THE COMPLETE HEALTH HISTORY
Subjective data: what the patient states
Objective: what is observed
Pain is always subjective;
● PQRSTU mnemonic:
P: Provokes (What might be the causes for the symptom? What makes it better or worse? Are
there activities that affect it?)
Q: Quality ( What does the symptom feel like? Is the pain sharp? Do you feel light headed?)
R: Radiate/ region ( Where is the symptom located? Is it in one place? Does it go anywhere
else?)
S: Severity scale (Ask the patient to rate the severity of a symptom on a scale of 0 to 10)
T: Time (When did the symptoms first occur? Does it come and go? For how long? What time
of the day or on what day of the week does it occur?)
U: understand patient’s perception
CH 24: COMMUNICATION
● Levels of communication
- Intrapersonal: self- talk. You use intrapersonal communication to develop
self-awareness. Positive self- talk example: Transforming statements from “ I'm
scared to work with this type of patient” into “ This is my opportunity to learn
about this patient, and I can ask for help when it's needed”.
- Interpersonal: 2 or more people interacting face to face or via text or other
electronic format.
- Small group: staff meeting, support groups
- Public: seminars, interaction with an audience.
- Electronic: patient portal records
ELEMENTS OF COMMUNICATION PROCESS
● Circular transactional model
- Referent: motivates one to communicate with another. This could be setting,
sights, sounds, sensations, ideas
- Sender and receiver: Sender is who encodes and delivers a message and the
receiver is the person who receives and decodes the message.
, - Message: is the content of the communication. It contains verbal and nonverbal
expressions of thoughts and feelings.
- Channel: ways to send and receive messages through visual, auditory, and tactile
senses
- Feedback: the message a sender receives from the receiver
- Interpersonal values: factors that influence communication. It person senses,
interprets, and understands a message differently
❖ Interpersonal variables: education and developmental level, sociocultural
background, values and beliefs, emotions, gender, and physical health status
- Environment: The setting for sender-receiver interactions. Noise, temperature
extremes, distractions, and lack of privacy or space create confusion, tension, and
discomfort.
FORMS OF COMMUNICATION
● Verbal communication: uses spoken or written words.
- Vocabulary: when you care for a patient that speaks another language, a
professional interpreter is necessary.
- Denotative and connotative meaning: you need to select words carefully, avoiding
misinterpreted words when talking to a patient.
- Pacing: speak moderately slowly and clearly.
- Clarity and brevity: effective communication is simple, brief, and direct.
- Timing and relevance: even though a message is clear, poor timing prevents it
from being effective. For example: you do not begin routine teaching when a
patient is in severe pain or emotional distress.
● Nonverbal communication: includes the five senses and everything that does not involve
the spoken or written word.
- Personal appearance: includes facial expressions, and manner of dress and
grooming.
- Posture and gait: the way people sit, stand, and move reflects attitudes, emotions,
and health status.
, - Facial expression: convey emotions such as surprise, fear, anger, happiness, and
sadness.
- Eye contact:
- Gestures
- Sounds
- Territoriality and personal space: territoriality is important because it provides
people a sense of privacy.
- Metacommunication: broad term that refers to all factors that influence
communication.
TERRITORIALITY AND PERSONAL SPACE
● Four distances:
- Intimate: 0-18 inches. Ex: performing physical assessment, bathing, changing a
patient’s surgical dressing
- Personal: 18-40 inches. Ex: sitting at a patient’s bedside, taking patient’s nursing
history
- Social: 4 to 12 feet. Ex: giving directions to visitors in the hallway
- Public: 12 feet and beyond. Ex: lecturing to a class of students
PROFESSIONAL NURSING RELATIONSHIP
● Nurse- patient caring relationships: care about the client and their unique health needs
promoting an environment for positive change and growth
● Motivational interviewing: encourage clients to share their thoughts, beliefs, fears, and
concerns with the aim of changing their behavior
● Nurse- family relationships: use same principles as one-on-one helping relationships
● Nurse- health care team relationships: affects client safety and the work environment (ex.
