1. Exemplars: The Interview, Complete Health History, Mental Status Assessment/Exemplars: Nursing process evidence-based, cultural, substance use, and violence assessments

The Nurse-patient interview: What kind of data do Nurses collect during an interview?

• Subjective data - give an example ______

  VS.

• When do we collect objective data? _______

The Nurse-patient interview: What should we evaluate before we start talking with the patient?

• Assure privacy

• Is the door closed?

• Are any guests in the room?

• Is the patient in a comfortable position?

• What is the nurse’s position and location in the room?

• How do we establish trust through the lens of Relationship-Based Care?

Before going into the room, 4 things to think about before the assessment:

IAPP

• Inspection

• Auscultation

  • Listen through stethoscope (heart sounds, murmur, etc.), bowel sounds

• Palpation

• Percussion

The Nurse-patient interview: Expectations

Set expectations with the patient, describe what your plan is for this encounter

The Nurse-patient interview: Introductions

• introduce yourself

• how would you introduce yourself in your first clinical?

  • student volunteer:___

• what is an open ended question?

  • student example: Tell me about yourself (hobbies, etc.)

• what is a closed (direct) question?

  • student example: Do you smoke?

• should we use open ended or closed lines of questioning?

The Nurse-patient interview: Reflection

• reflect upon your own reaction and responses to patient reply

• what might the patient notice?

  • facilitation, leading cues

  • silence

  • reflection

  • empathy

  • clarification

The Nurse-patient interview: DO-NOTS

• DO NOT provide the following to your patients

  • DO NOT provide false assurance “everything will be okay”

  • DO NOT give unwanted advice

  • DO NOT mis-use your authority i.e. The Nurse knows best

  • DO NOT use so-called avoidance language i.e. The patient passed on to describe death

  • DO NOT employ distancing

    • Example: “The” pressure ulcer versus “your” pressure ulcer

    • Your refers to the patient

  • Appropriately use medical (professional) jargon

    • Know your audience

    • What is clearly understood by a patient in the following example?

      • 1: Andrew’s left lateral aspect of his patella has an impressive amount of ecchymosis and soft tissue localized edema

      • 2: Andrew’s left side of his kneecap has a lot of bruising and swelling

  • DO NOT use biased or leading questions

    • Example: you dont binge drink, do you?

  • DO NOT talk excessively

    • If no one is talking, can they be listening?

  • DO NOT interrupt the patient

  • DO NOT phrase questions using the word “Why”

    • Implication of blame/condemnation

  • DO NOT cross your arms, eyeroll

  • DO NOT make assumptions

The Nurse-patient interview: DO’s

• DO actively listen, pay attention

• DO be non-judgmental

• DO provide empathy

• DO be kind

• DO ask the patient if there is anything else they would like to discuss or request follow-up on

• DO take notes of your data (health history, assessment)

• DO be curious

• If a patient gets worked up and mad, answer with:

  • How can I help? How can i make it better?

Health history: Order of operation

• Biographic data

• Rationale for seeking care

• History of presenting illness (HPI)

• Past history (medical / surgical / social)

• Medication reconciliation

• Family history

• Review of systems

• Function assessment - activities of daily living (ADL’s)

Heath history: Sign

objective abnormality assessed on physical exam or via diagnostic testing or in laboratory reports

Health history: Symptom

subjective report of sensation by a patient

Health history: reason for seeking care

• brief spontaneous statement in individuals own words describing reason for visit

• document reported findings

  • signs

  • symptoms

• reason for care is not a diagnostic statement

• focus on patient’s prioritized reasons for seeking care

Health history: history of presenting illness (HPI)

• review your notes and determine if the following were discussed

  • location

  • quality/character

  • quantity/severity

  • timeline (onset, duration, frequency)

  • setting

  • aggravating/alleviating factors

  • associated factors

  • patient perception

Health history: pain

• the so-called “5th vital sign”

  • evaluated using many assessment scales and scoring

Health history (pain): mnemonic PQRSTU (P)

provocative/palliative - what brings about your pain?

Health history (pain): mnemonic PQRSTU (Q)

quality/quantity - how intense is your pain?

Health history (pain): mnemonic PQRSTU (R)

region/radiation - where is it located? does it spread anywhere? localized?

Health history (pain): mnemonic PQRSTU (S)

severity - how bad is the pain? better, same or worse than ___?

Health history (pain): mnemonic PQRSTU (T)

timing - onset, duration, frequency

Health history (pain): mnemonic PQRSTU (U)

understand patient’s perception - what do you think your pain indicates?

