communication and health history (nur 230)

all nursing practice is dependent on an effective

nurse-patient relationship, complex ongoing, subjective understandings, perceptions and other variables

therapeutic communication includes

caring and empathy

what to look for nonverbal communication (general survey)

physical appearance; (facial expression), posture; positioning in relation to patient, gestures; eye contact, voice tone; use of touch, behavior

communicate with the patient at

eye level

touch nonverbal communication skills

essential, dominant component of physical exam, respect patients cultural norms

verbal communication skills

effective interviewing skills, patients with limited English, simple clear language at a normal volume

use active listening

ability to focus on patients, talking about difficult feelings helps patients heal, redirect the interview if a patient’s anger cannot be diffused

other techniques of communication

restatement, reflection, elaboration (facilitation), silence, focusing (redirecting), clarification

restatement

relates to the content of communication

reflection

summarizing main themes of communication

elaboration (facilitation)

assists patients to more completely describe difficulties

silence

purposefully allows patients time to gather thoughts and provide accurate answers

focusing (redirecting)

patients to pertinent topic being discussed

clarification

questions to ascertain patients me’s meaning when word choice or ideas are unclear

summarizing

reviewing and condesning important information into two or three most important findings

nontheraputic responses (traps)

false reassurance, sympathy, unwanted advice, biased questions, changes of subject, distractions, technical or overwhelming language, interrupting

nonprofessional involvement

establish social, personal, or economic patient ties, social media sites, sexual boundary violation (never acceptable)

cultural differences may relate to

group or ethnicity; region, age; degree of accuturation into western society, combination of factors

communication etiquette

limited english skills, working with an interpreter, gender and sexual orientation bias

phases of the interview process

preinteraction phase, beginning phase, working phase, closing phase

preinteraction phase

compiling existing data; preparing for patient interview from existing medical records

beginning phase

introduction; state purpose for interview; ensure privacy

working phase

close ended or direct questions: specific information

open ended questions: broad answers in patients own words avoid why questions

closing phase

summarizing, stating most important two to three problems or patterns, report any info thats required by law

health history sources

primary and secondary date sources, reliability

primary data source

individual to patient

secondary data source

charts and infromation from family members, all other sources of information

reliability of the source

reliable history vs inaccurate historian

types of health history

emergency, focused, comprehensive

emergency health history

gather information about the immediate problem. ( chest pain, extreme shortness of breath, ED)

focused health history

gather information about current situation (admitted for knee pain)

comprehensive health history

gather all medical info about the patient (new admission, back from the OR)

OLDCARTS

Onset
Location

Duration
Character
Aggravating factors
Relieving/Radiating Factors
Timing
Severity

Onset

abrupt or gradual

location

body part

duration

length persisted

character

burning, aching, sharp, dull, throbbing

aggravating factors

what worsens symptoms

releiving/ radiating factors

what improves the synptoms, does the symptom travel

timing

constant, intermittent

severity

0 to 10

past medical history (PMH)

childhood illness, past illness, surgeries, injuries and trauma, obstetric history, health screening, genetics, current medications, allergies, family history, genogram

functional health assessment

gordon’s functional health patterns, activites of daily living (ADLs), growth and development

review of systems (ROS)

general health state, nutrition, hydration, skin, hair, nails, head and neck, eyes, ears, nose, mouth, throat, thorax, lungs, heart neck vessels, preipheral vascular, breasts, abdominal - gastrointestinal, abdominal - urinary, muscuolskeletal, neurological, genitalia of males assigned at birth, gentillia of females assigned at birth, anus and rectum

psychosocial and lifestyle factors

social, cultural, spiritual assessment, mental health assessment, neglect, abuse and violence assessment, sexual history (establish baseline, identify need for education)

mental health asessment

mental health history, medications in use, alcohol/illegal drug use

life span consideration infants and children

parents, legal guardians, other adult representatives, validate roles of people bringing children

life span consideration adolescents

begin to participate in interview, vital info to collect pregnancy, birth, perinatal history, immunizations, growth and development

life span consideration older adults

possible sensory deficits, more complex health histories

challenging situations

hearing impairment, low level of consciousness, cognitive impairment, mental illness, anxitey, crying, anger, use of alcohol and drugs (mind altering substances), personal questions and boundaries, sexual agression