N326 week 4 health history

N326 week 4 health history - Health History Eileen McCann...

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Health History Eileen McCann DNP RN Family Nurse Practitioner
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Health History The purpose of assessment are: Collect data (objective and subjective) to make a judgment and a diagnosis about the health of an individual. To help you uncover significant problems and plan your care. Forms data base used to make diagnosis
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Assessment includes … Subjective: stated by the patient Objective: observed or measured Forms Data Base + History + Labs Diagnostic reasoning Initial cues (sign/symptom/lab value) Tentative hypothesis Gather more data to support or refute Evaluate hypothesis
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Assessment Provides complete picture of past and present health Well person – assess lifestyle, diet, exercise, risk reduction, health promotion behaviors Ill person – complete record of health problem
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History and Interviewing Process Taking the history usually begins your relationship with the patient. Discover information leading to diagnosis and management. Provide information about diagnosis. Negotiate and share in health care management, create a plan. Counsel about disease prevention
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Communication Building rapport Specific objectives, comfortable environment, patient focused Non Verbal Physical appearance Posture Gestures Eye contact Voice Techniques Open ended questions Closed or direct questions
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Interview Barriers 1. Providing false assurance 2. Giving unwanted advice 3. Using authority 4. Using avoidance language 5. Engaging in distancing 6. Using professional jargon 7. Using leading or biased questions 8. Talking too much 9. Interrupting 10. Using “why” questions
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Helpful hints Take notes sparingly Start with general concerns and move to specifics Clarify patient responses where, when what how and why questions Verify and summarize
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Special Circumstances Hearing impaired Acutely ill Terminal diagnosis Language barrier Cognitive impairment Older adult Age related barriers Draw on persons experience and wisdom
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This note was uploaded on 05/31/2011 for the course NUR 326 taught by Professor Meneghini during the Fall '10 term at St. Xavier.

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N326 week 4 health history - Health History Eileen McCann...

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