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History.Percuss.330.Fall.09
 

History.Percuss.330.Fall.09

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Week 1 Health History

Week 1 Health History

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History.Percuss.330.Fall.09 History.Percuss.330.Fall.09 Presentation Transcript

  • Health History Interview
    • Nursing 330
    • Shirley Comer
  • History and Physical – Overview of The Classic Format
    • Biographical Info
    • Chief Complaint – Reason for seeking Treatment
    • History of the Present Illness – (Current Health Status)
    • Past Health History
    • Family History
    • Psychosocial Profile
    • Review of Systems
    • Summary of Findings
    • Physical Assessment
      • Findings and Plan for treatment
  • Biographical and Chief Complaint
    • Biographical Data
      • Name, address, phone#, Sex, marital status, race, ethnic origin, occupation, religion, dependants, education level, Insurance, advanced directives
    • Source of Information
      • From pt or family or other
    • Chief Complaint
      • Why did pt seek services- In pt own words & in quotes
  • History of Present Illness
    • Elaborates on the Chief Complaint
      • Onset, Duration & severity
        • Pain rating if warranted
      • Symptoms
      • Precipitating, Alleviating or aggravating factors
      • Home treatments
      • Any medical treatments
      • Why seeking treatment now
  • Past History
    • Childhood Illnesses
      • Measles, Chicken Pox, Mumps ect
    • Accidents or Injuries
      • Dates and causes
    • Hospitalizations and operations (get dates)
    • Major Health Conditions
      • Dates, current state of condition
    • Immunizations- including flu, pneumonia, Hep B, gardisil, & tetanus vaccines
    • Allergies
      • Environmental, food and medication
      • Describe reaction
  • Health History (cont)
    • List of current medications
      • include doses and times
      • OTC meds
      • Health food supplements
      • Complimentary or alternative medicine treatments
    • Recent Travel/Military Service
  • Family History
    • Age and health or cause of death of each immediate blood relative, including grandparents
    • Age and health or cause of death of each natural child
    • Genogram
  • Genogram pix
  • Psychosocial Assessment
    • Heath care practices and beliefs
    • Typical day
    • 24 hour diet recall
    • Spiritual assessment
      • Religion if any
      • Is a Chaplin needed
      • Special practices of religion
        • Blood transfusions
        • Abortion
        • Surgery
        • Dietary concerns
  • Psychosocial Assessment cont
    • Assess activities of daily living
    • Assess self care abilities
      • Self-Esteem
        • Education, financial, values, religious practices
      • Activity
        • Amount and ability to perform
      • Sleep
        • Patterns and use of aids, naps
  • Psychosocial Assessment cont
      • Interpersonal relationships
        • Support systems
      • Coping
        • Perceptions of stress, major life changes
      • Personal habits
        • Can they care for themselves
      • Drugs, ETOH, Tobacco use
      • Environmental Hazards
        • Throw rugs, inadequate heat, water
      • Occupational
        • Hazards of work place
  • Review of Systems
    • General health status sexual
    • Skin nose lungs MS
    • Hair sinuses CV Neuro
    • Nails mouth PV Hemo
    • Head throat GI Endocrine
    • Eyes Neck GU
    • Ears Axilla Genital
  • Example of Subjective Write up of Review Of Systems
    • Skin Hair and Nails :
      • Pt denies psoriasis, itching, rashes, scars, sores, ulcers, and warts. Reports mole on left cheek that has been present and unchanged since early childhood. Pt reports no changes in hair textures, or reaction to hot and cold. Denies hair loss or changes to nails. Reports longitudinal ridges have been present in nails since childhood. Pt reports she colors her hair every 6 weeks at a salon and shampoos her hair daily.
  • Example of Objective information write up
    • Skin, Hair and Nails :
      • Uniform skin color with slightly darker exposed areas. No jaundice, cyanosis, pallor or erythema. Mucus membranes and conjunctiva pink. No unusual odors. Hair evenly distributed, no alopecia. Nails well groomed and convex. No clubbing noted.
  • Getting Started
    • Choose comfortable room
    • Provide privacy
    • Reduce noise, distractions
    • Sit 4 to 5 feet from pt. Avoid standing
    • Remain at pt’s level
    • Introduce your self and explain procedure
    • Don’t use first name unless invited to
  • Strategies in Interviewing
    • Use open ended questions to invite elaboration.
      • “ Tell me about your cancer treatment”
    • Use closed ended questions to inhibit elaboration or refine answer.
      • “ Did you have Chemotherapy.”
  • Strategies cont
    • Facilitation- encourage pt to continue
      • “ uh-Huh”, “go on”, “yes”
    • Silence- Allows interviewer and pt to gather thoughts
    • Reflection- Focuses on last topic
      • “ You said your head hurts after dinner”
    • Empathy- Allows pt to express feelings
      • “ This must be very hard for you”
  • Strategies cont
    • Clarification- clears up confusion
      • “ What do you mean by tired blood”
    • Confrontation- Allows interviewer to focus on topic not brought up by pt
      • “ You say your arm doesn’t hurt but you’re not moving it”
    • Interpretation- allows interviewer to link topics
      • “ It seems that you get a headache after every vacation”
    • Explanation- Teach
    • Summary- Condenses all information
  • Ten Traps of Interviewing
    • 1. Providing false reassurance
      • “ I’m sure you’re going to be OK”
    • 2. Giving unwanted advise
      • “ If I were you I’d ________”
    • 3. Using authority
      • “ Your Doctor knows best”
    • 4. Using avoidance Language- using euphemisms
      • “ Passed on, I’ve got sugar ect”
  • Traps cont
    • 5. Distancing- impersonal speech
      • “ the left breast has a lump”
    • 6. Using Professional jargon
      • “ When did you void last”
    • 7. Using leading or biased questions
      • “ You don’t smoke, do you?”
  • Traps cont
    • 8. Talking too much
      • prevents pt from focusing on task
    • 9. Interrupting
      • let pt finish own sentences
      • Don’t share personal info
    • 10. Asking “why” questions- implies blame
      • “ Why would you go near an x-ray machine if you’re pregnant”
  • Tools of Physical Assessment
  • Introduction to assessment techniques
    • Classic sequence used during physical assessment
      • Inspection – observation
      • Percussion – assessing underlying structures by taping technique
      • Palpation – touch
      • Auscultation – listening with stethoscope
  • Assessment Techniques (cont)
    • All physical assessments should follow this structure
    • Only exception is in the abdomen
      • Auscultation done before palpation and percussion to avoid stimulating bowel sounds
    • Note that auscultation is done last.
  • Inspection
    • Uses sense of sight, hearing and smell to assess pt
  • Palpation
    • Uses sense of touch
    • Allows assessment surface texture, consistency, temperature, symmetry
    • Pulsations, rigidity, chest excursion
  • Percussion technique
    • Lightly place only the middle finger of your nondominant hand on the surface to be percussed
    • Quickly strike with the pad of the middle finger of your dominate hand
    • Assess the quality of the sound
      • Dull = underlying solid tissue
      • Resonant/tympanic = air filled space
  • Auscultation
    • Uses stethoscope to assess sound
    • Breath sounds, bowel sounds, murmurs, bruits, egophony ect..
  • The Stethoscope pix