Hand off reports, SBAR)
❖ Subject, Background, Assessment, Recommendation or Request
○ S: My name is Sarah, nurse on Ward X, I am calling about Jane Doe because I am
concerned Patient came into emergency room with chest pain
○ B: Patient was admitted on 09/01. This patient has had a 10 year history of
hypertension, smokes 3 packs of cigarettes everyday for 20 years, drinks
, approximately a 6-pack of beer for 15 years, does not participate in exercise or
activity for 20 years.
○ A: I think the problem is xx. I have done xx. Patient is afebrile, heart rate is 120,
respirations are high, BP is 180/100, patient is diaphoretic
○ R: Patient should be evaluated by provider and admitted to unit
NURSE-PATIENT CARING RELATIONSHIPS
● Lateral violence: basically bullying at the same level of power, nurse to nurse abuse
● Nurse- community relationship: Form relationships with community groups by
participating in local organizations, volunteering for community service and becoming
politically active
Phases of therapeutic helping relationship
○ Pre Interaction stage: Checking the charts, BEFORE YOU GO INTO THE
ROOM
○ Orientation stage: introducing myself to the patient and telling them what you
will be doing today, find out their preferences in this stage
○ Working stage: working with the patient to solve problems and accomplish
outcomes: this is vital signs, physical assessment, wound care, medication
administration, taking down to MRI
○ Termination stage: Ending the interaction phase and explaining what will happen
after u leave
ELEMENTS OF PROFESSIONAL COMMUNICATION
● AIDET: Acknowledge, Introduce, Duration, Explain, and Thank you
○ Developed by healthcare professionals to provide accurate and timely
professional communication
- Courtesy: knock on the door before entering a patient’s room and say hello and
goodbye.
- Use of names: always introduce yourself. Ask how patients and co-workers prefer
to be addressed.
- Trustworthiness: being trustworthy means helping others without hesitation.
Subjective data: what the patient states
Objective: what is observed
Pain is always subjective;
● PQRSTU mnemonic:
P: Provokes (What might be the causes for the symptom? What makes it better or worse? Are
there activities that affect it?)
Q: Quality ( What does the symptom feel like? Is the pain sharp? Do you feel light headed?)
R: Radiate/ region ( Where is the symptom located? Is it in one place? Does it go anywhere
else?)
S: Severity scale (Ask the patient to rate the severity of a symptom on a scale of 0 to 10)
T: Time (When did the symptoms first occur? Does it come and go? For how long? What time
of the day or on what day of the week does it occur?)
U: understand patient’s perception
CH 24: COMMUNICATION
● Levels of communication
- Intrapersonal: self- talk. You use intrapersonal communication to develop
self-awareness. Positive self- talk example: Transforming statements from “ I'm
scared to work with this type of patient” into “ This is my opportunity to learn
about this patient, and I can ask for help when it's needed”.
- Interpersonal: 2 or more people interacting face to face or via text or other
electronic format.
- Small group: staff meeting, support groups
- Public: seminars, interaction with an audience.
- Electronic: patient portal records
ELEMENTS OF COMMUNICATION PROCESS
● Circular transactional model
- Referent: motivates one to communicate with another. This could be setting,
sights, sounds, sensations, ideas
- Sender and receiver: Sender is who encodes and delivers a message and the
receiver is the person who receives and decodes the message.
, - Message: is the content of the communication. It contains verbal and nonverbal
expressions of thoughts and feelings.
- Channel: ways to send and receive messages through visual, auditory, and tactile
senses
- Feedback: the message a sender receives from the receiver
- Interpersonal values: factors that influence communication. It person senses,
interprets, and understands a message differently
❖ Interpersonal variables: education and developmental level, sociocultural
background, values and beliefs, emotions, gender, and physical health status
- Environment: The setting for sender-receiver interactions. Noise, temperature
extremes, distractions, and lack of privacy or space create confusion, tension, and
discomfort.
