anxiety & caregiver will need to be present

Steps to Setting Priorities

1. Assign First-level priority problems (immediate priorities): "ABCV" A- airway problems B- breathing problems C- cardiac/circulation problems V- vital sign concerns 2. Next, Second-level priority problems: -Mental status change (confusion, decreased alertness) -Untreated med problems requiring immediate attention (diabetic who has not had insulin) -Acute pain, Acute urinary elimination problems -Abnormal lab values -Risks of infection, safety, or security 3. Address Third-level priority problems (later priorities): lack of knowledge, family coping, rest

Ten traps of Interviewing:

1.) *Providing false assurance or reassurance* 2.) *Giving unwanted advice* -provide approp. info, if "personal opinion" likely inapprop. 3.) *Using authority* -"your doctor/nurse knows best" diminishes communication -both have equal important roles 4.) *Using avoidance language* -euphemisms instead of discussing unpleasant topics: "passed away" instead of "died" -best way to deal w uncomfortable topics is w direct language 5.) *Engaging in distancing* -pt use to avoid admitting they have problem; if you use it then it imploes you are afraid of procedure disease -"there is a lump in THE left breast" ; using "the" instead of "your" 6.) *Using professional jargon* -important to adjust vocab to ensure understanding w/out sounding condescending 7.) *Using leading or biased questions* -"you dont smoke, do you?" or "you dont have unprotected sex, correct?" -shows disapproval, makes pt feel guilty 8.) *Talking too much* -listen more than you talk 9.) *Interrupting* -signals impatience or boredom 10.) *Using "why" questions* -implies blame or condemnation -"why did you take so much medication?"

Ch. 4: Health Hx Sequence:

1.) Biographic Data 2.) Reason for seeking care 3.) Present health or hx of present illness 4.) past hx 5.) medication reconciliation 6.) family history 7.) review of systems 8.) Functional assessment or ADLs

Principles of Setting Priorities

1.) Make complete list of current meds, medical problems, allergies, & reasons for seeking care. Refer to frequently, bc may affect how to set priorities. 2. Determine relationships among problems: If problem Y causes problem Z, problem Y takes priority over problem Z Setting priorities is a dynamic, changing process; at times, order of priority changes, depending on seriousness & relationship of problems

Guide to Exam:

1.) Screening history: dietary intake, physical activity, tobacco/alcohol/drug use 2.) Physical exam: height & weight, BP, & screening for cervical cancer & HIV 3.) Counseling: for physical activity & risk prevention (second-hand smoke, seatbelt use) 4.) Depression screening 5.) Healthy diet: counseling, including lipid disorder screening & obesity screening 6.) Chemoprophylaxis: include multivitamin w folic acid (females planning or pregnant)

Introducing the Interview

1.) address pt using surname (last) unless child or adolescent & shake hands if comfortable 2.) introduce yourself & state role (student, nurse, etc) 5.) give reason of interview 6.) ask open ended question RAPPORT IS BUILT DURING THE INTRODUCTION

Ch. 3: The interview

1.) gather data about pt health state -subjective & objective data 2.) establish trust 3.) teach the pt about their health state - sometimes have misunderstanding 4.) Build rapport for continuing therapeutic relationship (facilitates future diagnosis, planning, & treatment) 5.) discuss health promotion & disease prevention

Mrs. Johnson brings her daughter to the clinic for an initial examination. As the interviewer, at which age would you begin to directly ask the child about her presenting symptoms? a. 7 years old b. 5 years old c. 3 years old d. 14 years old

7 years old

Which guidelines apply when assessing a potentially aggressive patient?

Always face the person Maintain an unhurried manner.

Process of Communication: *Receiving*

Awareness of messages you send is only part of process -Words & gestures interpreted in specific context to have meaning Receiver attaches meaning determined by past experiences, culture, self-concept, & current physical /emotional state Pts' health problems intensify communication bc pts depend on you to get better

Communication of Adolescent

Begins w puberty -Sometimes capable of mature actions, other times fall back on childhood response patterns -Most important thing you can communicate to adolescent = respect -Communication must be totally honest -Provide rationale -Stay in character -Focus first on adolescent, not on problem -Keep questions short/simple -Silent periods are best avoided -Avoid reflection -Develop rapport before asking emotionally charged questions -Take every opportunity for positive reinforcement

Interviewing Parent or Caregiver of Child:

Build rapport w both child & caregiver -1-6 yr child, focus on caregiver -begin interviewing both together, w sensitive topics, discuss later when caregiver alone -provide toys to occupy child -caregiver can norm. provide most hx of child & also observe as child plays -remember bias can occur when asked to describe child achievements or abilities -be patient as parent sorts thru development memories (more than 1 child) -avoid judgement when asking about develop. milestones (parents sensitive) -always refer to child by name & caregiver by surname instead of "dad" or "mom" (dont assume) -dont ignore child, meet child at eye level to not intimidate -keep gestures slow, deliberate, & close to body (dont frighten child w quick gestures) -dont try to maintain constant eye contact (threatens small child) -use quiet measured voice & simple words

Consider interview as a ________ b/w nurse and patient.

