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past health, family history, review of systems, functional assessment,

5)• Fifth, investigate ______events, such as illnesses, injuries, hospitalizations, & allergies as well as current medications. 6)• Sixth, gather a _________to help detect health risks for the patient. To aid in this process, draw a pedigree or genogram. 7)• Seventh, perform a ______________ to evaluate the past & present health of each body system, double-check for significant data, & assess health promotion practices. For each body system, assess for symptoms & health-promoting behaviors. 8)• Finally, perform a __________, including activities of daily living, such as bathing dressing, toileting, eating, walking, housekeeping, shopping, cooking, & other factors.

Assessment

ASSESSMENT is the collection of subjective & objective data about a patient's health. • Subjective data consist of information provided by the affected individual. • Objective data include information obtained by the health care provider through physical assessment, the patient's record, & laboratory studies.

nonverbal

Acknowledging the patient's verbal and _______ communication conveys true interest and encourages further communication.

critical thinking

CRITICAL THINKING is the multidimensional thinking process needed for sound diagnostic reasoning & clinical judgment. Seventeen critical thinking skills have been identified, including setting priorities.

COLDSPAA

Character Describe the sign or symptom (feeling, appearance, sound, smell or taste if applicable). Onset When did it begin? Location Where is it? Does it radiate? Does it occur anywhere else? Duration How long does it last? Does it recur? Severity How bad is it? How much does it bother you? Pattern What makes it better or worse? Associated factors/ how it Affects the patient What other symptoms occur with it? How does it affect you?

Encoding

Communication skills are essential to establish an effective nurse-client relationship. • Communication is the exchange of information between individuals. • During communication, a message is transmitted by a sender to another individual. A message is heard and interpreted by the receiver. •_______ is the process of formulating a message for transmission to another.________ includes the use of words, body language, and signs to convey a message. • Decoding is searching one's memory, experience, and knowledge base to determine the meaning of a message.

Diagnostic reasoning

DIAGNOSTIC REASONING is the process of analyzing health data & drawing conclusions to identify diagnoses. This process has four major components:

evidence-based practice

EVIDENCE-BASED PRACTICE is a systematic approach to practice that uses the best evidence, the clinician's experience, & the patient's preferences & values to make decisions about care & treatment.

Complete (Total Health) Database, problem centered, follow up, emergency

Every examiner needs to collect FOUR KINDS OF DATABASES based on the situation. 1. A complete (or total health) database includes a complete health history & a full physical examination. 2. A focused (or problem-centered) database is used for a limited or short-term problem. It is smaller in scope & more targeted than the complete database. 3. A follow-up database evaluates the status of any identified problem at regular intervals to follow up on short-term or chronic health problems. 4. An emergency database calls for rapid collection of data, which commonly occurs while performing lifesaving measures.

Critical thinking

First-level priority problems are emergent, life-threatening, & immediate, such as establishing an airway or supporting breathing. • Second-level priority problems are next in urgency. They require prompt intervention to prevent deterioration, & may include a mental status change or acute pain. • Third-level priority problems are important to the patient's health, but can be addressed after more urgent problems. Examples include lack of knowledge or family coping.

minimal distractions

INTERVIEWING TECHNIQUES Begin the interview by establishing trust and conveying a caring attitude. Make sure that the environment is comfortable and that privacy is ensured with ____________. The following tips will help you get the most from your interviews: • Introduce yourself. • Don't rush. Allow enough time for the interview. • Avoid interruptions.

interactional skills

Interactional skills are used during encoding and decoding to exchange information, develop relationships, and promote understanding of self and others. • Listening, attending, paraphrasing, leading, questioning, reflecting, and summarizing are examples of ___________used in nurse-client interactions.

specific questions

Interviews can be either directive or non-directive. • Directive interviews are structured with _________ and are controlled by the nurse. These interviews require less time and are very effective for obtaining factual data. or she is. • Be nonjudgmental.

