Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
89 Cards in this Set
- Front
- Back
|
Goals of Interview
|
-Record complete health history
- Optimal health for patient - Identify strengths and problems as a bridge to physical exam - 1st and most important part of data collection - Collects subjective data - Individual knows everything about his own health state, and nurse knows nothing - collect objective data |
|
|
Subjective Data
|
- What the patient says about himself during history taking
|
|
|
Communication
|
- Exchanging info so that each person clearly understands the other
- Key to taking heath history - Many more pieces than just talking |
|
|
Internal Factors
|
- Liking others
- Empathy - Ability to listen |
|
|
External Factors
|
- Privacy
- No interruptions - Physical environment *comfortable for patient * Voice and noise control * Space (personal) |
|
|
Goals of Interview
|
-Record complete health history
- Optimal health for patient - Identify strengths and problems as a bridge to physical exam - 1st and most important part of data collection - Collects subjective data - Individual knows everything about his own health state, and nurse knows nothing - collect objective data |
|
|
Subjective Data
|
- What the patient says about himself during history taking
|
|
|
Communication
|
- Exchanging info so that each person clearly understands the other
- Key to taking heath history - Many more pieces than just talking |
|
|
Internal Factors
|
- Liking others
- Empathy - Ability to listen |
|
|
External Factors
|
- Privacy
- No interruptions - Physical environment *comfortable for patient * Voice and noise control * Space (personal) |
|
|
Interview Char.
|
- Introduction
* touch patients - Use open ended questions. - Do not use too many closed ended questions - Assist the narrative |
|
|
Methods to Assist the Narrative
|
- Facilitation - "Go On"
*Demonstrates Interest - Silence * Useful with bad news - Reflection * Act as a mirror to the patient - Empathy - Clarification - Confrontation - Interpretation - Explanation - Asking Why - Summary |
|
|
Traps In Interviewing
|
- Providing false assurance
- Giving unwanted advice - Using authority - "Doc knows best" - Using avoidance language - Engaging in distancing - Using professional jargon - Using leading questions - Talking too much - Interrupting - "Why" questions |
|
|
Listening with Eyes
|
- Physical appearance
- Posture - Gestures - facial expressions - Eye contact - Voice - Touch |
|
|
Interpreter Points
|
- No family members or friends
- Document that the patient and family understand what is happening to them * (tests, procedures, medication instruction, prognosis) |
|
|
Pieces of Health History
|
- Client Profile
- Biographical data - Reason for seeking care - Health Perception Health Management Pattern - Nutritional-Metabolic Pattern - Elimination Pattern - Activity-Exercise Pattern - Sexuality-Reproduction Pattern - Sleep-Rest Pattern - Sensory-Perceptual Pattern - Cognitive Pattern - Role-Relationship Pattern - Family Genogram 9 (Family Tree) - Self-Perception and Self-Concept Pattern - Coping-stress Tolerance Pattern - Value-Belief Pattern - Summary-Interviewing |
|
|
Client Profile Includes?
