Physical_Assessment__Exam_1_Study_Guide

 Physical Environment Considerations: o “Defining the environment so as to foster communication” ■ Ensure Privacy - aim for “geographic” privacy but ensure “psychological” privacy as well. ■ Avoid Interruptions - Concentrate and establish rapport; minimize and/or refuse. ■ Physical Environment - “Equal status” seating (sitting at the same level), placing client 4 to 5 feet away from you. ■ Dress - Client should remain in street clothes for interview. Gown causes power differential and may make client feel exposed. Build rapport before asking client to change into gown. Your appearance should be professional and avoid extremes. Promote professional image for self. ■ Note-taking - keep to a minimum, offer focused attention. Jot notes down, but also keep non-verbal communication up to par. ● Verbal / Non-Verbal Communication: o Verbal Communication : • Patient Perspective (Reaction—Patient leads):  Facilitation : Encourages patient to say more and shows them you are interested.  Silence : Directed attentiveness; provides chance to observe client and note non￾verbal cues.  Reflection : Echoing patient’s words to help elaborate problem.  Empathy: Names a feeling and allows its expression.  Clarification: Asking for confirmation and summarizing patient’s words. • Interviewer Perspective (Your thoughts—Nurse leads):  Confrontation : Clarifying inconsistent information.  Interpretation : Makes association to identify cause or conclusion.  Explanation : Informing person by sharing factual and objective information.  Summary : Provides conclusion based on verified information which in turn, identifies that the interview process is closing. o Nonverbal Communication : (Body language helps to provide cues which may be correlated with truer feelings)  Physical appearance : Image as initial perception. “First impression”.  Posture : Interpretation of body language can impact engagement with client.  Gestures : Gestures send messages so be aware of your own, as well as the client’s.  Facial expression : Reflects emotion and culture. Pay attention to your own facial expressions as well.  Eye contact : Maintain within the realm of interest, but be mindful of cultural diversity. Lack of eye contact may show the client may be shy, withdrawn, confused, bored, intimidated, etc.  Voice : Be aware of tone, intensity, and rate of speech.  Touch : Interpretation is influenced by age, gender, cultural background, past experience, and current setting.  Recognize importance of unconscious messages  When verbal and nonverbal messages are congruent, the verbal message is reinforced.  When they are incongruent, nonverbal message is viewed as the true one as it is under unconscious control  Can be viewed as either positive or negative therapy promoting the importance of self-awareness in order to promote communication. o For people with special needs:  Consider key elements that will address vulnerable populations  Acutely ill, drug/alcohol abuse, sexually aggressive, emotionally distraught (crying), angry and or threatening violence and anxious  Use appropriate resources as they relate to the context of the situation  Be alert to “personal questions” queries as they may indicate ulterior motives:  Provide appropriate response based on personal ethics o Types of questions :  Open ended - asks for narrative information  Closed ended - asks for specific information leading to a forced choice (yes/no) AVOID: -leading or biased questions -use “why” questions ● Therapeutic Responses:  Build rapport and continue therapeutic relationship and using therapeutic touch. Use therapeutic touch to provide empathy.  Language Barriers: o Potential exists for language barrier to be a key element in health care interactions due to cross-cultural communications. o Consider both verbal and non-verbal cues in communication pattern. o Bilingual team member or trained medical interpreter, preferably of the same gender. o Language alone does not imply understanding of cultural diversity. CHAPTER 4: HEALTH HISTORY ● Objective vs. Subjective Data: o Objective : Data collected that can be measured with the senses (what the nurse sees, physical data, labs, etc.—mostly signs). o Subjective : Data collected from what the patient says, what the patient feels from disorder, documented in quotes (usually a symptom). ● Components Of a Health History (What's Included): The purpose of health history is to collect subjective data to combine with objective data from a physical exam and lab studies to form the database. It provides a complete picture of patients past and present health status. Can be used as a screening tool for detection of abnormalities. Sequence may vary in terms of obtained information. Focus may differ in terms of clinical practice setting and/or nature of complaint. SEQUENCE: o Biographic data: ■ Name, address, phone number ■ Age, birthdate, birthplace ■ Gender (identification) and relationship status ■ Race and ethnic origin ■ Occupation: usual and present ■ Primary language ○ Source of history: ■ Record who furnishes information, usually the person, although source may be relative or friend. Judge reliability of information and how willing he or she is to communicate. ○ Reason for seeking care : ■ Brief and spontaneous statement in client’s own words describing reason for visit. ■ Document reported findings (signs and symptoms). ■ Reason for care is not a diagnostic statement. ■ Focus on patient’s prioritized reasons for seeking care (is it diagnostic, treatment, etc.). ○ Present health history or history of present illness : ■ Collect all provided data and identify 8 critical characteristics ● Location, character (quality), quantity (severity), timing, setting, aggravating or relieving factors, associated factors and patient’s perception. ○ Like when did it start? What were you doing? ○ Past history : ■ Childhood illnesses (measles, mumps, rubella, CP, pertussis, strep throat). ■ Accidents or injuries (MVAs, fractures, head injuries, burns, penetrating wounds). ■ Serious or chronic illnesses (asthma, depression, diabetes, HTN, heart disease, HIV, hepatitis, sickle cell, cancer, seizure disorder). ■ Hospitalizations (cause, name of hospital, how the condition was treated, how long hospitalization was, name of doctor). ■ Operations (type of surgery, date, name of surgeon, name of hospital, recovery). ■ Obstetric history (data related to childbearing, labor/delivery experience, condition of infant, and postpartum course) ■ Immunizations (Tdap, varicella, HPV, MMR, meningococcal, pneumococcal). ■ Last examination date (labs/diagnostics—blood work, ECG, chest x-ray, occult blood, gender specific testing—PAP/PSA). ■ Allergies (note allergen and reaction). ■ Current medications (Perform medication reconciliation, include prescribed and OTC medication and/or herbal therapy ○ Medication reconciliation : ■ A comparison of a list of current medications with a previous list, which is done at every hospitalization and every clinic visit. o Purpose is to reduce errors and promote patient safety. ○ Family history : ■ Highlights diseases or conditions that an individual may be at risk for as a result of genetics. ■ Provides age and health or cause of death of relatives ■ Ability based on results to seek early screening, make possible lifestyle adjustments, and/or undergo periodic surveillance. ■ Pedigree or genogram used as a standardized tool to organize data