NURS612 Advanced Health Assessment: Exam 1 Study Guide
What are concepts of developing a relationship with the patient?
The first meeting with the
... [Show More] patient sets the tone for a successful partnership as you inform the patient that you really want to know all that is needed and that you will be open, flexible, and eager to deal with questions and explanations. A primary objective is to discover the details about a patient’s concern, explore expectations for the encounter, and display genuine interest, curiosity and partnership. Identifying underlying worries, believing them, and trying to address them optimizes your ability to be of help. Personal interactions and physical examination play an integral role in developing meaningful and therapeutic relationships with patients. Because cost containment is also essential, the well performed history and physical examination can justify the appropriate and cost- effective use of technological resources. This underscores the need for judgment and the use of resources in a balance appropriate for the individual patient.
What are the effective communication strategies when obtaining a health history?
o Seeking connection
o Professional Dress and Grooming
o Enhancing Patient Responses
What is a patient-centered question? Give examples.
• Respecting and responding to patients’ wants, needs, and preferences, so that they can make choices in their care that best fit their individual circumstances.
• How would you like to be addressed?
• How are you feeling today?
• What would you like us to do today?
• What do you think is causing your symptoms?
• What is your understanding of your diagnosis? Its importance? Its need for management?
• How do you feel about your illness? Frightened? Threatened? Angry? As a wage earner? As a family member? (Be sure, however, to allow a response without putting words in the
patient’s mouth).
• Do you believe treatment will help?
• How are you coping with your illness? Crying? Drinking more? Tranquilizers? Talking more? Less? Changing lifestyles?
• Do you want to know all the details about your diagnosis and its effect on your future?
• How important to you is “doing everything possible’?
• How important to you is “quality of life’?
• Have you prepared advance directives?
• Do you have people you can talk with about your illness? Where do you get your strength?
• Is there anyone else we should contact about your illness or hospitalization? Family members? Friends? Employer? Religious advisor? Attorney?
• Do you want or expect emotional support from the healthcare team?
• Are you troubled by financial questions about your medical care? Insurance coverage? Tests or treatment you may not be able to afford. Timing of payments required from you.
• If you have had previous hospitalizations, does it bother you to be seen by teams of physicians, nurses, and students on rounds?
• How private a person are you?
• Are you concerned about the confidentiality of your medical records?
• Would you prefer to talk to an older/younger, male/female healthcare provider?
• Are there medical matters you do not wish to have disclosed to others?
What are potential barriers of patient and provider communication? Moments of Tension: Potential Barriers to Communication
Curiosity about you. Direct answer. Inform patients that you have similar experience can help
alleviate fears, and with further exploration, can help in the identification of the patient’s concerns. It is wise to exercise caution and remain professional in what and how much you disclose.
Anxiety. You can help by avoiding an overload of information, pacing the conversation, and presenting a calm demeanor.
Silence. Sometimes intimidated by silence, many healthcare providers feel the urge to break it. Be patient and do not force conversation. Silence may also be cultural: for example, some cultural groups take their time, ponder their responses to questions, and answer when they feel ready. Do not push too hard. Be comfortable with silence but give it reasonable bounds.
Depression. Being sick or thinking that you are sick can be enough to provoke situational depression. Serious or chronic, unrelenting illness or taking certain medications is often accompanied by depression. A sense of sluggishness in the daily experience; disturbances in sleeping, eating, and social contact; and feelings of loss of self-worth can be clues. In addition to screening for depression at ambulatory visits, pay attention. First ask, when did you start feeling this way? Then ask, “How do you feel about it? Have you stopped enjoying the things you like to do? Do you have trouble sleeping? Have you had thoughts about hurting yourself? Are you depressed?
Crying and compassionate moments. Name the emotion; be direct about such a tender circumstance, but gently, not too aggressively or insistently. Do not hesitate to say that you feel for the patient, that you are sorry for something that happened, and that you know it was painful. At times, the touch of a hand or even a hug is in order. Sometimes, a concern- a difficult family relationship, for example- must be confronted. You may have to check an assumption and hope that you have guessed correctly in bringing the patient’s feelings to the surface. If uncertain, ask without presupposing what the response might be.
Physical and emotional intimacy. Respect modesty, using covers appropriately without hampering a complete examination. You can keep the necessary from becoming too big an issue by being calm and asking questions with professional poise.
Seduction. Delivering the immediate message that the relationship is and will remain professional.
Anger. Confront it. It is all right to say, “It seems like you’re angry. Please tell me why. I want to hear. Speak softly and try not to argue the point.
Avoiding the full story. Patients may not always tell the whole story or even the truth. Do not push too hard when you think this is happening. Allow the interview to go on and then come
back to a topic with gentle questioning. You might say, “I think that you may be more concerned than you are saying” or I think you’re worried about what we might find out.”
Financial considerations. Provide resources (social worker or financial counselor). Otherwise, an appropriate care plan acceptable to the patient cannot be devised or implemented.
What is the structure and the components of a patient history? What kind of patient information is obtained in each section?
Structure of the History.
First, the identifiers: name, date, time, age, gender, identity, race, source of information, and referral source.
