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42 Cards in this Set
- Front
- Back
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INTERVIEW PROCESS PHASES
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1- introductory phase
2- working phase 3- termination or closing phase |
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INTRODUCTORY PHASE
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phase 1 of the interview process
-introduce youself and allow the client to introduce themself and explain why they are there -ask open ended questions to get specific reason for visit and specific concerns |
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WORKING PHASE
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second phase of the interview process
collect both subjective and objective data |
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SUBJECTIVE DATA
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data that cannot be measured
can only be told by another what they are expereincing or feeling --pain |
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OBJECTIVE DATA
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data that can be measured and proven
BP, vital signs, Is & Os |
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TERMINATION OR CLOSING PHASE
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final phase of the interview process
summarizing the discussion answer any questions they may have acclimate them to the environment assure confidence |
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TYPES OF QUESTIONS
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1- open ended
2- closed ended 3- directive 4- permission giving |
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OPEN ENDED QUESTIONS
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broad questions that can lead to getting a lot of information
encourage free-flowing response -"how are you feeling" vs "how are you feeling today" - "tell me more"; "tell me what happened" |
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CLOSED ENDED QUESTION
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direct, specific questions
require 1-2 word answers -not always bad |
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DIRECTIVE QUESTIONS
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focus on one set of thoughts
focus on a target idea |
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PERMISSION GIVING QUESTIONS
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explaining that you have sensitive questions to ask or by describing the clients in the past
-sexual, financial -will tell you when not comfortable; back off and respect if over stepping - could mean they were abused; back off and try again later if concerned |
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ART OF ASKING QUESTIONS
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-be clearly spoken and heard; low pitch for elderly
- encourage client to be specific; help them describe, use finger to point - ask one question at a time and wait; people are overwhelmed take you time; elderly and cognitively challenged - ask for clarification when confused- what is specifically confusing them that you are asking - be attentive to feelings - answer questions in a manner the client can understand- explain procedures and tests and that good acurate info is needed |
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NONVERBAL COMMUNICATION
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physical appearance
posture gestures facial expressions eye contact voice touch can be cultural or express depression, self-esteem issues and so on if you sense you are invaiding their space back off - explain procedure and need for closeness - need both subjective and objective data to fully understand the patient |
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PATIENT CENTERED CARE
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get down to their level by sitting with them
-instills comfort, gives message that they are important and you have time to talk, egocentric when ill-- |
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ACKWARD MOMENTS
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answering personal questions; must establish trust with the patient; go for a brief and direct answer
silence; gives the patient time to process, useful cultural diversity; be aware that differences may be cultural; respect displays of emotion ; ok to cry and deal with anger directly -ok to let them vent when angry but try to deesculate the situation -do not allow harmful threats -don't inflict your own values or thoughts into it |
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COMPONENTS OF THE HEALTH HISTORY
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1- biographical data- demographics
2- reason for seeking care- CC- chief compaint 3- present health or history of present illness- HPI- acute problems 4- past history- chronic problems- elderly have a lot 5- family history-* go back 2 generations/ parents and grandparents 6- review of systems- systems approach or head to toe assessment 7- functional assessment - ADLs- activities of daily living- holistic what they can do for themself |
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CHIEF COMPLAINT
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CC
the reason for seeking health care record in direct quotes a sign or symptom -subjective; quotes legally cover you; only quote if you know word for word what they said -signs are objective -symptoms are subjective |
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HISTORY OF PRESENT ILLNESS
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HPI
chronological account of the client's chief complaint CC -location- where - quality- description - quantity- severity; how much - chronology- when it started; how long its been present - setting- the place it started; does it change in different environments - associated manifestations- additional problems it causes -alleviating and aggravating factors- does anything make it better or worse |
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PRESENT HEALTH STATUS
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patient's current health promotion activities
their preceived level of health their current medications and use of herb/vitamins/OTCs - ask more questions- do they smoke - client's perception is important mind/body work together; educate them - contrain meds, blood thinners- vitamin K; non traditional |
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PAST MEDICAL HISTORY
