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30 Cards in this Set

  • Front
  • Back

Concept of Health

Defined by 2 models

1. Biomedical/Medical: focus is diagnosis, treatment of disease

2. Holistic Models (nursing): Expanded focus, views the body, mind, spirit as interdependent and functioning as a whole, individuals considered active participants in their health (make decisions with but not for patient), Assessment factors (expanded to include culture and values, family, social roles, self-care behaviors, environmental stress, developmental tasks)

Health Promotion/Disease prevention

Forms the core of nursing practice:

Primary, Secondary, Tertiary

Primary prevention

Promote optimum health prior to onset of problems: healthy diet, exercise, immunizations.

Major goal to prevent disease from occurring

Secondary Prevention

Early identification and treatment of existing health problems: Pap smears, mammogram, PPD.

Better treatment and outcomes with early detection

Tertiary Prevention

Rehabilitation and restoration of health: cardiac rehab, after disease or illness occurs, optimize health in light of disease process


Collection of subjective and obective data

Starts with first pt contact, early impressions

Forms data base, foundation for making diagnoses




Patient reported history




Inspection, palpation, percussion, auscultation (all physical assessment findings), laboratory and diagnostic test results, patient's medical records


Judgement of individual's state of health using subjective and objective data

Nsg and MD use data differently

Nursing Process



Outcomes Indentification




Diagnose pt response to illness and disease, care planning to improve response

Medical diagnosis

Diagnose disease using assessment data

Nursing diagnosis

Assessment data used to diagnose patient's response to actual or potential health problems, ie. pain, altered skin integrity, ineffective coping, etc.

Types of Data

Complete (health history and physicial examination), 1st apt in primary care, hospital admission

Episodic (mini data base concerning one problem), acute illness, common cold

Follow-up (to assess progress), getting better or worse, focused and limited

Emergency (rapid and focused) r/t or to r/o life threatening problems, collected quickly to increase/decrease the level of suspicion for a certain type of problem


Allows for collection of subjective data

Assists patient in identifying areas of concern and perceptions of health status

Identifies person's problems and strengths

Establishes rapport and trust

Provides bridge to physical examination

Provides opportunity for education

Terms of Interview

Purpose (clarify) - Why are you here?

Time ( set limits in the beginning)

Pesence of others - affects communication, unable to speak freely, may help with ino acquisition, Interpreter

Confidentiality or limits to - avoid conversations in public, don't discuss patients with friends, builds trust and decreases litigation


Verbal and nonverbal - tone, words, speed, vocalizations, what you don't say, posture, gestures, facial expression, eye contact, body position, location in room, sometimes conveys more than verbal

Communication is two way

Emotional impact of illness can affect interpretation of messages, may not be able to process information, teaching may have to be minimal in hospital setting - give written instruction and revisit with lower stress level

Factors affecting interview: Internal factors

Internal factors: within ourselves, how we perceive others, self-awareness necessary

Convey warmth, acceptance, respect for health care decisions

Empathy - understanding for how patient feels, not feeling what they feel

Active listening - full attention, limit simultaneous activities

Factors affecting interview: External Factors

Environment: attempt to achieve comfortable settings, control interruptions, sit 4-5 ft from patient, slightly to the side, avoid standing

Professional Dress: good hygiene, keep clothes and shoes neat, wear name tag

Ensure physical and psychological privacy, close door or close curtain

Challenges of note taking

Impedes eye contact

Attention shifting

Interrupts patient's narrative flow

Impedes observation of nonverbal behavior

Can be threatening

Beginning the Interview

Questioning client to gather relevant health data

Introduction, always introduce yourself, explain role

Address pt by surname unless permission granted to use first name

Open-Ended questions

Requires narrative responses

Used to begin interview

Allows for description, leads to more info

Closed-Ended questions

Requires 1-2 word answers, yes/no responses

Used to fill in omitted info or to get specific facts

Ask only one question at a time

Communication Techniques

Facilitation: encourages pt to say more, "go on"

Silence: gives pt time to think, help to focus

Reflection: echoes the response, helps pt elaborate

Empathy: shows understanding, acceptance

Clarification: describe what you mean

Confrontation: use if the hx is inconsistent

Interpretation: links events and associations, impressions of what pt has said

Explanation: providing objective info, pt teaching, factual

Summary: final review of what the patient has said, surveys what we perceive the health problems/concerns to be

Traps to Avoid

Providing false assurance: may lead to disappointment and lack of trust

Giving advice: make pt accountable for decision making

Using authority

Avoiding difficult topics

Engaging in distances: personalize to pt

Using jargon

Using leading or biased questions

Talking too much


Asking "Why" questions: teach regarding furture behavioir

Non-Verbal behavior

Conveys important info

Physical appearance



Facial Expressions




Close interview

Open-ended question, allows for last opportunity to present important info

Special Considerations affecting interview

Hearing impaired: even-tone

Acutely ill: break into segments, use family for info

Substance abuse: wait until pt sober

Personal Question: redirect conversation to the pt

Sexually Aggressive: Don't tolerate, confront

Crying: allow expression of emotions, don't change the subject

Anger: deal with this emotion before going on with the interview, remove yourself or ask for assistant for those who threaten you


Older Adult interview considerations

The interview takes longer, longer story to tell

Patience, allow for time

Cross-cultural interview considerations

Eye-to-eye contact

Hand shaking

Touch (may or not be acceptable)

Personal space and interview distance

Space and distance

4 to 12 ft - Social distance, interview range

1.5 to 4 ft - Personal Distance, distance for physical assessment

0 to 1.5 ft - Intimate zone, some physical assessment (HEENT) done here