• "What medications have you used in the recent past and currently, both those that your doctor prescribed and those you can buy over the counter at a drug or grocery store? For what purpose did you take the medication? How much (dose) and how often did you take the medication?" • "How much beer, wine, or other alcohol do you drink on the average?" • "Do you drink coffee or other beverages containing caffeine (e.g., cola)?" If so, how much and how often? • "Do you now or have you ever smoked cigarettes or used any other form of nicotine? How long have you been smoking/did you smoke? How many packs per week? Tell me about any efforts to quit." • "Have you ever taken any medication not prescribed by your healthcare provider? If so, when, what type, how much, and why?" • "Have you ever used, or do you now use, recreational drugs? Describe any usage." • "Do you take vitamins or herbal supplements? If so, what?"

Medication and Substance Use - The information gathered about medication and substance use provides the nurse with information concerning lifestyle and a client's self-care ability. Medication and substance use can affect the client's health and cause loss of function or impaired senses. In addition, certain medications and substances can increase the client's risk for disease. Because many people use vitamins or a variety of herbal supplements, it is important to ask which and how often. Prescription medications and these supplements may interact (e.g., garlic decreases coagulation and interacts with warfarin [Coumadin]). Sample questions include

biographic data, source, reason, present health, PQRSTU

No matter what form is used to record the health history, plan to gather data in eight categories. 1)• First, collect __________, such as the patient's name, address, & date of birth as well as language & communication needs. 2)• Second, note the ________ of the history, which is usually the patient, but may be someone else, such as a relative or interpreter. 3)• Third, obtain the ______for seeking care, formerly known as the chief complaint. In the patient's own words, briefly describe the reason for the visit. 4) Fourth, record the __________or history of present illness. For a well person, briefly note the general state of health. For a sick person, chronologically record the reason for seeking care. When a patient reports a symptom, perform a symptom analysis. If you find it helpful, use the mnemonic _________ to do this. PQRSTU stands for Provocative or palliative, Quality or quantity, Region or radiation, Severity scale, Timing, & Understanding the patient's perception of the problem.

.....

PHASES OF THE INTERVIEW The interview is divided into three phases: the introductory phase, the working phase, and the termination phase. Each phase has a specific purpose and different communication patterns.

one, response

PITFALLS• Asking more than ____ question at a time. If you do, the patient may not know which one to answer. Or, you may not be sure which question is being answered. • Not allowing enough _______ time. Give the patient time to think through his or her answer. This is especially important with older patients.

biases, answer,

PITFALLS• Biasing yourself. You can bias yourself because of the patient, a particular disease, or a particular physician. But if you fail to check your ______, you limit your objectivity during assessment. • Letting family members ______ for patient. You will learn a lot more by having the patient describe things in her or his own words.

clichés, disregard

PITFALLS• Feeling personally uncomfortable. This often happens with beginning students. Stay focused. It will get easier with experience. • Using ________. Interviewers often resort to clichés when they feel uncomfortable or unsure of an answer. No one expects you to have all the answers. If you do not have an answer, tell the patient that you will try to find one and get back to him or her. Clichés like, "You'll feel better in the morning," show a________ for your patient's feelings.

......

PITFALLS• Giving advice. The patient needs to be informed, but can make her or his own decisions. • Jumping to conclusions. Make sure you have all the facts before drawing conclusions.

condescending, probing, attending

PITFALLS• Offering false reassurance. Telling the patient that everything will be fine is _______. It may not be. • Asking persistent or________questions. Persistent or probing questions make your patient uncomfortable. Remember, the patient has a right to not answer a question. • Changing the subject. Some nurses change the subject when the interview is making them uncomfortable. This is not very helpful for the patient. Remember: You are ________ to the patient's needs, not your own.