|
- Biographical
- Reason for seeking Care - Treatments/Medications - Past Illnesses/Hospitalizations - Allergies (food, drug, env.) - Developmental History as appropriate |
|
|
Biographical Data
|
- Name
- Address - Phone - Age & DOB - Gender - Marital Status - Race - Ethnic Origin - Occupation - Language - Comm. Needs - Source of info if not patient - |
|
|
Reason for Seeking Care
|
- In person's own words
- Sings and Symptoms - P,Q,R,S,T,U |
|
|
P,Q,R,S,T,U
|
- Provocative or palliative
- Quality or Quantity - Region or radiation - Severity ( Pain Scale) - Timing - Understanding patient's perception (What he thinks it is) |
|
|
Health Perception Health Management Pattern
|
- Clients Perception of Health
- Clients perception of illness - Health management and Habits (Cultural) - Compliance |
|
|
Nutritional-Metabolic Pattern
|
- Dietary and Fluid Intake
(24 Hr Dietary Recall) - Condition of Skin - Condition of Hair & Nails - Metabolism |
|
|
Elimination Pattern
|
- Bowel and Bladder Habits
|
|
|
Activity-Exercise Pattern
|
- Activities of Daily Living
- Leisure Activities - Exercise Routine - Occupational Activities |
|
|
Sexuality- Reproduction Pattern
|
- Menstrual History
- Obstetric History *(# of babies, Breast health) - contraception - Perception of Sexual activities - Concerns & Problems - history of Sexual Abuse |
|
|
Sleep Rest Pettern
|
- Sleep Habits
- Special Problems * Apnea, Sleepwalking - Sleep Aids *Prescriptions |
|
|
Sensory-Perceptual Pattern
|
- Perception of Senses
- Pain - Special Aides |
|
|
Cognitive Pattern
|
- Ability to:
Understand Communicate Remember Make Decisions |
|
|
Role-Relationship Pattern
|
- Perception of Major Roles and Responsibility
* Family, Work, and Social - Genogram |
|
|
Self Perception and Self Concept Pattern
|
- Perception of Identity
- Perception of Abilities and Self worth - Body image |
|
|
Coping- Stress Tolerance Pattern
|
- Perception of stress and Problems in Life
- Coping Methods and Support Systems |
|
|
Value-Belief Pattern
|
- Values, Goals, and Philosophical Beliefs
- Religious and Spiritual Beliefs |
|
|
Summary Interviewing
|
- Active Listening
- Guided questioning - Nonverbal communication - Empathetic response - Validation - Reassurance - Summarization - Transitions - Empowering the Patient |
|
|
Assessment
|
- The collection of data about an individuals health state
|
|
|
Biomedical Model
|
- The Western European/North American tradition that views health as the absence of disease
|
|
|
Complete database
|
- A complete health history and full physical exam
|
|
|
Critical Thinking
|
- simultaneously problem-solving while self-improving one's own thinking ability
|
|
|
Diagnostic Reasoning
|
- A method of collecting and analyzing clinical information with the following components
1. attending to initially available cues. 2. formulating diagnostic hypotheses 3. Gathering data relative to the tentative hypotheses 4. evaluating each hypothesis with the new data collected 5. arriving at a final diagnosis |
|
|
emergency database
|
- Rapid collection of the database, often compiled concurrently with lifesaving measures
|
|
|
Environment
|
The total of all the conditions and elements that make up the surroundings and influence the development of a person
|
|
|
Evidence-Based Practice
|
- a systematic approach to emphasizing the best research evidence, the clinician's experience, patient preferences and values, physical examination, and assessment
|
|
|
Focused database
|
- one used for a limited or short-term problem; concerns mainly one problem, one cue complex, or one body system
|
|
|
Follow-up Database
|
- used in all settings to monitor progress on short-term or chronic problems
|
|
|
Holistic Health
|
- the view that the mind, body, and spirit are interdependent and function as a whole within the environment
|
|
|
Medical Diagnosis
|
- used to evaluate the cause and etiology of disease; focus is on the function or malfunction of a specific organ system
|
|
|
Nursing Diagnosis
|
- used to evaluate the response of the whole person to actual or potential health problems
|
|
|
Nursing process
|
- A method of collecting and analyzing clinical information with the following:
1. Assessing 2. diagnosis 3. outcome identification 4. planning 5. implementation 6. evaluation |
|
|
Objective Data
|
- What the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination
|
|
|
Prevention
|
any action directed toward promoting health and preventing the occurrence of disease
|
|
|
Wellness
|
- A dynamic process and view of health; a move toward optimal functioning