Contract Contract consists of spoken & unspoken rules for behavior: -what pt needs & expects & what health professional offers

Mr. Child is a 35-year-old patient who comes to the clinic for a general health visit. When asked about past medical problems and surgeries, his answers are confusing. Which communication technique do you use? a. Explanation b. Reflection c. Facilitation d. Clarification

D. Clarification

Mrs. Denier tells you that she is paranoid and that family members are "out to get her." You respond, "Tell me more." This technique is best described as:

Facilitation

Communication of Older Adult

Finding purpose in own existence & adjusting to inevitability of death Address by surname Avoid "elderspeak" such as: -diminutives (honey, sweetie, dearie) -inapprop. plural pronouns ("are we ready for our interview?") -tag questions ("You would tather sit in this nice soft chair, wouldnt you?") -shortened sentences, slow speech rate, simple vocab. Expect interview to take longer May need greater amount of response time Consider physical limitations when planning interview Touch is important

During the interview, you notice that the patient is grimacing and guarding his or her abdomen with movement. When asked, the patient denies pain. What should you do?

Focus the patient's attention on the discrepancy between his or her verbal responses and nonverbal behavior.

Complete (Total Health) Database

Includes complete health history & full physical exam Describes current & past health state & forms baseline to measure all future changes Yields first diagnoses

Internal factors that influence communication are particular to the interviewer. Which is an internal factor that should be cultivated because it facilitates communication? a. Distancing b. Liking others c. Selective listening d. Ability to confront

Liking others

When you use the communication technique of interpretation while interviewing Mr. Thacker, a 39-year-old carpenter who comes to the office for a routine examination, what are you doing?

Making associations and possibly implying cause.

Helping Health Illiterate

Oral Teaching Written Materials -12 pt font, avoid all Cap letters, use headings/subheadings, use pictures Teach Back Method

Which communication strategy offers children an opportunity to explore alternatives? a. Drawing b. Play c. Writing d. Mutual storytelling

Play

Play is a communication strategy appropriate for which age group? a. Infant b. Toddler c. School age d. Preschool

Preschool

The interview is essentially a contract formed between the nurse and the patient. Which statement is descriptive of this contract?

The contract consists of spoken and unspoken rules for behavior.

What is the priority information to obtain when interviewing a patient admitted to the emergency department under the influence of illicit drugs?

Time, name, and amount of drug last taken

Which is a guideline to be followed when preparing or using written informational materials with patients?

Use bullet points to organize and condense information.

Mrs. Beckman brings her 4-year-old son in for a routine follow-up appointment. Which is a guideline you should follow when talking to the boy during the interview?

Use short, simple, concrete sentences.

Ms. Lockhart is an 18-year-old patient who tells you that she is paranoid and that family members are "out to get her." You respond, "Paranoid and out to get you?" Which communication technique have you used? a. Reflection b. Clarification c. Facilitation d. Validation

a. Reflection

Mr. Grayson is a 67-year-old new patient who comes to the office for an examination. Which behaviors suggest to you that he may have a hearing impairment?

a. Staring intently at your mouth c. Interjecting comments when you are speaking d. Not answering questions asked when not looking at you e. Speaking in an unusually loud voice

What do you do when ending the patient interview? a. Summarize the patient's health concerns. b. Emphasize the patient's role in maintaining health. c. Review your key findings with the patient. d. Advise the patient on ways to maintain health.

a. Summarize the patient's health concerns.

Mrs. James is a 49-year-old patient who returns to the clinic for a routine gynecologic examination. During the interview, she expresses feelings and beliefs about sexuality that are very different than yours. Nonetheless, you recognize and accept her feelings without criticism. Which term best defines your actions? a. Empathy b. Facilitation c. Confrontation d. Reflection

a. empathy

Interviewing Hearing-Impaired People

ask if preferred way of communicating (sign lang, lip reading, writing) complete health hx of deaf requires sign lang interpreter face pt, dont exaggerate lip movement, dont shout -speak slowly & supplement voice w approp gestures -nonverbal cues important

Nursing Process

assessment diagnosis outcome identification planning implementation evaluation

Communication of Toddlers (12-36 mon)

begins to devlop. communication skills -limited vocab w grunts & pointing w interwined words at 2yr: simple 2 word phrases: -*telegraphic speech* -combination of nouch & verb w concrete meaning ("me up") older toddlers want to know why -provide simple explanations -struggle w control & autonomy; provide simple choices

Interviewing Intoxicated or Drug Use People

behaviors depend on drugs used ask simple, direct questions; keep manner & question nonthreatening- avoid confrontation top priority: time of last drug/drink, how much, & name of it

Use of which type of language is an interviewing trap? a. Egalitarian language b. Professional language c. Avoidance language d. Confrontational language

c. Avoidance language

Evidence-Based Practice (EBP)

combination of: -pt preferences & values -evidence from research -physical exam & assessment -clinical expertise to make decisions about care & treatment

What is assessed by the tool called the Newest Vital Sign? a. Health literacy b. Ankle-brachial index c. Pain d. Nutrition status

d. Nutrition status

Which guideline is advisable to follow when interviewing a patient? a. Keep any interruptions brief. b. Ask your next question promptly following each patient response. c. Use "why" questions to clarify symptoms. d. Spend more time listening than talking.

d. Spend more time listening than talking.

