Patient Analysis Interviewing A comprehensive assessment is an amalgamation of subjective and objective data. The role of the nurse is to complete the head-to-toe assessment as well as obtain a health history from the patient. This includes personal and familial health history, verifying current medications, clarifying concerns the patient has indicated, and providing education to the patient throughout the exam as appropriate (Jensen, 2019). When interviewing a patient, establishing a positive rapport is crucial. Jensen states that the nurse only has one chance to make a positive first impression when completing an initial interview with a patient (2019). Collecting data during an interview involves asking two different types of questions. Direct questions are appropriate when searching for yes-or-no answers (Jensen, 2019). In the case of Tina Jones, an example of a direct question would be, “Do you use a glucometer to check your blood sugar?” Open-ended questions are broad and elicit answers in the patient’s own words (Jensen, 2019). An example appropriate for interviewing Ms. Jones would be, “What is your typical breakfast?” or “Tell me
PATIENT ANALYSIS AND TEACHING TOOL 4 how you manage your diabetes.” It is inappropriate to use leading questions, as they can imply judgement on the nurse’s part, and cause the patient to answer a question in a manner they feel is acceptable to the nurse, or cause the patient to feel guilty or inferior (Jensen, 2019). Ensuring the use of appropriate language, and minimizing medical jargon ensures a therapeutic interview process, as it allows the patient to be an active part of the interview process and understand what is being asked (Jensen, 2019). Data Collection When completing a physical assessment, inspection is the first technique used in order to obtain a generalized survey and for each body part/system (Jensen, 2019). Inspection allows the nurse to gain an overall impression of the patient and assess any potential severe situations (Jensen, 2019). Inspection starts with the initial contact with a patient and continues through each body system, utilizing sight, hearing, and smell. It is important to maintain the comfort and privacy of the patient during inspection, and to ask for the patient’s permission before doing so (Jensen, 2019). Palpation involves using touch to assess several factors, including: texture, temperature, size, shape, moisture, location, position, crepitus, vibration, pain, edema, and tenderness (Jensen, 2019). Palpation is a necessary part of assessing each body system. Light palpation allows for assessment of surface characteristics, while deep palpation is utilized to assess the size and shape of abdominal organs specifically (Jensen, 2019). As with inspection, it is critical to ask permission from the patient before proceeding, and explain the rationale for doing so (Jensen, 2019). Palpation is the second step in the physical assessment for all systems except the gastrointestinal system, where palpation should be performed last, in order to ensure no alteration of bowel sounds and yielding potentially inaccurate findings (Jensen, 2019).
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- Fall '17
- Diabetes, Diabetic retinopathy