CHAPTER 1: HISTORY AND INTERVIEWING PROCESS

PHYSICAL ASSESSMENT
1. Observation / Inspection
2. Gathering accurate data
3. Continuous documentation

** Assessment is always done around a skill**

comprehensive assessment – a thorough history and exam (family, history,

sexual orientation, total
physical exam, etc.)

focused assessment – information concerning only the problem at hand in

order to stabilize the current
situation

NURSING PROCESS
1. Assessment
2. Nursing Diagnosis (What’s the problem? What are the patient’s needs?)
3. Planning (What needs to be done?)
4. Implementation (Do what needs to be done to meet the patient’s
needs.)
5. Evaluate / Reassess (Have the patient’s needs been met?)
6. Documentation (If you don’t write it, you didn’t do it!!)
- documentation allows for thorough assessments to be passed to
others and followed up

USE COMMUNICATION SKILLS DURING THE INTERVIEW AND ASSESSMENT PROCESS

- interview is the basis for forming a disease prevention and therapeutic
partnership with the patient based on
honesty, empathy, mutual trust, and respect
- the personality and behavior of you and the patient during the interview, the
nature of the problem being
confronted, the physical setting and the economic basis on which care is
provided will have an
impact on the interview’s outcome

subjective interview data – information that the patient gives to the care
provider

objective interview data – information that you gather from assessing

(looking, touching, hearing) the
patient

RECOGNIZE ETHICAL CONSIDERATIONS IN PATIENT-EXAMINER RELATIONSHIPS

Autonomy – the patient’s need for self-determination
Beneficence – the clinician’s need to do good for the patient
Nonmaleficence – the clinician must do no harm to the patient
 Utilitarianism – appropriate use of resources for the greater good of the larger
community
Fairness and Justice – balance between autonomy and the competing interests
of the family and community
Deontologic Imperatives – duties of care providers established by tradition and
in cultural contexts

**We know why we do what we do, we don’t just do it.**

IDENTIFY ASPECTS OF COMMUNICATION THAT AFFECT THE INTERVIEW PROCESS

Flexibility – be flexible
- ask open ended questions
- open-endedness cannot be allowed to go on forever - - gently guide
interview back on track in
order to get all the needed questions answered
Specificity – open ended questions leaves discretion to the patient about the
extent of the answer
- direct questions seeks specific information
- leading questions are the most risky because they may limit the
information provided to what the
patient thinks you want to know

Facilitate – encourage your patient to say more

Reflect – repeat what you have heard to encourage more detail
Clarify – your questions must be clearly understood; be clear and
concise
Empathize – show your understanding and acceptance
Confront – Do not hesitate to discuss the patient’s disturbing behavior
Interpret – repeat what you have heard to confirm the meaning

Subtley – choose your words carefully

- children need age-appropriate responses to their questions
Empathy – show you care
Curiosity – often a direct answer, unvarnished by detail, will satisfy the
patient’s curiosity without significant
invasion of your personal life
Anxiety – a painful uneasiness of mind resulting from an impending procedure
or anticipated diagnosis
- answer questions forthrightly, never dissembling
- avoid an overload of information
Silence – be patient and do not force the conversation
- silence may have its uses, such as a moment of reflection or the
summoning of courage
- most people will begin to talk when they are ready
- patient’s demeanor, use of hands, and facial expressions contribute to
your interpretation of the
moment
Crying – people will cry, let them
Manipulation – be aware that it happens
 - be aware that it should not encourage you to depart from your
professional standard of care
Seduction – there are limits to your expressions of warmth and cordiality
- can be averted by being courteously calm and firm from the start,
delivering the clear – and –
immediate – message that the relationship is and must remain
professional
Anger – deal with it by confronting it, face it head on
- “put yourself between the patient and the door

DESCRIBE THE APPROPRIATE WAY TO CONDUCT AN INTERVIEW WITH CLIENTS OF DIFFERENT AGE GROUPS
Children - children are people, they want to have attention paid to them
- they do not want to be patronized or ignored
- they have anxieties and fears that must be anticipated and eased
- talk with them, hold them, reassure them, include them!
- allow them to be heard fully
- the older the child, the more productive it becomes to ask questions
directly

Adolescents – are sometimes reluctant to talk, give clear evidence of your

respect for their need for
confidentiality and for their impending adulthood
- do not force conversation
- they do not readily respond to confrontation

DESCRIBE AN IDEAL SETTING FOR A PATIENT INTERVIEW

- comfortable as possible
- make sure there are no bulky desks or tables between you and the patient

DISCUSS ELEMENTS TO INCLUDE IN A HISTORY

Biographical Information – personal information (name, weight, height, age,
contacts, insurance, etc.)
Chief Complaint (CC) – reason for seeking care
History of present illness or problem (HPI) – probably find that it is natural and
easiest to question the patient
on the details of the current problem immediately after obtaining the
chief complaint
- ultimately need the chronologic ordering of events
- need to establish state of health just before the onset of the present
problem
- get complete description of the first symptoms
Past medical history (PMH) – in-depth information about the patient
Family History (FH) – any blood relative
- with breast cancer in females, need to branch out into the family
Personal and social history (SH) – personal status, habits, sexual history, home
conditions, occupation,
environment, drinking, drugs (prescription and illicit), etc.
Review of systems (ROS) –
Concluding questions – trust is built and patient may be willing to give the
actual reason for seeking help or
 clarify in further encompassing other systems

