Intro to Health Assessment/Communication

communication

the active process of using words, sound, signs, or behaviors to exchange information

-documentation

-handoff communication

what are some examples of interprofessional communication?

-therapeutic communication

-interviewing

-caregiving

what are some examples of intraprofessional communication?

1. introduction

2. discussion

3. summary

what are the 3 phases of an interview?

establishing rapport to gain the client's trust

what is the single most important factor for successful interviewing?

-ask questions clearly

-avoid medical jargon

-encourage client to be specific

-ask one question at a time

-be attentive to patient feelings

outline the 'art of asking questions'

open-ended questions

type of question that encourages free flow; elicits responses of more than one or two words; start with these types of questions during interviewing

close-ended questions

type of question that yields more precise data; yes/no questions

directive

type of question that leads client to focus on one set of thoughts; a lot of specific questions

-using medical terminology

-expressing judgements

-interrupting

-being authoritarian

-using "why" questions"

what are some techniques that diminish data collection?

health history

the process of collecting and documenting subjective data about the client through an interview process

-comprehensive

-problem based or focused

-episodic or follow up (shift)

what are the types of health histories?

comprehensive health history

type of health history in which you ask all components of the interview; usually done on new patients

problem based or focused health history

type of health history in which you focus on a specific issue; typically done in emergency situations

episodic or follow up (shift) health history

type of health history in which you are trying to obtain updates on any changes in the patient

-biographic data

-reason for seeking care

-history of present illness

-present health status

-past health history

-family history

-personal and psychosocial history

-review of systems

what are the essential portions of a health history?

OLDCARTS

what is included in history of preset illness (HPI)/symptom analysis?

-o: onset

-l: location

-d: duration

-c: characteristics

-a: aggravating and alleviating factors

-r: related symptoms

-t: treatment

-s: severity

what does each letter stand for in OLDCARTS?

-subjective information

-symptoms

what does the nurse interview the patient to obtain?

document/documentation

serves as a baseline for all healthcare professionals; considered a legal record and permanent document

-comprehensive

-problem based/focused

-episodic/follow-up

-shift

-screening

what are the types of health assessments?

-inspection

-palpation (superficial and deep)

-percussion (direct and indirect)

-auscultation

what are the 4 basic assessment techniques?

general survey

what is the first thing that a nurse should look at/review during a health assessment?

-physical appearance and hygiene

-body structure/posture

-body movement

-emotional, mental, and behavioral

what types of things are included in the general survey?

signs

objective data observed, felt, heard, or measured; examples include rash, enlarged lymph nodes, and swelling of an extremity

symptoms

subjective data perceived and reported by the patients; examples include pain, itching, and nausea

-noticing

-interpreting

-responding

-reflecting

what are the 4 components of clinical judgement?

-active listening

-facilitation

-clarification

-reflection

-confrontation

-interpretation

-summarization

what are some techniques that enhance the health history interview?

-name/preferred name

-gender

-address, telephone number, and email address

-birth date

-race/ethnicity

-religion

-marital status

-occupation

what are some examples of biographic data?

inspection

refers to data obtained by a visual examination of the body, including body movement and posture, as well as that obtained by smell

palpation

involves using the hands to feel texture, size, shape, consistency, pulsation, and location of certain parts of the patient's body

percussion

performed to evaluate the size, borders, and consistency of internal organs; detect tenderness; determine the extent of fluid in a body cavity

auscultation

involves listening to sounds within the body.