| 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 |
Buen Viaje lv.2 ch 8