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-allergies; food, drugs; environmental-latex
- childhood illnesses - surgeries - hospitalizations - blood transfusions - accidents- old injuries, bumps, scars - chronic illnesses - immunizations - commuicable diseases- TB, do they travel - last exams - obstetric history- sex history |
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FAMILY HISTORY
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-records history of blood relatives, spouses, children
- identifies any genetic, familial, or environmental illnesses - traces back 2 generations -genetics -toxin exposures |
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REVIEW OF SYSTEMS
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ROS
done to inquire aout past and present health of each body system done to ensure no significant data was overlooked follows a head to toe assessment includes symptoms and diseases related to them requires interpretation for client but is documented in medial terms - review of systems of the body |
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SOCIAL HISTORY/ FUNCTIONAL ASSESSMENT
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explores lifestyle that can affect health- exercise, habits, nutrition, sleep
habits- alcohol use, smoking, drug use their position within their family unit their work and home environment their education and economic status if they trave or will be -determines their safety at home; resources available or that may be needed -team members who can help; family or friends if they are literate; able to understand materials and how they will need to be educated allows for feedback and questions of the home life if they have no money so they dont take their meds correctly |
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2 COMMON ASSESSMENT METHODS
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1- systems approach
2- head to toe approach -should go for a method that uses both |
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POSITIONS FOR EXAMINATION
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1- supine- lying down on back
2- sims- lying on side 3- prone- lying on belly |
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TECHNIQUES FOR EXAMINATION
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1- inspection
2- palpation 3- percussion 4- ausculation |
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INSPECTION
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1 technique for examination
observations developing "new eyes" smelling; hearing; seeing the patient as whole |
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PALPATION
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using touch to detect variations in normal and investigate any abnormalities
-feeling with the fingertips - looking for symmetry - looking for abnormal findings |
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USING THE SENSE OF TOUCH FOR PALPATION
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use fingertips- fine, tactile discrimination
dorsa- back - of the hand- use to detect temperature - base of the fingers/ulnar surface of the hands- use to sense vibrations -use warm hands and have short nails for sanitation and to avoid scratching |
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PERCUSSION
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to determine tissue/sound density and the presence of air, fluids, or solids within the body
listen for intensity, pitch, duration and quality listen for tones |
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TONES
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resonance- clear/hallow sounding- lung
flatness- dead stop/ heard over a bone dullness- muffled thud/ liver- heard over an organ tympany- musical/drumlike drum like sounds- abdomen area hyperresonanace- increased hallow sounds; COPD- air trapped within the lung- abnormal |
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ASSCULATION
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the use of the stethoscope to amplify sounds
bell/diaphragm 12-18in long tubing warm chestpiece before using keep instrument clean !! |
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DIAPHRAGM
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used for high pitched sounds
large chest piece |
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BELL
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used for soft, low-pitched sounds
heart murmurs; extra heart sounds -cardio typically smaller side of chest piece |
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EARPIECES
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should be pointed in torward your nose
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CRITERIA OF A PHYSICAL EXAMINATION
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-vital signs
- general survey - head to toe assessment of major body systems using the 4 techniques of assessment--inspection, palpation, percussion, ausculation |
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GENERAL SURVEY COMPONENTS
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their physical appearance
their body structure their mobility their behavior |
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VITAL SIGNS COMPONENTS
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temperature
pulse respiration blood pressure |
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MAKEUP OF ONE'S PHYSICAL APPEARANCE
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their age- appears to be __
their age group= child, teen, yound adult, middle aged, elderly gender level of consciousness race- caucasian, blk , hispanic, asian facial features- symmetric with movement signs of acute distress |
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MOBILITY
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are they walking with a gait
what is their range of motion ROM |
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COMPONENTS OF ONE'S BODY STRUCTURE
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their build- small, average, large
their stature- height/weight - stout, stocky, robst, rotund, statuesque do they look well nourished is their body symmetric how is their posture and body positioning do they have any obvious deformities |
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COMPONENTS OF ONE'S BEHAVIOR
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their facial expressions
their mood and affect their speech how are they dressed are they maintaining good personal hygiene |
