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Patient Evaluation

Patient Interview

QuestionAnswer
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