Literal, figurative, frustration

PITFALLS• Taking things literally. _______responses may lead to misunderstanding. Patients who have difficulty expressing feelings directly may use _______ language. So always consider the context in which the statement is made, and clarify if you are still unsure. For example, an extremely frustrated patient might say, "If I don't get out of here soon, I'll go crazy!" Don't rush to have a psychiatric consultation; recognize the patient's feelings of _______ and focus on them.

lay, conclusions, personally,

PITFALLS• Using medical jargon. Express your questions in _____terms to make sure your patient understands you. • Assuming rather than clarifying and validating. Assuming can lead to inaccurate interpretations and incorrect _________. • Taking the patient's responses _______. An angry or frustrated patient may verbally attack you or the healthcare facility. Realize that the patient is displacing her or his feelings on you and using you as a sounding board.

• "Can you tell me how your mother described your birth? Were there any problems? As far as you know, did you progress normally as you grew to adulthood? Were there any problems that your family told you about or that you experienced?" • "What diseases did you have as a child such as measles or mumps? What immunizations did you get and are you up to date now?" • "Do you have any chronic illnesses? If so, when was it diagnosed? How is it treated? How satisfied have you been with the treatment?" • "What illnesses or allergies have you had? How were the illnesses treated?" • "Have you ever been pregnant and delivered a baby? How many times have you been pregnant/delivered?"

Past Health History - This portion of the health history focuses on questions related to the client's past, from the earliest beginnings to the present. These questions elicit data related to the client's strengths and weaknesses in her health history. The client's strengths may be physical (e.g., optimal body weight), social (e.g., active in community services) emotional (e.g., expresses feeling openly), or spiritual (often turns to faith for support). The data may also point to trends of unhealthy behaviors such as smoking or lack of physical activity. The information gained from these questions assists the nurse to identify risk factors that stem from previous health problems. Risk factors may be to the client or to his significant others. Information covered in this section includes questions about birth, growth, development, childhood diseases, immunizations, allergies, previous health problems, hospitalizations, surgeries, pregnancies, births, previous accidents, injuries, pain experiences, and emotional or psychiatric problems. Sample questions include

biomedical model

THE CONCEPT OF HEALTH has expanded & is based on the practice model used. The concept of health also includes HEALTH PROMOTION & DISEASE PREVENTION. • The___________ of Western medicine views health as the absence of disease. It focuses on collecting data on biophysical signs & symptoms & on curing disease.

Database

THE DATABASE is the totality of information available about the patient. The purpose of assessment is to make a judgment or diagnosis.

Nursing process

THE NURSING PROCESS includes six phases: assessment, diagnosis, outcome identification, planning, implementation, & evaluation. It is a dynamic, interactive process in which practitioners move back & forth within the steps.

Directive interviews

TYPES OF QUESTIONS Questions are classified as closed or open. • Closed questions are often those that elicit a "yes" or "no" response, for example, "Do you have pain?" This type of question takes little time and is very effective for factual dat frequently use many closed questions. are completing are more important than he

1. Biographic data 2. Reasons for seeking health care 3. History of present health concern 4. Past health history 5. Family health history 6. Review of body systems (ROS) for current health problems 7. Lifestyle and health practices profile 8. Developmental level

Taking a health history should begin with an explanation to the client of why the information is being requested, for example, "so that I will be able to plan individualized nursing care with you." This section explains the rationale for collecting the data, discusses each portion of the health history, and provides sample questions. The health history has eight sections:

Comprehensive Older Person's Evaluation

The ___________________ is particularly useful because it addresses: • Basic & instrumental activities of daily living, • Functional assessments, • And physical, social, psychologic, demographic, financial, & legal issues

......

The depth of information obtained for each health history category may vary from one setting to another. However, you should address all categories before making a diagnosis or judgment about the patient's health status.

secondary

The health history interview is planned, formal interaction between the nurse and the client. • The source of information for the health history must be able to provide accurate and reliable information. • The primary source for health history information is the client. • Clients who may be unable to provide accurate and reliable information include infants and children, developmentally challenged clients, disoriented or emotionally disturbed individuals, aphasic persons, or those who do not speak a common language. • Secondary sources of information for the health history include individuals who have known the client for some time, generally a significant other. • Client records and charts are________ sources of information for the health history. • The health history interview occurs in three phases. The preinteraction phase occurs before the nurse meets the client. The initial interview is the second phase of the health history interview. The focused interview is the third phase of the health history interview.

