Health Assessment notes Chapter 2: Be aware of non-verbal quos Make sure to ask permission before entering their personal space Verbal communication skills Nurses speech needs to be moderate pace and volume with clear articulation Active listening – is the ability to focus on the patients and their perspectivesRestatement – relates to the content of the communication – the nurse makes a simple statement, using the patients words Reflection – similar to restatement but the nurse identifies main themes in the communication skills Silence Focusing – is redirecting the client to the issue at hand Clarification Summarizing Encouraging elaboration Is a technique that assists patients to describe their concerns in more detailTo show that the nurse is interested it is important to get feedback Non-therapeutic responses False reassurance Sympathy Unwanted advice Biased information Changes of subjects with clients Distractions Technical or overwhelming language Interrupting patientsPhases of the interviewPre-interaction -> beginning phase -> working phase -> closing phase Intercultural communication Patients with limited English When possible a interrupter is used however interpreters cannot be used throughout the entire care of the patient Use simple wordsThere responses are often delayed Gender and sexual orientation issues
Men often want facts Females often want the social aspect of the treatment In a lot of cultures the male can be there to represent the family Must be sensitive to sexual orientation Also more sexual preference With hearing impairment speak louder to the patients Chapter 3 – the health history Types of health histories Emergency – allergies ect. Focused – asking questions that obtain to the event eg. broken bone Comprehensive – when someone goes into surgery Follow-upPrimary and secondary data sources Primary – patientSecondary – patient’s family & chartNeed to establish and document the reliability of the data sourceReliable historianInaccurate historianComponents of the complete health history Demographical or identifying data – 3 or 4 ect. Reason for seeking care or chief concernPresent health/history of present illness – PQRSTU or OLDCARTS – pain goals, functional goals Past health history Current medications & allergiesFamily history - genogramFunctional assessment Growth & developmentReview of systems – Jensen p. 46Social, cultural & spiritual assessmentMental healthHuman violenceStructure of the adult health history Demographic or identifying dataDate and time, name, age, gender, marital status, occupationSource of data & reliabilityChief ConcernTry to quote the client’s own wordsI.e.. “the client states my stomach hurts”
Present illness Needs to be clear and chronological.