Communication & Health History

what is involved in therapeutic communication?

caring & empathy

• communicate feelings without criticism or judgement

what is a general survey?

quick, overall visual and auditory inspection of a patient's health status

what are important components of the general survey?

• physical apperance / facial expressions

• posture

• gestures

• eye contact

• voice tone; use of touch

• behavior

what is important to remember about touch when performing nonverbal communication?

respect the patients cultural norms

how should the nurse communicate with patients with limited English?

simple, clear language at normal volume, use simple medical terms

what is active listening

the ability to give the speaker your full attention, give them space to talk about difficult feelings in a non-bias non judgemental way

what should you do when the patient seems unconfortable with a question?

redirect conversation, do not pry

what is the restatement technique of communication

relates to the content of communication

what is the reflection technique of communication

summarize main themes of communication

what is the elaboration/facilitation technique of communication

assist patients to more completely describe difficulties

what is the silence technique of communication

purposefully allow patients time to gather thoughts, provide accurate answers

what is the focusing technique of communication?

redirecting patients to pertinent topic being discussed (seen in older populations)

what is the clarification technique of communication?

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

what is the summarizing technique of communication?

reviewing & condensing important information into two or three most important findings

what are some nontherapeutic responses to avoid?

• false assurance

• sympathy

• unwanted advice

• biased questions

• changes of subject

• distractions

• technical or overwhelming language

• interrupting

why should famiily members not be the interpreter

you don’t know whats actually being said, information can be misconstrued

name the phases of the interview process

1. preinteraction phase

2. beginning phase

3. working phase

4. closing phase

what is the preinteraction phase

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

what is the beginning phase of the interview process?

introduction; state purpose for interview; ensure privacy

what are the two components of the working phase?

1. closed-ended or direct questions

   1. open-ended questions

what are close-ended or direct questions

specific information

what are open-ended questions

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

what is the closing phase of the interview process?

summarizing, stating the most important two to three problems or patterns; report any information that is required by law

what are primary data sources

individual patient

what are secondary data sources

• charts & information from family members

• all other sources of information

what are the three types of health history?

1. emergency

2. focused

3. comprehensive

what is emergency health history

gather information about immediate problem (acute phase, most common in ED)

what is focused health history

gather information about current health situation; not full head to toe

what is comprehensive health history?

gather all medical information about patient; full head to toe

what is a chief complaint

the patient’s main reason for seeking care

what does HPI stand for

History of Present Illness

what mneumonic assesses pain

OLDCARTS

what does the O in OLDCARTS stand for?

onset; abrupt or gradual

• ex: all of the sudden, gradually worse over time

what does the L in OLDCARTS stand for?

location; body part / where on the body

• ex: left right, generalized, superficial, deep

what does the D in OLDCARTS stand for

duration; length persisted

• ex: how long has this been going on? days, weeks

what does the C in OLDCARTS stand for?

character; burning, aching, sharp, dull, throbbing

• can you describe the pain?

what does the A in OLDCARTS stand for?

aggravating factors; what worsens symptoms

• does anything make it worse; movement, etc

what does the R in OLDCARTS stand for?

relieving/radiating factors; what improves symptoms

• have you taken anything over the counter, ex: rest, ice packs

what does the T in OLDCARTS stand for?

timing; constant, intermittent

• ex: all the time, just at night, after exercise, waking up, etc.

what does the S in OLDCARTS stand for?

severity; 0-10 scale

• how would you rate your pain on a scale from 0 to 10, 10 being that you’re gonna blow

what does PMH stand for?

past medical health history

what are some examples of PMH

• childhood illness

• past illnesses

• surgeries

• injuries & trauma

• obstetric history

• health screening

• genetics

• current medications

• allergies

• family history

  • genogram

what does ADLs stand for?

activities of daily living

what question should be asked about ADLs

are you able to perform your ADLs by yourself or do you need assistance with them?

list some examples of ADLs

• eating

• showering

• moving

• dressing

• continence (bladder)

list the Review of Systems (ROS)

• General health state

• Nutrition, hydration (eating enough? Enough calories? Caffiene intake? Hydration status)

• Skin, hair, & nails

• Head & neck

• Eyes

• Ears

• Nose, mouth, & throat

• Thorax, lungs

• Heart, neck vessels

• Peripheral vascular

• Breasts

• Abdominal-gastrointestinal (GI)

• Abdominal-urinary (GU)

• Musculoskeletal

• Neurological

• Genitalia of males assigned at birth

• Genitalia of females assigned at birth

• Anus & rectum

what should you assess for psychosocial & lifestyle factors

• social, cultural, & spiritual assessment

• mental health assessment

• neglect, abuse, & violence assessment

• alcohol/illegal drug use

• sexual history

what are some questions you can ask for assessment for psychosocial & lifestyle factors?

• do you feel supported at home?

• do you attend church

• do you feel safe at home? is there any violence at home or in your neighborhood

• do you drink or smoke

• 
  

what is included in the mental health assessment?

• mental health history

• medications in use

  • alcohol/illegal drug use

what should you say when a patient feels like they’ll get in trouble for the alcohol/illegal subatances they may take

“i’m not here to get you in trouble, its important to know what you take because some thinks may interact negatively with potential medications we give you

what are some considerations for infants & children

parents / legal guardians are present, they are the ones giving majority of the information

• validate the role of people bringing children, include all parties in the conversation

what is some vital information to collect for adolescents?

• pregnancy, birth, perinatal history

• immunizations

• growth & development

what are some considerations for older adults

• possible sensory deficits (ex: if they have hearing issues you may want to speak up or move closer, ex: if they have vision issues then print a paper with bigger font to acommodate and adapt like mahoraga)

• more complex health histories

list some challenging situations

• Hearing impairment

• Low level of consciousness

• Cognitive impairment

• Mental illness

• Anxiety

• Crying

• Anger

• Usse of alcohol, drugs, & mind-altering substances

• Personal questions & boundaries

• Sexual aggression

what should you do in a challenging situation if it becomes too hostile

de-escalate and move on from the question