Term
|
Definition
| therapeutic interpersonal interaction which generally involves the meeting of needs |
|
|
Term
|
Definition
| involves therapeutic touch (short term) and listening (long term) |
|
|
Term
| 4 areas of interest for verbal communication & 4 forms of non-verbal |
|
Definition
| MELT: "Mr. or Mrs./Ms.", Enunciation, Language (lay terms, propriety), and Tone; vs. PEG Face: Posture, Eye contact, Gestures, and Facial expressions |
|
|
Term
| 4 main factors influencing communication |
|
Definition
| Development, Gender, Culture, and Physiological Ability |
|
|
Term
|
Definition
| pay Attention, monitor Non-verbals, Paraphrase and repeat, don't Interrupt, Encourage talking, Visualise: A New PIE Voice |
|
|
Term
|
Definition
| AEIOU: Audition, Evaluation, Inquiry, Observation, and Understanding |
|
|
Term
|
Definition
one designed to elicit a long-answer, for the pt to synthesize information
ex: "What can you tell me about your fever?" |
|
|
Term
|
Definition
one designed to glean further information about a prior statement
"What do you mean when you say, 'hurts'?" |
|
|
Term
| close-ended/direct question |
|
Definition
one designed to elicit a clear, black and white answer.
"Do you smoke?" |
|
|
Term
|
Definition
| repetition to verify meaning |
|
|
Term
|
Definition
| vocalization of nurse's impression of pt's emotional state |
|
|
Term
| List 4 barriers/blocks to a good interview |
|
Definition
| There are seven: talking too much, false reassurance, professional/esoteric language (in lieu of layman's terms), "why" questions, interrupting, authoritativeness, leading questions, and unwanted advice |
|
|
Term
| 5 aspects of Health History |
|
Definition
who, what, when, where, and how
Who: source of information (self, parent, PCP, etc.)
What: reason for seeking care
When: History of Present Illness or Health
Where: location of pain/illness, location of pt upon onset
How: does it feel? did it happen/start?
Where and How often go together (present health status) |
|
|
Term
|
Definition
| chief complaint, written in pt's words, including onset, duration, frequency, location, and radiation |
|
|
Term
|
Definition
PQRSTU:
P: Pt's Perception; Provocative/Palliative
Q: Quality/Quantity
R: Region/Radiation
S: Setting/Severity
T: Timing
U: Understanding |
|
|
Term
| Past Medical History (list 5 aspects) |
|
Definition
| There are 8: childhood illnesses, major adult illnesses, immunizations, surgeries, accidents, Allergies, Transfusions, and Medications |
|
|
Term
| Important things to remember about: Transfusions and Medications |
|
Definition
T: when was it, how'd it go; is pt allowed if needed during stay?
M: dose, frequency, start time, and last for each |
|
|
Term
|
Definition
Causes of death for immediate family if applicable
Major medical problems in immediate family if applicable |
|
|
Term
Which system(s) would/could be reviewed upon pt report of:
a. weird mole b. dizziness c. SOB d. swelling e. lethargy |
|
Definition
a. integumentary
b. HEENT, neuro, cardio
c. respiratory
d. lymph, cardio, GI/GU
e. HEENT, cardio, musculoskeletal, psych, neuro |
|
|
Term
|
Definition
Assess 3 areas
1. ADLs/IADLs, including exercise/rest
2. Nutrition/Elimination (diet, frequency of voiding/BMs)
3. Psychosocial: including self-concept, interpersonal relationships, and coping |
|
|
Term
| Other Functional Assessments |
|
Definition
Health Promotion: exercise, vaccines
Environment/Occupation
Spirituality |
|
|
Term
| Gender Specific Assessments |
|
Definition
Puberty: onset, menses
Secondary: breast health, testicular pain
Infertility
Health promotion/Prevention: breast/prostate cancer screening, etc. |
|
|
Term
| Sensitive Topics for History |
|
Definition
| Sex, drugs, and rock n' roll (alcohol) |
|
|
Term
|
Definition
Growth and Development
Mother's Prenatal Health
Labor and Delivery
Neonatal health
Feeding (breast or otherwise) |
|
|
Term
|
Definition
PACES
Parents/Peers
Accidents, Alcohol/Drug use
Cigarettes
Emotional Status
School & Sex: overweight, gay, etc. lots of judgement, don't add to it |
|
|
Term
|
Definition
| Mobility, ADLs, and Cognition (MAC) |
|
|
Term
| Special Considerations for Taking Aging Medical History |
|
Definition
| May take longer, pt may not report all symptoms/meds |
|
|