Health history components, response

The health history is a comprehensive record of the client's past and current health. • The nurse's health history differs from that of the physician in that it focuses on the client's________ to a health concern as a whole person, rather than on the diagnosis of a disease. • The health history is performed at the time of the initial encounter with the client and occurs before the physical assessment. • The health history includes subjective data about wellness and illness.

interpersonal

The interview is usually structured communication intended to obtain subjective data. An interview is most useful when taking the health history. For an interview to be successful, you need good __________ communication skills. Many factors, including cultural or developmental differences or life experiences, can impair effective communication with your patient. You need to examine your values and beliefs to minimize any bias that may interfere with the interview.

database

The purpose of the "complete health history" is to collect subjective data, which is what the person says about himself or herself. By combining this subjective data with objective data from the physical examination & diagnostic tests, you create a ______ to make a judgment about the person's health status.

Skin, hair, and nails: Skin color, temperature, condition, excessive sweating, rashes, lesions, balding, dandruff, condition of nails • Head & neck: Headache, swelling, stiffness of neck, difficulty swallowing, sore throat, enlarged lymph nodes

The questions about problems and signs or symptoms of disorders should be asked in terms that the client understands, but findings may be recorded in standard medical terminology. If the client appears to have a limited vocabulary, the nurse may need to ask questions in several different ways and use very basic lay terminology. If the client is well educated and seems familiar with medical terminology, the nurse should not insult her by talking at a much lower level. The most obvious information to collect for each body part or system is listed below.

intimate partner

The two types of__________ violence include: • Physical and/or sexual violence or the threat of such violence • And psychologic or emotional abuse and/or coercion.

PPDPPN, IAI, F/A

When obtaining a child's health history, use the same structure you would use for an adult, but make pertinent modifications or additions. Additions include: • A prenatal & perinatal history • A developmental overview, • The parents' description of the present problem, • And a nutritional history. • Any childhood illnesses or accidents, • Immunization data, When assessing functional abilities, consider the child's environment & his or her function or role in the environment.

changes, impact, record the person's reason

When taking an older adult's health history, also ask additional questions. For example, explore _________ in activities of daily living that may result from the aging process or chronic illness. Remember that the _______ or burden of a disease may be more important to an older adult than the actual disease diagnosis or pathology. So be sure to _____________ for seeking care, not your assumption about the problem.

therapeutic, empathetic, nonjudgmental

When you use your interpersonal skills in a healing way to help your patient, this is known as ________ use of self. Showing empathy, demonstrating acceptance, and giving recognition are three techniques that enhance therapeutic use of self. Being ________ is the ability to understand another's feelings. Maintaining a neutral, ________ position and demonstrating acceptance of your patient's verbal and nonverbal communication are essential to developing a trusting relationship.

information

• 1)Attending to initially available cues, which are pieces of______, signs, symptoms, or laboratory data;

hypotheses

• 2)Formulating diagnostic________, which are tentative explanations for a cue or a set of cues & can serve as a basis for further investigation;

data

• 3)Gathering________ relative to the tentative hypotheses;

evaluating

• 4)And________ each hypothesis with the new data collected, which leads to a final diagnosis.

defensive,

• Avoid "why?" questions; they tend to put patients on the ______. • Nonverbal behavior is more accurate than verbal. Take a look at yours—What is it telling your patient? • Take a good look at your patient's nonverbal behavior. Is it consistent with what she or he is telling you? • Now look at your patient's nonverbal behavior another way. Does it indicate health problems? purpose and different communication patterns.

developmental, preoccupied

• Consider your patient's ______ level. How does it affect the interview and your interpretation of the data? • Don't become _________ with writing. You may convey to the patient that the forms you are completing are more important than he or she is. be nonjudgmental

listen, Two to 4

• Explain that information from the interview is confidential. • Actively _______to what your patient is saying. • Maintain eye contact. • Work at the same level as your patient. Pull up a chair and sit next to her or him. • Don't invade your patient's personal space. _________ feet away is a comfortable distance for most patients.

problem, nonsensitive, cultural,

• Explain what you are doing and why. • If the patient presents with a _______, begin by asking questions about that. • Begin with _______ issues. Leave more sensitive topics until the end. • Consider your patient's ______ background. How does it affect the interview and your interpretation of the data?