REVISE HISTORY TAKING TO ACCOMMODATE AGE AND CONDITION RELATED VARIATIONS

Children - children are people, they want to have attention paid to them
- they do not want to be patronized or ignored
- they have anxieties and fears that must be anticipated and eased
- talk with them, hold them, reassure them, include them!
- allow them to be heard fully
- the older the child, the more productive it becomes to ask questions
directly

Adolescents – are sometimes reluctant to talk, give clear evidence of your

respect for their need for
confidentiality and for their impending adulthood
- do not force conversation
- they do not readily respond to confrontation
CHAPTER 2: CULTURAL AWARENESS

DISTINGUISH THE DIFFERENCE BETWEEN CULTURAL AND PHYSICAL CHARACTERISTICS

Cultural is a complex, integrated system reflecting the whole of human
behavior and experience
- a group’s adoption of shared values, the attempt to make sense of
their world

Physical is gender or skin color

- physical should not symbolize the cultural

DISCUSS THE IMPACT OF CULTURE ON HEALTH BELIEFS, PRACTICES, AND DISEASE

- poverty and inadequate education can have negative cultural impact
- racial and gender differences can have an impact on the care of individuals
even in the absence of financial
differences

IDENTIFY QUESTIONS THAT EXPLORE A CLIENT’S CULTURE

What do you think caused your problem?
when it did?
What does your sickness do to you?
How bad is your sickness?
What should be done to get rid of it?
treatment?
Why do you think it started
How does it work?
How long do you think it will last?
Why did you come to me for
CHAPTER 3: EXAMINATION TECHNIQUES AND EQUIPMENT

APPLY THE STANDARD PRECAUTIONS FOR INFECTION CONTROL TO THE EXAMINATION PROCESS
- applies blood and body fluid precautions universally to all persons regardless
of their presumed infection
status

Handwashing Mask, Eye Protection, Face Shield

Gloves Gown
Patient-Care Equipment Occupational Health and Bloodborne
Pathogens
Patient Placement Latex Allergy Awareness

DESCRIBE THE FOUR PRIMARY ASSESSMENT TECHNIQUES

Observation – always look first!!
- inspection is the process of observation
- observe gait and stance, color and moisture of the skin or unusual odor
- continues throughout the total time of care

Palpation – involves the use of the hands and fingers to gather information
through the sense of touch
- palmar surface of the fingers and finger pads is more sensitive than
the fingertips and is used
whenever discriminatory touch is needed for determining position,
texture, size, consistency,
masses, fluid, and crepitus
- ulnar surface of the hand and fingers is the most sensitive area for
distinguishing vibration
- dorsal surface of the hands is best for estimating temperature
- may be either light or deep and is controlled by the amount of
pressure applied with the fingers or
hand
light = press in to a depth up to 1 cm
deep = press in about 4 cm
- actuality of the “laying on of hands”

Percussion – involves striking one object against another, thus producing

vibration and subsequent sound
waves
- sound waves are heard as percussion tones (resonance) arise
 TONE INTENSITY PITCH DURATIO QUALITY EX. WHERE HEARD
N
Tympanic Loud High Modera Drumlik Stomach area
te e
Hyperreson Very Loud Low Long Boomlik Emphysematous
ant e Lungs
Resonant Loud Low Long Hollow Healthy Lungs
Dull Soft to Moderate to Modera Thudlike Over Liver
Moderate Hi te
Flat Soft Hi Short Very Over muscle,
dull bone
Auscultation – involves listening for sounds produced by the body
- stethoscope is usually used to augment the sound
- listening for breath sounds, heartbeats, or sequence of respirations
and heartbeats, each segment
of the cycle must be isolated and listened to specifically

DEFINE THE FOLLOWING PATIENT POSITIONS:

supine – patient lies flat on the back with legs extended and knees slightly
flexed
- facilitates abdominal muscle relaxation and is used to assess vital
signs and the head, neck,
anterior thorax and lungs, heart, breasts, abdomen, extremities,
and peripheral pulses

prone – patient lies flat on the abdomen with the head turned to one side
- used to asses the hip joint and posterior thorax

dorsal recumbent – patient lies on the back with legs separated, knees
flexed, and soles of the feet on the
bed
- should not be used for abdominal assessment as it causes contraction
of the abdominal muscles
- used to asses the head, neck, anterior thorax and lungs, heart,
breasts, extremities, and peripheral
pulses

sims – patient lies on either side with the lower arm below the body and the
upper arm flexed at the shoulder
and elbow
- both knees are flexed, with the upper leg more acutely flexed
- used to assess the rectum or vagina

lithotomy – patient is in the dorsal recumbent position with the buttocks at

the edge of the examining table
and the heels in stirrups
- used to asses female genitalia and rectum
 knee chest – patient kneels, with the body at a 90-degree angle to the hips,
back straight, arms above the
head
- used to assess the anus and rectum

erect – patient stands erect

- position should not be used for patient who are weak, dizzy, or prone
to fall
- used to assess posture, balance, and gait (while walking upright)

sitting – patient may sit in a chair or on the side of the bed or examining
table, or remain in bed with the
head elevated
- allows visualization of the upper body and facilitates full lung
expansion
- used to asses vital signs and the head, neck, anterior and posterior
thorax and lungs, heart,
breasts, and upper extremities

GIVE THE MAJOR PURPOSE FOR DRAPING AND PREPARING THE ENVIRONMENT AND PATIENT FOR
ASSESSMENT
Draping prevents unnecessary exposure, provides privacy, and keeps the
patient warm during the physical
assessment.
- gather all equipment and supplies and place within range for easy
access
- keep patient covered until ready to complete procedure