Health Assessment Chapter 3
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Phases of an Interview
- Introduction Phase
- Discussion Phase
- Summary Phase
Introduction Phase of an Interview
- Nurse introduces self to client
- Nurse describes the purpose of the interview
- Nurse describes the process of the interview so client knows how long interview will take and what to expect
Discussion Phase of an Interview
- Nurse facilitates discussion
- Discussion is client centered
- Nurse uses various communication techniques to collect data
Summary Phase of an Interview
- Summarization of data
- Allows for clarification of data
- Provides validation to the client that the nurse understands problems.
The Physical Setting of an Interview
- Comfortable (temperature, personal space, street clothes)
- Free from Distraction
Professional Nursing Behavior
- Good Personal Hygiene : clean hair, nails, and modest dress
- Professional yet warm demeanor
- Make every attempt to understand client's POV
- Avoid being careless with words
- Avoid extremes of reaction-- startle, surprise, laughter, grimacing-- as clients provide information
- Speak Clearly
- Define words clients may not understand (but don't use a lot of technical language)
- Use language that is familiar, even slang
- Encourage specificity in answers
- Ask one question at a time
- Be attentive to client's emotional responses and follow up if necessary
- Use permission giving with sensitive questions
- Be concise and specific when answering client questions
lead clients to focus on one set of thoughts; this type of question is most often used in reviewing systems or in evaluating functional status.
Techniques that Enhance Data Collection
- Active Listening
- Facilitation: "Go oh", "Uh-huh", "Then?"
- Clarification: "What do you mean by that?"
- Reflection: repeating a phrase or sentence the client just said.
- Confrontation: used when there are inconsistencies between what the client says and what your observations or other data show; use tone that communicates confusion or misunderstand
- Interpretation: when you want to share with clients conclusions you have drawn from data they have given
- Summary: condenses and orders data obtained during the interview to help clarify a sequence of events.
Techniques that Diminish Data Collection
- Using medical terminology
- Expressing value judgements
- Interrupting the client
- Behaving authoritarian or paternalistic
- Using "Why" questions
Managing Awkward Moments During an Interview
- Answering personal questions: brief and direct
- Silence: do not break silence-- clients may need the silence to reflect or to gather courage. May indicated client isn't ready to discuss or approach needs to be evaluated.
- Displays of Emotion: let patient cry if they need too; acknowledge anger and discuss approach for talking to person or apologize yourself if need be.
Components of a Comprehensive Health History
- Biographical Data
- Reason for seeking care
- History of present illness
- Present health status
- Past Health History
- Family History
- Personal and psychosocial history
- Review of systems
Symptom Analysis used when taking history of present illness
- OLD CARTS
- Onset: when did the symptoms begin?
- Location: Where are the symptoms?
- Duration: How long do the symptoms last
- Characteristics: Describe the characteristics of the symptom
- Aggravating and Alleviating Factors: What affects the symptoms?
- Related Symptoms: What other symptoms are present?
- Treatment: describe self treatment tried before seeking care.
- Severity: Describe the severity of the symptom (number, extent, size, amount, rank 0-10)
- Address and Telephone Number
- Birth Date
- Birthplace (especially if in a foreign country)
- Marital Status
- Contact person
- Source of Data
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