nurs 225 quiz 1

health history interview

conversation with a purpose
the purpose is to establish a trusting and supportive relationship, gather information, and offer information
the goal is to improve the well-being of the patient

phases of interviewing

pre-interview, introduction, working, termination

pre-interview

self-reflection, reviewing patient record, set interview goals, review own clinical behavior and appearance

self-reflection

acknowledging bias and assumptions in the pre-interview

introduction

Put the patient at ease and establish trust
Greet the patient and establish rapport
Establish the agenda for the interview
- Sometimes you might have to alter your goals to the goals of the patient for an interview

working

obtaining patient information
Invite the patient’s story: allow the patient to tell their story in their own words
Identify and respond to emotional cues- ask the patient about their perspective on their health concern/illness
Expand and clarify the patient’s story (OLDCART)

OLDCART

onset, location, duration, characteristic symptoms, associated manifestations, relieving/exacerbating factors, treatment

onset

when did (does) it start?

location

where is it? does it radiate?

duration

how long does it last?

characteristic symptoms

What is it like? How severe is it?

associated manifestations

Have you noticed anything else that accompanies it?

relieving/exacerbating factors

Is there anything that makes it better or worse?

treatment

What have you done to treat this? Was it effective?

generating and testing diagnostic hypotheses

Identifying the attributes and details of the patient’s symptoms is fundamental to recognizing patterns of problems and generating nursing diagnoses

Create a shared understanding of the problem (asking the patient about their perception of illness; FIFE)

Negotiate a plan, including further evaluation, treatment, education, and self-management support and prevention
(cone: Open with broad questions and narrow it down to specific)

FIFE

feelings, ideas, function, expectations

termination

Let the patient know when the interview is approaching the end so that they ask questions
Summarize the patient’s problems
Discuss plan of care: address any concerns or questions the patient may have about the plan of care

therapeutic communication

The use of good communication techniques will help the nurse obtain key information and create a trusting relationship with the patient
Skilled interviewing uses the following:
- Active listening, guided questioning, nonverbal communication, empathetic responses, validation, reassurance, summarizing, transitions, empowering the patient

active listening

Involves paying close attention to what the patient is communicating
An awareness of the patient’s emotional state
Requires the nurse to use verbal and nonverbal skills to encourage the patient to elaborate

guided questioning

Encourages the patient to disclose while minimizing the risk of distorting the patient’s ideas or missing significant details

Moving from open-ended to focused questions
- general to specific
- avoid leading questions

Using questioning that elicits a graded response

asking a series of questions, one at a time

Pause after each question and establish eye contact with a patient after each question

offering multiple choices for answers

Can help patients describe symptoms while minimizing bias

empathetic responses

verbal and nonverbal responses must reflect a precise understanding of what the patient is feeling

nonverbal communication

Allows the nurse to read the patient
Sound nonverbal communication is universal, and some are dependent on culture. For example, eye contact

summarizing

Lets the patient know you are listening
Identifies what is known and not known

transitions

Helps put the patient at ease when the focus of the interview has changed

the nurse process

assessment, nursing diagnosis, planning, implementation, evaluation

subjective data

Communicated to the nurse by the patient
Reveals the perspective, thoughts, feelings, beliefs, and sensations of the person giving the data
Interview and health history
- pain is subjective!

objective data

Gathered by the physical exam, diagnostic or laboratory tests
Observation of client’s behavior
Can be measured or observed by the nurse or other healthcare providers
- Objective data is used to help with subjective data
- Subjective data might not match up with objective data
-- I.e., shoulder pain, but someone else might not know that when looking at the individual with shoulder pain if they can move it

four types of health histories

comprehensive, focused or problem-oriented, follow-up, emergency

comprehensive health history

general physical assessment on the patient

focused or problem-oriented assessment

The patient is known to nurse
Focuses mostly on a current problem

follow-up history

Focus assessment that evaluates problem either after treatment or when new care provided meets patient

emergency history

Focuses on emergent problem

initial information (comprehensive health history)

Date and time of history
Identifying data: age, gender, birth date, marital or relationship status, occupation, other as appropriate
Source of history- patient or family member, or chart
History of present illness (HPI): patient’s story (why they’re here)
Starts with the chief complaint
Past history: medical, surgical, psychiatric
Family history: if parents are alive. If dead, how did they die, how their siblings are
Review of the system: presence or absence of common symptoms related to each major system
Health Patterns: social and personal history

cultural assessment

Refers to a systematic, comprehensive examination of individuals, families, groups, and communities regarding their health-related cultural beliefs, values, and practices
Form a foundation for the client's plan of care, providing valuable data for setting mutual goals, planning care, intervening, and evaluating the care

cultural assessment: self-reflection

Am I aware of my biases? Prejudices? Stereotypes?
Am I comfortable interacting with people from different cultures?
Do I seek out experiences with other cultures?
Do I seek out opportunities to learn about other cultures?
Do I respect the beliefs of individuals from other cultures?
Do I know how to access language interpreter services for the patient?