Chief concern (CC). The chief concern is a brief statement about why the patient is seeking care. Direct quotes are helpful. It is important, however, to go beyond the given reason and to probe for underlying concerns that cause the patient to seek care rather than just getting up and going to work. If the patient has a sore throat, why is help sought? Is it the pain and fever, or is it the concern caused by experience with a relative who developed rheumatic heart disease? Many interviewers include the duration of the problem as part of the chief concern.
History of present illness. Past medical history Family history
Personal and social history Review of systems
Understanding the present illness or problem requires a step-by-step evaluation of the circumstances that surround the primary reason for the patient’s visit. The full history goes beyond this to an exploration of the patient’s overall health before the chief concern, including past medical and surgical experiences. The spiritual, psychosocial, and cultural contexts of the patient’s life are essential to an understanding of these events. The patient’s family also requires attention to their health, past medical history, illnesses, deaths and the genetic, social, and environmental influences. One question should underlie all of your inquiry: why is this happening to this particular patient at this particular time? In other words, if many people are exposed to a potential problem and only some of them become ill after the exposure, what are the unique factors in this individual that led to that outcome? Careful inquiry about the personal and social experiences of the patient should include work habits and the variety of relationships in the family, school, and workplace. Finally, the ROS includes a detailed inquiry of possible concerns in each of the body’s systems, looking for complementary or seemingly unrelated symptoms that may not have surfaced during the rest of the history. Flexibility, the appreciation of subtlety, and the opportunity for the patient to ask questions and to explore feelings are explicit needs in the process.
What is the difference between objective and subjective data? What components of the health history are objective and subjective?
How do you approach sensitive issues when interviewing a patient?
• Provide privacy
• Do not waffle. Be direct and firm. Avoid asking leading questions.
• Do not apologize for asking a question.
• Do not preach. Avoid confrontation. You are not there to pass judgment.
• Use language that is understandable to the patient, yet not patronizing.
• Do not push too hard.
• Afterward, document carefully, using the patient’s words (and those of others with the patient) whenever possible. It is all right to take notes, but try to do this sparingly,
especially when discussing sensitive issues.
• You must always be ready to explain again, why you examine sensitive areas. A successful approach will have incorporated four steps:
1. An introduction, the moment when you bring up the issue, alluding to the need to understand its context in the patient’s life.
2. Open-ended questions that first explore the patients’ feelings about the issue-whether, for example, it is alcohol, drugs, sex, cigarettes, education, or problems at home- and then the direct exploration of what is actually happening.
3. A period in which you thoughtfully attend to what the patient is saying and then repeat the patient’s words or offer other forms of feedback. This permits the patient to agree that your interpretation is appropriate, thus confirming what you have heard.
4. Finally, an opportunity for the patient to ask any questions that might be relevant.
What does it mean to be culturally aware and culturally competent when caring for patients with diverse backgrounds?
• Cultural awareness- the deliberate self-examination and in-depth exploration of one’s biases,
• Stereotypes, prejudices, assumptions, and isms that one holds about individuals and groups who are different from them.
• Cultural competency-requires that healthcare providers be sensitive to patient’s heritage, sexual orientation, socio-economic situation, ethnicity, and cultural background.
What are examples of questions to explore the patient’s culture? What are the components of a cultural response to a patient?
• Modes of communication- the use of speech, body language, and space.
• Health beliefs and practices that may vary from your own or those of other patients you care for
• Diet and nutritional practices
• The nature of relationships within a family and community.
EYES
How do you measure visual acuity and test cranial nerve II? Describe the various tests to measure different types of visual acuity. How do you document your findings?
• Position the patient 20 feet away from the Snellen chart. Test each eye individually by covering one eye with an opaque card or gauze, being careful to
avoid applying pressure to the eye. If you test the patient with and without corrective lenses, record the readings separately. Always test vision without glasses first.
• Ask the patient to identify all of the letters, beginning at any line. Determine the smallest line in which the patient can identify all of the letters and record the
visual acuity designated by that line. When testing the second eye, you may want to ask the patient to read the line from right to left to reduce the chance of recall influencing the response. Visual acuity is recorded as a fraction in which the numerator indicates the distance of the patient from the chart and the denominator
indicates the distance at which the average eye can read the line. Thus 20/200 means that the patient can read at 20 feet what the average person can read at 200 feet.
• Measurement of near vision should be tested in each eye separately with a handheld card such as the Rosenbaum Pocket Vision Screener. Have the patient
hold the card at a comfortable distance about 14 inches from the eyes and read the smallest line possible.
• Peripheral vision is generally estimated by the confrontation test. Ask the patient to cover the right eye while you cover your left eye, so the open eyes are directly
opposite each other. Both you and the patient should be looking at each other’s eye. Fully extend your arm midway between the patient and yourself and then wiggle your fingers as you move your arm slowly centrally. Have the patient tell you when the fingers are first seen. Compare the patient’s response to the time you first note the fingers. Test the nasal, temporal, superior, and inferior fields. Lesions most likely to produce confrontation abnormalities include stroke, retinal detachment, optic neuropathy, pituitary tumor compression at the optic chiasm, and central retinal vascular occlusion.
Describe how you would perform and external examination of the eyes. What is the normal and abnormal? How do you document your findings?
• Carry out examination of the eyes in a systematic manner, beginning with the appendages, the eyebrows, surrounding tissues, and moving inward.
• Inspect the eyebrows for size, extension, and texture of the hair. Note whether the eyebrows extend beyond the eye itself or end short of it. If the patient’s [Show Less]