Topic 2 Key Terms

Health Hx, Functional Assessment, Culture, and Communications

race

a socially constructed way of grouping people based on perceived physical appearance (skin color, facial features, hair texture)

ethnicity

the extent to which one identifies with a particular ethnic group. a component of self-concept that focuses on being part of a cultural group

religion

refers to a codified way of organizing rituals and beliefs to create meaning. structures and differentiated, includes rituals, practices, and organized belief systems

spirituality

larger, less differentiated. can include beliefs from many religions and philosophies

cultural assessment

integral part of forming a complete database of information about each patient. used to identify beliefs, values, and health practices that may help of hinder nursing interventions.

steps to cultural competency

it's a lifelong developmental process. Think of it as being on a continuum where you continuously develop skills to provide care that understands, appreciates, and respects cultural differences.

spirituality assessment

A spirituality assessment helps you identify patients' spiritual beliefs, values, and practices that influence their health and well-being. It's essential for understanding the personal resources patients bring to their healthcare situation.

verbal communication

consists of all speech and represents the most obvious aspect of communication. involves words you choose to convey a message.

non-verbal communication

includes all the ways you communicate without words

introduction phase

first stage of nurse-patient therapeutic relationship where you establish initial contact and begin building trust

working phase

second phase of nurse-patient therapeutic relationship where you ask the patient actively address the tasks and goals outlined during orientation phase

closing phase

last phase of nurse-patient interaction. includes activities that enable you and the patient to end the therapeutic relationship.

open-ended questions

questions that are open to interpretation and cannot be answered by "yes," "no," or a one-word response. They allow patients to express their problems or health needs in their own words.

closed-ended questions

questions that elicit a "yes," "no," or one-word response such as a number or frequency. They seek specific, limited information and require short answers.

reflection

a therapeutic communication technique where the nurse serves as a mirror for the patient, demonstrating understanding and acceptance.

clarification

the act or process of making something clear, understandable, or less confusing by explaining it in more detail or correcting misunderstandings.

false reassurance

a non-therapeutic communication technique where you offer hope or comfort with statements that are non supported by facts

advice

non-therapeutic communication technique where the nurse tells the patient what they should do based on the nurse’s own perspective rather than helping the patient

professional jargon

technical terminology used by health care providers that can sound like a foreign language to patients unfamiliar with the health care setting

using authority

the power, influence, or credibility of recognized position, role, or expert guide decisions, enforce rules, persuade others, or justify actions.

“why” questions

can be a non-therapeutic communication technique that may cause problems during patient interactions, though they have their place in assessment.

silence

therapeutic communication technique where the nurse allows periods of quiet thought during an interaction without feeling pressure to fill the silence with conversation or activity.

ten traps of interviewing

1. leading questions

2. closed questions

3. multiple questions at once

4. using jargon or complex language

5. interrupting

6. using authority

7. judging or criticizing

8. failing to listen actively

9. poor timing or pacing

10. stereotyping or making assumptions

source of the history

refers to who provides the health history information during the patient interview. This is documented at the beginning of the health history to establish the reliability and origin of the data collected.

reason for seeking care

also called chief concern or chief complaint is a brief, spontaneous statement in the person's own words that describes why they are seeking healthcare.

health or history of present illness

detailed, chronological account of the patient's current health concern, including:

• Location, quality, quantity, timing, setting

• Aggravating and alleviating factors

• Associated symptoms

• Patient's perception of what's happening

past health events

provides a holistic view of a patient's health care experiences and current health habits. This section captures significant health information from the patient's past that may influence their current health status.

family history

a written or graphic record of health problems present in a patient's family that helps identify genetic risks and guide preventive care.

review of systems

systematic collection of subjective information from patients about the presence or absence of health-related issues in each body system.

functional assessment

the systematic evaluation of a patient's ability to perform activities necessary for daily living and self-care.

health history components

1. physical and developmental

2. intellectual

3. emotional

4. social

5. spiritual

functional ability

refers to one's ability to perform activities of daily living (ADLs), including bathing and toileting, and independent living skills such as shopping and housework.

activities of daily living (ADL's)

ADLs are the essential tasks that each individual needs to perform, on a regular basis, to sustain basic survival and well-being.

1. Toileting

2. Feeding/Eating

3. Dressing

4. Grooming

5. Bathing

6. Ambulation

instrumental activities of daily living (IADL’s)

IADLs are activities that support daily life and are oriented toward interacting with the environment. They are typically more complex than ADLs and are essential for independent living in the community.

1. Use of telephone

2. Shopping

3. Meal preparation

4. Housekeeping

5. Laundry

6. Transportation

7. Self-medication (managing medications)

8. Management of finances (paying bills, writing checks)

advanced activities of daily living (AADL’s)

complex activities that reflect a person’s ability to participate fully in society, beyond basic self-care. AADLs often involve social, occupational, recreational, and community roles and require higher-level physical, cognitive, and emotional functioning.

1. Working or volunteering

2. Managing a career or education

3. Participating in hobbies or sports

4. Socializing and maintaining relationships

5. Community involvement (e.g., clubs, religious activities)

timed up and go test (TUG)

The TUG Test is a reliable and valid clinical assessment used to quantify functional mobility and identify fall risk in older adults.

• Patient starts seated in a chair

• Patient wears usual footwear

• Patient uses any assistive device typically used (cane, walker, etc.)

Procedure:

1. Patient rises from the chair

2. Walks 10 feet

3. Turns around

4. Walks back to the chair

5. Sits back down

What to observe

• Sitting balance

• Transferring from sitting to standing (Does the patient need to push off the armrest?)

• Pace and stability of gait

• Ability to turn without staggering

• Sitting back down in the chair