communication and language assistance

offer language assistance to individuals with communication needs at no cost to them or facilitate timely access to all health care and services

inform all individuals of the availability of language assistance services

ensure the competence of individuals providing language assistance

provide easy-to-understand print and multimedia materials in common languages of local populations

areas to assess in health history

communication and language
family structure
family roles and organization
social networks
educational background and learning style
nutrition
Child-bearing and child-rearing practices
High-risk behaviors
Health care beliefs and practices
Health care practitioners
Spirituality and religion
Alcohol

alcohol

Assess what the patient considers alcohol
Screening tool: CAGE

CAGE (alcohol)

Have you ever felt the need to cut down on drinking?
Have you ever felt annoyed by criticism of your drinking?
Have you ever felt guilty about drinking?
Have you ever taken a drink first thing in the morning (eye-opener) to steady your nerves or get rid of the hangover?

Positive CAGE results: 2 or more affirmative answers

If you detect misuse, ask about:
Blackouts
Seizures
Accidents
Injuries while drinking
Job problems
Conflicts
Legal problems

illicit drugs

Focus questions to distinguish use from misuse
Adapt CAGE questions by adding “or drugs”
Ask about patterns of use
Ask about modes of consumption

review of systems

Address each body system, from head to toe
Most questions pertain to symptoms
May uncover problems patient has overlooked
Do not use medical terms

review of systems examples

General
Skin
HEENT
Neck
Breasts
Respiratory
Cardiovascular
Gastrointestinal
Peripheral vascular
Urinary
Reproductive
Musculoskeletal
Psychiatric
Neurologic
Hematologic
Endocrine

health patterns

Self-perception/self-concept
Value-belief
Activity-exercise
Sleep-rest
Nutrition
Role-relationship
Coping stress-tolerance

sensitive topics with patients

The single most important rule is to be non-judgmental
Explain why you need to know certain information
Find opening questions for sensitive topics and learn about the specific kinds of information needed for your assessments
Consciously acknowledge whatever discomfort you are feeling. Denying your discomfort may lead you to avoid the topic altogether

documentation

often computerized
must be accurate and thorough

reasons to perform a physical exam

To process to collect objective data from the patient
Purpose to determine changes in a patient’s health status
Determine how to respond to a problem
Promote healthy lifestyles and well-being

adjusting the lighting and environment (physical exam)

Adjust the bed to a convenient height
Good lighting
- tangential lighting
- perpendicular lighting

tangential lighting

casts light across body surfaces

standard and MRSA precautions

All blood, body fluids, secretions, excretions, nonintact skin, and mucous membranes may contain transmissible infectious agents
Apply to all patients
Include: hand hygiene, use of PPE, safe injection practices, safe handling of contaminated equipment or surfaces, respiratory hygiene and cough etiquette, patient isolation, and precautions related to various objects

situations where hand hygiene should be performed

Before touching a patient, even if gloves are worn
Before exiting a patient’s care area after touching the patient or patient’s immediate environment
After contact with blood, body fluids or excretions, or wound dressings
Before performing an aseptic task
If hands will be moving from a contaminated body site to a clean body site during patient care
After glove removal

making the patient comfortable

how concern for privacy and modesty
Provide proper draping
Visualize one area of the body at a time
Tell the patient what you will be doing
Be sensitive to the patient’s nonverbal cues
Tell the patient your general impression

sequence of physical exam

Maximize the patient’s comfort
Maintain patient safety
Avoid unnecessary changes in position
Enhance clinical accuracy and efficiency
In the general move “head to toe”
Minimize how often you ask the patient to change position
Examine the patient from the right side, moving to the opposite side or foot as needed

the cardinal techniques of examination

inspection, palpation, percussion, auscultation

inspection

Exam patient using sight

palpation

Exam patient using touch
Nurses use light palpation

percussion

Exam patient using sound vibrations
- Using hands and flicking

auscultation

Direct auscultation: exam patient using ears
Indirect auscultation: exam patient using a stethoscope

diaphragm

in auscultation, used to hear high-pitch sounds such as lungs and bowl sounds)

bell

in auscultation, used to hear low-pitch sounds (murmurs)

