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Patient Evaluation
Patient Interview
| Question | Answer |
|---|---|
| Patient Interview Determining Level of Consciousness/Alert | normal / alert and responsive |
| Patient Interview Determining Level of Consciousness/Lethargic | somnolent, sleepy consider: COPD, O2 overdose, or sleep apnea |
| Patient Interview Determining Level of Consciousness/Stupor | confused, responds inappropriately, drug overdose, intoxication |
| Patient Interview Determining Level of Consciousness/Semi comatose | response only to pain |
| Patient Interview Determining Level of Consciousness/Obtunded | drowsy state may have decreased cough or gag reflex |
| Patient Interview Determining Level of Consciousness/Coma | doesn't respond to pain stimuli |
| Patient Interview Check orientation to time, place and person Well-Orientated | cooperative, knows who people are |
| Patient Interview Check orientation to time, place and person Disoriented | confused, delirious |
| Patient Interview Check orientation to time, place and person Ability to cooperate | ask to perform simple tasks, ask to repeat instructions |
| Patient Interview Check orientation to time, place and person Inability to cooperate | *Language difficulties *Influence of medications * Hearing Loss * Fear, apprehension, depression |
| Patient Interview Assess Emotional State: Anxiety | nervousness- watching every movement asthmatic, respiratory distress, hypoxemia. |
| Patient Interview Assess Emotional State: Depressed | quiet or Denial |
| Patient Interview Assess Emotional State: Anger | combative, irritable-electrolyte imbalance |
| Patient Interview Assess Emotional State: Euphoria | Drug Overdose |
| Patient Interview Assess Emotional State: Panic | hypoxia, tension Pneumothorax, status asthmaticus |
| Patient Interview Activities of Daily Living: Define | Activities of Daily Living is defined of basic tasks of everyday life. |
| Patient Interview Activities of Daily Living: Assessment | *nursing home admission *need for homecare providers * use of hospital services * living arrangements * use of physician * insurance coverage * mortality |
| Patient Interview Activities of Daily Living: based upon | * Bathing with Sponge * Eating * Dressing * Toilet Use * Transferring * Urine and Bowel Incontinence |
| Patient Interview Activities of Daily Living Katz ADL | scoring system, each activity is graded on the level of dependence |
| Patient Interview Activities of Daily Living Katz ADL Scoring 0 | If the patient is unable to perform or needs assistance in performing the activity, a score of zero is assigned |
| Patient Interview Activities of Daily Living Katz ADL Scoring 1 | If the patient needs no direction or assistance in performing the activity, a score of one is assigned. |
| Patient Interview Activities of Daily Living Katz ADL Scoring Interpretation | Score of 6: Patient is independent and has full functional capacity. Score of 4: Patient is moderate needs some assistant. Score of 2: Or less patient is severe and needs assistant with daily activity. |
| Patient Interview Measure Subjective Symptoms/ Orthopnea | difficulty breathing except in the upright position (heart problem, CHF) |
| Patient Interview Measure Subjective Symptoms/General Malaise | run down feeling, nausea, weakness, fatigue, headache (electrolyte imbalance) |
| Patient Interview Measure Subjective Symptoms/Dyspnea Define | a feeling of shortness of breath or difficulty in breathing |
| Patient Interview Measure Subjective Symptoms/Dyspnea Grade1 | Dyspnea occurs after usual exertion. |
| Patient Interview Measure Subjective Symptoms/Dyspnea Grade2 | Breathless after going uphill or stairs. |
| Patient Interview Measure Subjective Symptoms/Dyspnea Grade3 | Dyspnea while walking normal speed. |
| Patient Interview Measure Subjective Symptoms/Dyspnea Grade4 | Dyspnea slowly walking short distance. |
| Patient Interview Measure Subjective Symptoms/Dyspnea Grade5 | Dyspnea at rest, shaving, dressing. |
| Patient Interview Measure Subjective Symptoms/Pain Define | a reaction of specific nervous tissue, May increase blood pressure and heart rate. Lung tissue is not pain sensitive, but ribs, muscle, and pleura are sensitive to pain. |
| Patient Interview Measure Subjective Symptoms/Pain Identifiers | a) Location b) Quality(what it is) c) Severity ( On a 10 point scale) d )Aggravating Factors e) Relieving Factors f) History (when did it start g) Context (under what circumstance does it occur h) Accompanying symptoms |
| Patient Interview Measure Subjective Symptoms/Nose and Throat 1 | Excessive nasal secretions from irritants, pollutants, and allergies. |
| Patient Interview Measure Subjective Symptoms/Nose and Throat 2 | Itching and Burning sensations in nose and throat. |
| Patient Interview Measure Subjective Symptoms/Nose and Throat 3 | Dysphagia(difficulty swallowing) and hoarseness are also common symptoms. |
| Patient Interview Respiratory Care Plan/Changes | a) Case management b) Therapy protocols c) Disease management e) Patient and family education needs |
| Patient Interview Social Support Systems | family, friends, social services etc. |
| Patient Interview Physical Environment | ramps, doorways, stairs, electrical wiring |
| Patient Interview Use proper Interview Techniques | a)Ask open-ended questions (yes or no) b) Communicate using simple language (KISS method) c) Utilize pictures, diagrams, (language difficulties) d)Begin to identify patient major problems |
| Patient Interview Assessing Patient Learning Needs /Definition | Patient education is the process of influencing behavior and producing the changes in knowledge, attitudes and skills necessary to maintain or improve help. |
| Patient Interview Assessing Patient Learning Needs/ Description | Effective education begins with an assessment of the patient and family learning needs to determine what learning needs to occur and how the learning can best occur. |
| Patient Interview Assessing Patient Learning Needs/Assessment Ability to learn | a) Cultural and religious values. b) Emotional barriers c) Desire and motivation to learn d) Physical and cognitive limitations e) Language barriers f) Age and educational level |
| Patient Interview Assessing Patient Learning Needs/Assessment Addition Barrier | a) Financial considerations b) Lack of support system c) Environment d) misconceptions about disease and treatment e)Negative past experiences f) Denial and personal responsibility |
| Patient Interview Assessing Patient Learning Needs/ Learning Topics | * learning can occur formally or informally * take advantage of teachable moments * patient will benefit from education about - health status - disease management - use of medication and equipment - nutrition - community resources - rehab techniq |
| Patient Interview Assessing Patient Learning Needs/Nutritional Status | * Review dietary history - usual food intake - food likes and dislikes - appetite * note any recent weight gain or loss |
| Patient Interview Patient/ Family History/ History Present Illness | current medical/physical problem (problems) |
| Patient Interview Patient/ Family History/Past Medical History | previous medical problems, accidents, injuries |
| Patient Interview Patient/ Family History/ Family History | Heart disease, diabetes, cystic fibrosis etc. |
| Patient Interview Patient/ Family History/ Social History | smoking, substance abuse etc. |
Created by:
sukar
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