Personal Questions Asked During Interview

dont need to answer every question but may supply info thats approp. try directing response back to pt frame of reference

Interviewing Angry Patient

dont take anger personally, typically doesnt relate to you feelings of anxiety or helplessness ask about anger & hear pt out; deal w feelings before moving on

Communication of Preschooler (3-6 yrs)

egocentric: sees world from own point of view (everything revolves around them) 3-4yr child uses 3-4 word *telegraphic* sentences w essential words 5-6yrs: 6-8 word sentences & grammar develop. preschoolers communicate direct, concrete, literal, & set in present; can have animistic thinking (objects come to life)

First-level priority problems

emergent, life-threatening, & immediate, such as establishing an airway or supporting breathing

Facilitation Response

encourages pt to say more & shows youre interested -"mm-hmm, go on, uh-huh" -nodding yes -maintaining eye contact, shifting forward

Interviewing Crying Patient

examiner usually feel horrified; reassure that they dont need to be embarrassed dont go to new topic, allow to cry & express feelings before moving on

Interviewing Acutely Ill People

focus on hx of illness, medication, allergies, last meal, basic health state subjective info crucial of providing care, interview as much as possible while providing lifesaving actions focus on making comfortable first then ask priority questions of hx (close, direct, precise questions)

Novice nurse

has no experience w specific pt populations & uses rules to guide performance.

Tips for Sexual Orientation

instead of asking marital status of spouse, use term *partner* dont marginalize homosexual relationship (ask same questions as heterosexual couple) know state laws (some allow both same sex parents on birth certificate, others dont) use approp. health teaching materials dont make assumptions of sex based on appearance avoid heterosexist assumptions ("have you ever used birth control") be nonjudgemental

Body Language

posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair

Ch. 1 Diagnostic Reasoning

process of analyzing health data & drawing conclusions to identify diagnoses Hypothesis forming & Deductive Reasoning: 1.) attending to cues (piece of info) 2.) forming diagnostic hypothesis 3.) gathering relative data 4.) evaluating & arriving at final diagnosis

Working With or Without Interpreter

pts w/out interpreter: -many negative health outcomes -longer hospital stays -receive fewer preventative services -less satisfied -undergo unnecessary testing -greater risk of discharge w/out follow up app. -more likely admitted into hospital pts w interpreter: -lower admission rates -increased preventative services -improved health outcomes, primary care, & satisfaction -cost savings & reduce complications *dont use "ad hoc" interpreter (family, friends)

Emergency Database

rapid collection of the database, often compiled concurrently w lifesaving measures

Interviewing Patient w Threats of Violence

red flags: fist clenching, pacing back & forth, vacant stare, confusions, statements out of touch w reality or dont make sense, hx of drug use or rage obtain additional support from staff if suspected leave door to exam room open & position self b/w pt & door, never turn back to pt dont raise voice or try to argue, act calm w soft voice & interested, unhurried way

Heterosexism

refers to belief that heterosexuality is only natural choice & assumes everyone should be heterosexual -form of homophobia & leads to discrimination

Interviewing Sexually Aggressive People

response must be clear that your health professional who can best care for pt by maintaining professional relationship communicate that you cant tolerate sexual advances; set approp verbal boundaries

Third-level priority problems

those important to pt's health but can be addressed after more urgent health problems are addressed -interventions to treat these problems are more long term, & response takes more time (Knowledge deficit, altered family processes, low self esteem)

Collaborative Problems

those in which approach to treatment involves multiple disciplines -nurses have primary responsibility to diagnose onset & monitor change in mental status -once identified problem, identify expected outcomes & work to achieve

Second-level priority problems

those next in urgency requiring prompt intervention to forestall further deterioration. (mental status change, acute pain, acute urinary elimination problem, untreated medical problems, abnormal lab test results

Communication of School Age (7-12 yrs)

tolerate & understand others viewpoints; more objective & realistic -wants to know functional aspects (how things work) -recognize things they do affect others (be nonjudgemental) stable & logical thinking: *decenter* & consider all sides of situation to form conclusion interview caregiver & child together but ask child s/s first then caregiver

Proficient nurse

understands pt situation as whole rather than list of tasks, attends to assessment data pattern, & acts w/out consciously labeling it

Focused or Problem-Centered Database

used for a limited or short-term problem. smaller in scope & more targeted than complete database: "mini" database

Follow-Up Database

used in all settings to monitor progress of short-term or chronic health problems

Expert nurse

vault over steps & arrive at a clinical judgment in one leap *has intuition (knowledge received as a whole)

Holistic Health

view that mind, body, & spirit are interdependent and function as a whole w/in environ.