Health assessment exam 1: the interview and steps of assessment

process of communication: setting

Communication is behavior, conscious and unconscious, verbal and nonverbal

All behavior has meaning

Body language: posture, gestures, facial expression, eye contact, foot tapping, touch, where you place your chair

process of communication: receiving

Awareness of messages you send is only part of process

Words and gestures must be interpreted in a specific context to have meaning

Receiver attaches meaning determined by his or her past experiences, culture, self-concept, and current physical and emotional state

Successful communication requires mutual understanding by sender and receiver

Patients' health problems intensify communication because patients depend on you to get better

Communication can be learned and polished

process of communication: internal factors

Specific to the examiner

Four internal factors:

1. Liking others

2. Empathy

3. Ability to listen

4. Self-awareness

process of communication: external factors

Ensure privacy

Refuse interruptions

Physical environment

Dress

Note-taking may be unavoidable- cannot relay completely on memory for details of previous illnesses or review of body systems

Electronic health record (EHR)

3 phases of the interview

intro, working, closing

open-ended questions

Ask for narrative responses, state topic only in general terms, use them in the following situations: to begin interview, to introduce a new section of questions, whenever the patient introduces a new topic

closed or direct questions

Ask for specific information, elicit short one- or two- word answers, a yes or no answer, or a forced choice, use them in the following situations: after opening narrative to fill in details person may have left out, when you need many specific facts about past health problems or during review of systems, to move the interview along

Facilitation

encourages the patient to say more

silence

gives patient time to think and organize what to say without interruption from you; gives you a chance to observe person unobtrusively and note nonverbal cues

reflection

echoes patient's words, repeating what person has just said, focuses further attention on a specific phrase, and helps person continue in his or her own way

empathy

recognizes a feeling and puts it into words; names the feeling and allows expression of it; patient feels accepted and can deal with feeling openly

clarification

use when person's words are ambiguous or confusing; used to summarize person's words and to simplify them to make them clearer; you are asking for agreement, and the person can then confirm or deny your understanding

confrontation

frame of reference shifts from patient's perspective to yours; may focus on discrepancy or inconsistency in person's narrative; you have observed a certain action, feeling, or statement and now focus person's attention on it; you give honest feedback about what you see or feel

interpretation

based on your inference or conclusion; links events, makes associations, implies cause, ascribes feelings; helps person understand his or her own feelings in relation to the verbal message

explanation

These statements inform the person; you share factual and objective information, offering reasons for requirements or actions

summary

Final review of what person has said; it condenses facts and presents your view of health problem; Is a type of validation that person can agree with or correct; both you and patient should participate; Occurring at the end of the interview, it signals that termination of the interview is near

10 traps of interviewing

Providing false assurance or reassurance, giving unwanted advice, using authority, using avoidance language, engaging in distancing, using professional jargon, using leading or biased questions, talking too much, interrupting, using "why" questions

elements of the interview process

Nonverbal skills

Physical appearance

Posture

Gestures

Facial expression

Eye contact

Voice

Touch

Closing the interview

nonverbal behaviors

Vocal cues

Action cues

Object cues

Personal space

Touch

tools for determining health literacy

Test of functional health literacy (TOFHLA), rapid estimate of adult literacy in medicine (REALM), newest vital sign (NVS)

Assessment skills are performed in the order of

Inspection

Palpitation

Percussion

Auscultation

inspection

Begins when you first meet a person with a general survey

As you proceed through examination, start assessment of each body system with inspection

Inspection always comes first

Inspection requires:

Good lighting

Adequate exposure

Occasional use of instruments such as otoscope, ophthalmoscope, penlight, or nasal/vaginal specula

palpation

Applies sense of touch to assess the following:

Texture, temperature and moisture, organ location and size, swelling, vibration, pulsation, crepitation, rigidity or spasticity, presence of lumps, masses, tenderness or pain

Should be performed slow and systematic

Start with light and proceed to deep

Bimanual palpation is used for certain body parts or organs

fingertips best used for

fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps

fingers and thumb best used for

detection of position, shape, and consistency of an organ or mass

dorsa (back) of hands and fingers best used for

determining temperature because skin here is thinner than on palms

base of fingers or ulnar surface of hand best used for

vibration

Percussion

Tapping person's skin with short, sharp strokes to assess underlying structures to do the following:

Map location and size of organs

Detect a superficial abnormal mass

Percussion vibrations penetrate about 5 cm deep.

Deeper mass would give no change in percussion

Eliciting pain if underlying structure is inflamed

Eliciting deep tendon reflex using percussion hammer

Auscultation

listening to sounds produced by the body

Setting

Exam room should be warm, comfortable, quiet, and well lit

Avoid distractions and/or interruptions

Lighting- natural and/or tangential

Positioning of exam table allows easy access, ability to raise head to 45 degrees

Bedside table or countertop of equipment

Roll up stool for when a seated position is needed during the exam