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Health History

Interview techniques

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