general survey

first impression of patient

assess many factors, such as:
- general appearance
- level of consciousness
- facial expression
- posture, gait, motor activity, and speech
- fatigue
- weakness
- skin color and obvious lesions
- dress, grooming, and personal hygiene
- distress

level of consciousness

Awake, alert, responsive
Orientation to person, place, time

fatigue

Nonspecific symptoms with many causes; a sense of weariness and loss of energy
- Depression, anxiety, hepatitis, infectious mononucleosis, hypothyroidism, diabetes mellitus, and others cause this

weakness

demonstrable loss of muscle power
- possible neuropathy or myopathy
- odors of the body or breath (could detect diabetes)

dress, grooming, and personal hygiene

Clothing appropriate for the weather
Clean, properly buttoned
Clothing appropriate for the age and/or social group
Tattoos, piercings
Hygiene and grooming appropriate for age, lifestyle, occupation

signs of distress

Cardiac or respiratory distress
- Clutching chest, pallor, diaphoresis, labored breathing, shortness of breath, tripod position

Pain
- Facial expression, grimacing, crying

Anxiety or depression
- Anxious face, fidgety movements, poor eye contact, flat affect, psychomotor slowing

pain

One of the most common symptoms in patients
Often under-assessed and under-treated

acute pain

Occurs suddenly with a recent injury or illness

chronic pain

Pain that persists for more than 3 to 6 months
Recurring at intervals of months or years

types of scales to assess pain

Visual analog scale
Numeric rating scale
Verbal pain rating scale
Combination of pain scales

types of pain

nociceptive or somatic, neuropathic, psychogenic or idiopathic

nociceptive or somatic pain

pain related to tissue damage

neuropathic pain

pain related to direct injury to peripheral nervous system or central nervous system

psychogenic or idiopathic pain

Psychogenic refers to many factors that influence a patient’s report of pain. Idiopathic is pain without identifiable etiology

pain management

Focus on the Four A’s to monitor patient outcomes:
Analgesia
Activities of daily living
Adverse effects
Aberrant drug-related behaviors

the integumentary system

Provides a barrier
Regulates body temperature
Synthesizes vitamin D
Sensory perception
Provides nonverbal communication
Provides identity
Allows wound repair
Allows excretion of metabolic wastes

layers of the skin

epidermis, dermis, subcutaneous or adipose tissue

epidermis

layer of the skin that is superficial, thin, and has no blood vessels

dermis

layer of the skin that contains blood vessels, connective tissue, sebaceous glands, sweat glands, and hair follicles

subcutaneous or adipose tissue

layer of the skin that connects to underlying structures

pigments of the skin

Melanin
Carotene
Oxyhemoglobin
Deoxyhemoglobin

abnormal colors of the skin

jaundice, cyanosis

jaundice

yellowish color skin
Deposition of bilirubin
Easier to observe in sclera, nails, palms, soles

cyanosis

bluish discoloration of the skin and mucous membranes; a sign that oxygen in the blood is dangerously diminished

hair

two types: vellus and terminal

vellus hair

short, fine, inconspicuous, unpigmented

terminal hair

coarser, thicker, conspicuous, usually pigmented

nails

protect distal ends of fingers and toes
three parts:
- nail plate
- lunula
- cuticle

types of glands

sebaceous and sweat

sebaceous glands

Produce sebum
Lubricates hair and skin
Reduces water loss through the skin

sweat gland types

eccrine and apocrine

eccrine gland

widely distributed, open directly on the surface, help control body temperature

apocrine gland

in axillary and genital areas, stimulated by emotional stress, responsible for adult body odor

health history and integumentary system

Purpose to identify the following:
Diseases of the skin
Systemic diseases that have skin manifestations
Physical abuse
Risk for pressure ulcer formation
Risk for skin cancer
Need for health promotion education regarding the skin

common or concerning systems of skin checks

Rash
Lesions
Non-healing lesions
Bruising (ecchymosis)
Moles
Hair loss
Growths
Nail changes

past history for skin checks

asking patients for any prior experiences with these diseases:
Skin diseases
Diabetes or peripheral vascular disease
Allergies or food sensitivities
Burns or sunburns
Corticosteroid medications
Medication use
Immunization record

family history for skin checks

asking patients if anyone in the family has same or similar symptoms of their skin, any skin diseases, or allergies

lifestyle and personal habits to look out for for skin checks

Bathing and shampooing routines
Change of products
Wear false nails or wigs
Go to a nail salon or gym
Sun exposure
Skin self-examination
Exposure to chemicals or radiation
Diet

physical exam: skin check

Use natural or artificial light that resembles it
Ensure patient is properly draped
Inspect and palpate

look out for:
color
moisture
temperature
texture
mobility or turgor
edema
lesions