FORMS OF COMMUNICATION
● Verbal communication: uses spoken or written words.
- Vocabulary: when you care for a patient that speaks another language, a
professional interpreter is necessary.
- Denotative and connotative meaning: you need to select words carefully, avoiding
misinterpreted words when talking to a patient.
- Pacing: speak moderately slowly and clearly.
- Clarity and brevity: effective communication is simple, brief, and direct.
- Timing and relevance: even though a message is clear, poor timing prevents it
from being effective. For example: you do not begin routine teaching when a
patient is in severe pain or emotional distress.
● Nonverbal communication: includes the five senses and everything that does not involve
the spoken or written word.
- Personal appearance: includes facial expressions, and manner of dress and
grooming.
- Posture and gait: the way people sit, stand, and move reflects attitudes, emotions,
and health status.
, - Facial expression: convey emotions such as surprise, fear, anger, happiness, and
sadness.
- Eye contact:
- Gestures
- Sounds
- Territoriality and personal space: territoriality is important because it provides
people a sense of privacy.
- Metacommunication: broad term that refers to all factors that influence
communication.
TERRITORIALITY AND PERSONAL SPACE
● Four distances:
- Intimate: 0-18 inches. Ex: performing physical assessment, bathing, changing a
patient’s surgical dressing
- Personal: 18-40 inches. Ex: sitting at a patient’s bedside, taking patient’s nursing
history
- Social: 4 to 12 feet. Ex: giving directions to visitors in the hallway
- Public: 12 feet and beyond. Ex: lecturing to a class of students
PROFESSIONAL NURSING RELATIONSHIP
● Nurse- patient caring relationships: care about the client and their unique health needs
promoting an environment for positive change and growth
● Motivational interviewing: encourage clients to share their thoughts, beliefs, fears, and
concerns with the aim of changing their behavior
● Nurse- family relationships: use same principles as one-on-one helping relationships
● Nurse- health care team relationships: affects client safety and the work environment (ex.
Hand off reports, SBAR)
❖ Subject, Background, Assessment, Recommendation or Request
○ S: My name is Sarah, nurse on Ward X, I am calling about Jane Doe because I am
concerned Patient came into emergency room with chest pain
○ B: Patient was admitted on 09/01. This patient has had a 10 year history of
hypertension, smokes 3 packs of cigarettes everyday for 20 years, drinks
, approximately a 6-pack of beer for 15 years, does not participate in exercise or
activity for 20 years.
○ A: I think the problem is xx. I have done xx. Patient is afebrile, heart rate is 120,
respirations are high, BP is 180/100, patient is diaphoretic
○ R: Patient should be evaluated by provider and admitted to unit
NURSE-PATIENT CARING RELATIONSHIPS
● Lateral violence: basically bullying at the same level of power, nurse to nurse abuse
● Nurse- community relationship: Form relationships with community groups by
participating in local organizations, volunteering for community service and becoming
politically active
Phases of therapeutic helping relationship
○ Pre Interaction stage: Checking the charts, BEFORE YOU GO INTO THE
ROOM
○ Orientation stage: introducing myself to the patient and telling them what you
will be doing today, find out their preferences in this stage
○ Working stage: working with the patient to solve problems and accomplish
outcomes: this is vital signs, physical assessment, wound care, medication
administration, taking down to MRI
○ Termination stage: Ending the interaction phase and explaining what will happen
after u leave
ELEMENTS OF PROFESSIONAL COMMUNICATION
● AIDET: Acknowledge, Introduce, Duration, Explain, and Thank you
○ Developed by healthcare professionals to provide accurate and timely
professional communication
- Courtesy: knock on the door before entering a patient’s room and say hello and
goodbye.
- Use of names: always introduce yourself. Ask how patients and co-workers prefer
to be addressed.
- Trustworthiness: being trustworthy means helping others without hesitation.
