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30 Cards in this Set
- Front
- Back
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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) |
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Health Promotion/Disease prevention |
Forms the core of nursing practice: Primary, Secondary, Tertiary |
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Primary prevention |
Promote optimum health prior to onset of problems: healthy diet, exercise, immunizations.
Major goal to prevent disease from occurring |
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Secondary Prevention |
Early identification and treatment of existing health problems: Pap smears, mammogram, PPD.
Better treatment and outcomes with early detection |
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Tertiary Prevention |
Rehabilitation and restoration of health: cardiac rehab, after disease or illness occurs, optimize health in light of disease process |
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Assessment |
Collection of subjective and obective data Starts with first pt contact, early impressions Forms data base, foundation for making diagnoses |
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Subjective |
Statements Symptoms Patient reported history |
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Objective |
Observations Signs Inspection, palpation, percussion, auscultation (all physical assessment findings), laboratory and diagnostic test results, patient's medical records |
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Diagnosis |
Judgement of individual's state of health using subjective and objective data
Nsg and MD use data differently |
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Nursing Process |
Assessment Diagnosis Outcomes Indentification Planning Implementation Evaluation
Diagnose pt response to illness and disease, care planning to improve response |
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Medical diagnosis |
Diagnose disease using assessment data |
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Nursing diagnosis |
Assessment data used to diagnose patient's response to actual or potential health problems, ie. pain, altered skin integrity, ineffective coping, etc. |
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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 |
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Interview |
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 |
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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 |
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Communication |
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 |
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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 |
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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 |
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Challenges of note taking |
Impedes eye contact Attention shifting Interrupts patient's narrative flow Impedes observation of nonverbal behavior Can be threatening |
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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 |
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Open-Ended questions |
Requires narrative responses Used to begin interview Allows for description, leads to more info |
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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 |
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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 |
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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 Interrupting Asking "Why" questions: teach regarding furture behavioir |
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Non-Verbal behavior |
Conveys important info Physical appearance Posture Gestures Facial Expressions Eye-Contact Voice Touch |
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Close interview |
Open-ended question, allows for last opportunity to present important info |
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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 Anxious |
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Older Adult interview considerations |
The interview takes longer, longer story to tell Patience, allow for time |
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Cross-cultural interview considerations |
Eye-to-eye contact Hand shaking Touch (may or not be acceptable) Personal space and interview distance |
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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 |