Past health history

• illness of childhood

• accidents

• injuries

• acute and chronic ailments

• hospitalizations

• surgeries

• obstetric history

• immunizations

• allergies

• last examination by healthcare professional

Medication health history

• review all currently prescribed, over the counter (OTC), vitamins/supplements

• review generic and trade names of medications

• consider how medications can impact your nursing assessment of the patient

  • medications: commit to memory a sequence of recall for medications

Medication health history: so-called rights of medication administration

• drug

• dose

• route

• patient

• time

• indication

• contraindication

• adverse effects

• allergies

Review of systems (ROS) health history: purpose

evaluate past and current health of each body system, verify all data captured and no omissions, and evaluate health promotion activities of the patient

• evaluate past and present state of each body system

• assess that all pertinent data relative to each body system have been noted

• evaluate health promotion practices

Review of systems (ROS) health history: cephalocaudal approach

organized manner proceeding in a logical sequence

Review of systems (ROS) health history: items within different systems may not be inclusive

if information obtained in HPI, then it doesn’t have to be re-assessed again

Review of systems (ROS) health history: example of health promotion (eyes)

• vision changes

• double or blurry

• cataracts

• glaucoma

Review of systems (ROS) health history: example of health promotion (eyes)

• wears contact lenses/prescription glasses

• annual vision check

• prior glaucoma test

Review of systems (ROS) health history

• general overall health state

• skin, hair, and nails

Review of systems (ROS) health history: head

• eyes and ears

• nose and sinuses

• mouth and throat

• neck

• breast and axilla

Review of systems (ROS) health history: Focus on body systems looking at specific indicators and focusing on health promotion

• respiratory

• cardiovascular

• peripheral vascular

• gastrointestinal

• urinary

• male/female genital system and sexual health

• musculoskeletal

• neurologic

• hematologic

• endocrine

Functional assessment of health history

• what are activities of daily living (ADL’s)?

• what does this mean?

• does the patient function independently, minimal assistance, moderate to impressive assistance, total care?

Functional assessment of health history: ADLs

self-care activities of daily living as they relate to general health status

Functional assessment of health history: objectively measure functional status

monitor and assess for changes over time

Mental status assessment: evaluate the following:

• consciousness

• language

• mood/affect

• orientation

• attention

• memory

• abstract reasoning

• thought process

• thought content

• perceptions (of the five senses)

Mental status assessment

• appearance

• behavior

• cognition

• thought process

When a full mental status examination is necessary: initial screening

suggests an anxiety disorder or depression

When a full mental status examination is necessary: behavioral changes

memory loss, inappropriate social interaction

When a full mental status examination is necessary: brain lesions

trauma, tumor, cerebrovascular accident, or stroke

When a full mental status examination is necessary: aphasia

impairment of language ability secondary to brain damage

When a full mental status examination is necessary: symptoms of psychiatric mental illness

especially with acute onset

Factors that could affect interpretation of findings (mental assessment): known illnesses or health

such as alcoholism or chronic renal disease

Factors that could affect interpretation of findings (mental assessment): medications

side effects of confusion or depression

Factors that could affect interpretation of findings (mental assessment): educational and behavioral level

note factor as normal baseline

Factors that could affect interpretation of findings (mental assessment): stress responses observed in

social interactions, sleep habits, drug and alcohol use

Supplemental mental status examination: Mini-Mental State Exam (MMSE)

• concentrates only on cognitive functioning

• standard set of 11 questions requires only 5 to 10 minutes to administer

  • useful for both initial and serial measurement

  • detect dementia and delirium and to differentiate these from psychiatric mental illness

  • normal mental status average 27; scores between 24 and 30 indicate no cognitive impairment

Supplemental mental status examination: Montreal Cognitive Assessment (MoCA)

• examines more cognitive domains, more sensitive to mild cognitive impairment

• ten minutes to administer

  • total score of 30 with a score of greater to or equal than 26 considered normal

7 priority setting frameworks of nursing decision making

• maslow’s hierarchy of needs

• nursing process

• airway, breathing, circulation

• safety and risk reduction

• least restrictive/least invasive

• survival potential

• acute versus chronic

• unstable versus stable

• urgent versus nonurgent

Ethical principles in nursing practice: nonmaleficience

do no harm

Ethical principles in nursing practice: beneficience

do good

Ethical principles in nursing practice: autonomy

• respecting a patient and family’s decision making

• what if the patient has altered mental status or is a threat to themselves or the public?

Ethical principles in nursing practice: justice

fair treatment

Ethical principles in nursing practice: confidentiality

• respecting patient rights and privacy

• HIPAA

HIPAA

health insurance portability and accountability act of 1996

Therapeutic communication: verbal and nonverbal communication

• describe effective communication using the principles of relationship-based care (RBC)

• describe ineffective communication scenario

  • opportunity for improvement?

Social determinants of health: healthy people 2020

• goal to eliminate disparities

• using evidence-based research, poverty has greatest influence on health status

• what can we do in the nursing community to help?

Social determinants of health

• health promotion

• risk reduction

• patient teaching and education

• how can we perform the above as a nurse caring for a patient?

  • think social history

    • smoking

    • intake of alcohol

    • illicit drug use

CIWA

Clinical institute withdrawal assessment scale

Types of violence

• physical violence

• sexual violence

• stalking

• psychological aggresion

Types of violence: what questions could we ask the patient in this photo?

• pain? does the bruising hurt?

• how did this happen?

  • who is our audience? are there family members of friends in the environment?

  • does the patient report match the pattern of injury

• when did this happen?

• what makes it better or worse?

• any vision changes?

• double vision, blurry vision?

• any nose bleeds?

• numbness or tingling?

Subjective data

what the person says during history taking

Objective data

what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination

Diagnostic reasoning

process of analyzing health data and drawing conclusions to identify diagnoses

The nursing process

5 steps includes:

1. assessment

2. diagnosis

3. planning

4. implementation

5. evaluation