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Week 1 Day 1 Communication and Health History VB 24

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11 views

Week 1 Day 1 Communication and Health History VB 24

Uploaded by

klouanny
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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COMMUNICATION, THE

HEALTH HISTORY, AND


INTERVIEW
Copyright © 2023 Wolters Kluwer • All Rights Reserved
Communication Process

All nursing practice is dependent on an


effective nurse–patient relationship
Complex, ongoing
o Subjective understanding, perceptions,
other variables
Therapeutic communication
o Caring
o Empathy

Copyright © 2023 Wolters Kluwer • All Rights Reserved


Nonverbal Communication Skills

What to look for in the nonverbal…


 Important components (General survey)
o Physical appearance; facial expression
o Posture; positioning in relation to the patient
o Gestures; eye contact
o Voice tone; use of touch
o Behavior
 Communicate at patient’s eye level
 Touch (??): essential, dominant component of physical exam
o Respect patient’s cultural norms

Copyright © 2023 Wolters Kluwer • All Rights Reserved


Verbal Communication Skills

Effective interviewing skills


Patients with limited English
o Simple, clear language at normal volume
Use Active Listening
o Ability to focus on patients
o Talking about difficult feelings helps patients
to heal
o Redirect interview if a patient’s anger cannot
be diffused

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Other Techniques of Communication
 Restatement: relates to the content of communication.
 Reflection: Summarizing main themes of communication
 Elaboration (facilitation): Assists patients to more
completely describe difficulties
 Silence: Purposefully allow patients time to gather thoughts,
provide accurate answers
 Focusing: Redirecting patients to pertinent topic being
discussed
 Clarification: Questions to ascertain patient’s meaning when
word choice or ideas are unclear
 Summarizing: Reviewing and condensing important
information into two or three most important findings

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Nontherapeutic Responses…Traps

False reassurance
Sympathy
Unwanted advice
Biased questions
Changes of subject
Distractions
Technical or overwhelming language
Interrupting

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Professional Expectations and Boundaries

Nonprofessional involvement
o Establish social, personal, or
economic patient ties
 Social media sites
o Sexual boundary violation
 Never acceptable within the therapeutic
nurse–patient relationship

Copyright © 2023 Wolters Kluwer • All Rights Reserved


Culturally Competent Communication

Cultural differences may relate to


o Group or ethnicity; region
o Age; degree of acculturation into Western society
o Combination of factors
Communication etiquette
Limited English skills
Working with an interpreter
Gender and sexual orientation bias

Copyright © 2023 Wolters Kluwer • All Rights Reserved


Phases of the Interview Process
 Preinteraction phase: compiling existing data; preparing
for patient interview from existing medical records
 Beginning phase: introduction; state purpose for interview;
ensure privacy
 Working phase
o Closed-ended or direct questions: specific
information
o Open-ended questions: broad answers in patient’s
own words; avoid “why” questions
 Closing phase: summarizing, stating most important two to
three problems or patterns
o Report any information that is required by law

Copyright © 2023 Wolters Kluwer • All Rights Reserved


Health History Sources

Primary Data Sources


o Individual patient
Secondary Data Sources
o Charts and information from family members
o All other sources of information
Reliability of the source
o Reliable historian
o Inaccurate historian

Copyright © 2023 Wolters Kluwer • All Rights Reserved


Types of Health History

Emergency
o Gather information about immediate problem
(chest pain, extreme shortness of breath,
ED)
Focused
o Gather information about current situation
(admitted for knee pain)
Comprehensive
o Gather all medical information about patient (new
admission, back from the OR)

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Components of the Health History #1
 Demographic data
 Reason for seeking care. Chief Complaint
 History of present illness (HPI)
o OLDCARTS; PQRSTU; COLDSPA
o O = Onset (abrupt or gradual)
o L = Location (body part)
o D = Duration (length persisted)
o C = Character (burning, aching, sharp, dull,
throbbing)
o A = Aggravating factors (what worsens symptom)
o R = Relieving/Radiating factors (what improves
symptom; does the symptom travel)
o T = Timing (constant, intermittent)
o S = Severity (0 to 10)
Copyright © 2023 Wolters Kluwer • All Rights Reserved
Components of the Health History #2

Past medical health history (PMH)


o Childhood illnesses
o Past illnesses
o Surgeries
o Injuries and trauma
o Obstetric history
o Health screening
o Genetics

Copyright © 2023 Wolters Kluwer • All Rights Reserved


Components of the Health History #3

Current medications
Allergies
Family history
o Genogram

Copyright © 2023 Wolters Kluwer • All Rights Reserved


Components of the Health History #4
 Functional health assessment
o Gordon’s functional health patterns
o Activities of Daily Living (ADLs)
o Growth and development
 Review of systems (ROS)
o General health state
o Nutrition, hydration
o Skin, hair, and nails
o Head and neck

Copyright © 2023 Wolters Kluwer • All Rights Reserved


Components of the Health History #5

Review of systems—(cont.)
o Eyes
o Ears
o Nose, mouth, and throat
o Thorax, lungs
o Heart, neck vessels
o Peripheral vascular
o Breasts
o Abdominal-gastrointestinal

Copyright © 2023 Wolters Kluwer • All Rights Reserved


Components of the Health History #6

Review of systems—(cont.)
o Abdominal-urinary
o Musculoskeletal
o Neurological
o Genitalia of males assigned at birth
o Genitalia of females assigned at birth
o Anus and rectum

Copyright © 2023 Wolters Kluwer • All Rights Reserved


Psychosocial and Lifestyle Factors

Social, cultural, spiritual assessment


Mental health assessment
o Mental health history
o Medications in use
o Alcohol/illegal drug use
Neglect, abuse, and violence assessment
Sexual history
o Establish baseline
o Identify need for education

Copyright © 2023 Wolters Kluwer • All Rights Reserved


Life Span Considerations

 Infants and children


o Parents, legal guardians, other adult representatives
o Validate roles of people bringing children
 Adolescents
o Begin to participate in interview
 Vital information to collect
o Pregnancy, birth, perinatal history
o Immunizations
o Growth and development

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Life Span Considerations

Older adults
o Possible sensory deficits
o More complex health histories

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Challenging Situations

 Hearing impairment
 Low level of consciousness
 Cognitive impairment
 Mental illness
 Anxiety
 Crying
 Anger
 Use of alcohol, drugs, and mind-altering substances
 Personal questions and boundaries
 Sexual aggression

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Question #1

Is the following statement true or false?

The therapeutic communication strategy of


reflection is when the nurse restates content of the
communication to the patient. Its purpose is to
encourage the patient to elaborate.

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Answer to Question #1

False
Rationale: Reflection is similar to restatement;
however, instead of simply restating comments, the
nurse summarizes the main themes of
communication.

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Question #2

In what phase of the interview are open-ended


questions used?
A. Preinteraction
B. Beginning
C. Working
D. Ending

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Answer to Question #2

C. Working
Rationale: During the working phase, the nurse
collects data by asking specific questions. Two types of
questions are closed-ended questions and open-ended
questions. Each type has a purpose; the nurse
chooses which type will help solicit the appropriate
information.

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