Communication and health history

nursing practice is dependent on

an effective nurse–patient relationship

General Survey components

Physical appearance

Posture

Gesture

Voice tone

Behavior

essential, dominant component of physical exam

touch

what should be done if a patients anger cannot be diffused

redirect

Comm techs

Restatement

Reflection

Elaboration

Silence

Focusing

Clarification

Summarizing

Restatement

Repeat message in own words to confirm understanding

Reflection

Summarizing main themes of communication

Elaboration

Assists patients to more completely describe difficulties

Silence

Purposefully allow patients time to gather thoughts, provide accurate answers

Focusing

Redirecting patients to pertinent topic being discussed

Clarification

Questions to ascertain patient’s meaning when they are unclear

Summarizing

Reviewing and condensing important information into two or three most important findings

Nontherapeutic responses

False reassurance

Sympathy

Unwanted advice

Biased questions

Changes of subject

Distractions

Technical or overwhelming language

Interrupting

Nonprofessional involvement

Establishment of social, personal, or economic patient ties

Sexual boundary violation

Never acceptable within the therapeutic nurse–patient relationship

Phases of interview process

Preinteraction

Beginning

Working

Closing

Preinteraction

compiling existing data

Beginning

Introduction; state purpose for interview; ensure privacy

Working

Closed or open ended questions

Closing

summarizing

stating most important two to three problems or patterns

report anything required by law

Closed-ended or direct questions

specific information

Open-ended questions

broad answers in patient’s own words; avoid “why” questions

Primary data sources

Individual patient

Secondary data sources

Charts and information from family members

All other sources of information

Reliability of source

dependent on “historian”

Emergency interview

Gather information about immediate problem

(chest pain, extreme shortness of breath, ED)

Focused interview

Gather information about current situation

Comprehensive interview

Gather all medical information about patient

(new admission, back from the OR)

OLDCARTS

Onset

Location

Duration

Character

Aggravating factors

Relieving/Radiating factors

Timing

Severity

In old carts what is character?

characteristics of symptoms

(burning, aching, sharp, dull, throbbing)

In OLDCARTS what are aggravating factors

(what worsens symptom)

In old carts what is relieving/radiating

what improves symptom; does the symptom travel

in OLDCARTS how should severity be measured

0 to 10

Past medical health history

Child Protective Services is over here gary come aid fast
Childhood illnesses

Past illnesses

Surgeries

Injuries and trauma

Obstetric history

Health screening

Genetics

Current medications

Allergies

Family history

Functional health assessment uses:

Gordon’s functional health patterns (See Table 2.2)

Activities of Daily Living (ADLs)

Gordon's Functional Health Patterns

Harry never eats apples, sally cooks shellfish, ralph slurps cold vegetables

• Health perception–health management

• Nutritional–metabolic

• Elimination

• Activity–exercise

• Sleep–rest

• Cognitive–perceptual

• Self-perception–self-concept

• Role–relationship

• Sexuality–reproductive

• Coping–stress tolerance

• Value–belief

ADLs

• Bathing

• Dressing

• Toileting

• Transferring (e.g., bed → chair)

• Continence

• Eating/feeding

Psychosocial and Lifestyle Factors

Social, cultural, spiritual

Mental health

Neglect, abuse, and violence

Sexual history

Mental health assessment

o Mental health history

o Medications in use

o Alcohol/illegal drug use

Sexual history assessment

Establish baseline

Identify need for education

Components of health history

History of past illness(OLDCARTS)

Functional health assessment

Review of systems

Psychosocial and lifestyle factors

Lifespan considerations: infants

Parents, legal guardians, other adult representatives

Validate roles of people bringing children

Lifespan considerations: Adolescents

Begin to participate in interview

Lifespan considerations: Older adults

Possible sensory deficits

More complex health histories