|
|
|
Cultural and Linguistic competence
|
- a set of congruent behaviors, attitudes, and policies that come together in a system among professionals that enables work in cross-cultural situations
|
|
|
Cultural Care nursing
|
- professional healthcare that is culturally sensitive, appropriate and competent
|
|
|
Culture
|
- the nonphysical attribute of a person;
thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups |
|
|
Culture bound syndrome
|
- a condition that is culturally defined
|
|
|
Ethnicity
|
- a social group within the social system that claims to possess variable traits such as a common geographic origin, migratory status, and religion
|
|
|
Ethnocentrism
|
- the tendency to view your own way of life as the most desirable, acceptable, or best and to act superior to another culture's lifeways
|
|
|
Folk Healer
|
- Lay healer in the person's culture apart from the biomedical/scientific healthcare system
|
|
|
Health/Illness
|
- the balance/imbalance of the person, both within one's being
(physical, mental and spiritual) and in the outside world (natural, communal, and metaphysical) |
|
|
Heritage consistency
|
- the degree towhich a person's life style reflects his traditional heritage whether it is American Indian, European, Asian, African, or Hispanic
|
|
|
Socialization
|
- the process of being raised within a culture and acquiring the characteristics of that group
|
|
|
Title IV of the Civil Rights Act of 1964
|
- a federal law that mandates that when people with minimal English proficiency seek healthcare services can not be denied
|
|
|
Values
|
- a desirable or undesirable state of affairs and a universal feature of all cultures
|
|
|
Ad hoc Interpreter
|
- using a patients family member, friend or child as interpreter for a limited English proficiency patient
|
|
|
Avoidance Language
|
- using euphemisms to avoid reality or hide feelings
|
|
|
clarification
|
-examiner's response used when the patient's word choice is ambiguous or confusing
|
|
|
Confrontation
|
- response in which examiner gives honest feedback about what he has seen or felt after observing a certain patient action, feeling, or statement
|
|
|
Distancing
|
- the use of impersonal speech to put space between the self and a threat
|
|
|
Elderspeak
|
- infantilizing and demanding language used by health care professional when speaking to an older adult
|
|
|
Electronic health recording
|
- Direct computer entry of the patient health record while in the patients presence
|
|
|
Explanation
|
- examiners statements that inform the patient; examiner shares factual and objective information
|
|
|
Facilitation
|
- examiners response that encourages the patient to say more, to continue with the story
|
|
|
Geographic Privacy
|
- private room or space with only examiner and patient present
|
|
|
Interpretation
|
- examiners statement that is not based on examiner's inference or conclusion; it links events, makes associations, or implies cause
|
|
|
Telegraphic Speech
|
- speech used by age 3 or 4 in which three or four word sentences contain only essential words
|
|
|
Abstract Reasoning
|
- pondering meaning beyond the concrete and literal
|
|
|
Attention
|
- concentration, ability to focus on one specific thing
|
|
|
Consciousness
|
- Being aware of ones own existence, feelings and thoughts being aware of the environment
|
|
|
Delirium
|
- an acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness, and usually resolves when the underlying cause is treated
|
|
|
Mental Disorder
|
- Significant behavioral or psychological pattern that is associated with distress or disability and has a significant risk of of pain, disability, or death or a loss of freedom
|
|
|
Organic Disorder
|
- brain disease of known organic cause (delirium, dementia, alcohol and drug intoxication and withdrawal)
|
|
|
Psychiatric Mental Illness
|
- a mental disorder in which an organic etiology is not yet been established
|
|
|
Recent Memory
|
-evokes day to day events
|
|
|
Remote Memory
|
- brings up a years worth of memories
|
|
|
Moderate Drinking
|
- Men 2 drinks/day
- Women 1 drink/ day - >65yrs 1 drink/day |
|
|
Organic Disorder
|
- brain disease of known organic cause (delirium, dementia, alcohol and drug intoxication and withdrawal)
|
|
|
Psychiatric Mental Illness
|
- a mental disorder in which an organic etiology is not yet been established
|
|
|
Recent Memory
|
-evokes day to day events
|
|
|
Remote Memory
|
- brings up a years worth of memories
|
|
|
Moderate Drinking
|
- Men 2 drinks/day
- Women 1 drink/ day - >65yrs 1 drink/day |