Eyes: Vision, eye infections, redness, excessive tearing, halos around lights, blurring, loss of side vision, moving black spots/specks in visual fields, flashing lights, double vision, and eye pain • Ears: Hearing, ringing or buzzing, earaches, drainage from ears, dizziness, exposure to loud noises • Mouth, throat, nose, and sinuses: Condition of teeth and gums; sore throats; mouth lesions; hoarseness; rhinorrhea; nasal obstruction; frequent colds; sneezing or itching of eyes, ears, nose, or throat; nose bleeds; snoring • Thorax and lungs: Difficulty breathing, wheezing, pain, shortness of breath during routine activity, orthopnea, cough or sputum, hemoptysis, respiratory infections • Breasts and regional lymphatics: Lumps or discharge from nipples, dimpling or changes in breast size, swollen or tender lymph nodes in axilla • Heart and neck vessels: Last blood pressure, ECG tracing or findings, chest pain or pressure, palpitations, edema • Peripheral vascular: Swelling, or edema, of legs and feet; pain; cramping; sores on legs; color or texture changes on the legs or feet • Abdomen: Indigestion, difficulty swallowing, nausea, vomiting, abdominal pain, gas, jaundice, hernias • Male genitalia: Excessive or painful urination, frequency or difficulty starting and maintaining urinary stream, leaking of urine, blood noted in urine, sexual problems, perineal lesions, penile drainage, pain or swelling in scrotum, difficulty achieving an erection and/or difficulty ejaculating, exposure to sexually transmitted infections

• Female genitalia: Sexual problems; sexually transmitted diseases; voiding problems (e.g., dribbling, incontinence); reproductive data such as age at menarche, menstruation (length and regularity of cycle), pregnancies, and type of or problems with delivery, abortions, pelvic pain, birth control, menopause (date or year of last menstrual period), and use of hormone replacement therapy • Anus, rectum, and prostate: Bowel habits, pain with defecation, hemorrhoids, blood in stool, constipation, diarrhea • Musculoskeletal: Swelling, redness, pain, stiffness of joints, ability to perform activities of daily living, muscle strength • Neurologic: General mood, behavior, depression, anger, concussions, headaches, loss of strength or sensation, coordination, difficulty speaking, memory problems, strange thoughts and/or actions, difficulty learning

database

• For sick patients, the "health history" includes a detailed, chronologic record of the health problem. • For all patients, it is a screening tool for abnormal symptoms, health problems, & concerns. It also records the patient's responses to health problems.

teach, reassurance, want, describe

• Never pass up an opportunity to ______. • Present reality. • Be honest. • Provide ________ and encouragement. • Be respectful. INTERVIEWING PITFALLS Avoid the following traps when interviewing a patient: • Leading the patient. People will tell you what you _____ to hear. So don't lead the patient. Having him or her ______what is happening in his or her own words is much more helpful.

perceptions and feelings

• Non-directive interviews are controlled by the patient, although the nurse often needs to summarize and clarify the data. These interviews require more time than directive interviews but are very effective at eliciting the patient's _______________. Non-directive interviews help you to identify what is important to the patient.

non-directive interviews

• Open questions elicit the patient's perceptions, for example, "What brought you to the hospital?" More time is needed for this type of question. They are frequently used in_________ . may convey to the patient that the forms you

holistic health

• The_________ model assesses the whole person because it views the mind, body, & spirit as interdependent & functioning as a whole within the environment. Health depends on all these factors working together.