Nursing 202

• 1. Biomedical "Medical" Model
• - focus is the diagnosis and treatment of disease
• - assessment factors (signs and symptoms of disease)

• 2. Holistic Models (e.g. Nursing)
• - Expanded focus
• - Individuals are considered active participants in their health care
• - Assessment factors (expanded to include culture and values, family and social roles, self care behaviors, environmental stress, developmental tasks, etc. )

Primary Prevention: (promote optimum health prior to the onset of problems)-healthy diet, exercise, immunization, etc.

Secondary Prevention: (early identification and treatment of existing health problems)- PAP smear, mammogram, PPD, etc.

Tertiary Prevention: (rehabilitation and restoration of health)- cardiac rehab, etc.

A collection of subjective and objective data.

statements, symptoms (patient history)

• the signs, observations
• The methods include:
• 1. Inspection
• 2. Palpation
• 3. Percussion
• 4. Auscultation
• 5. Laboratory and diagnostic test results
• 6. Patient's medical records

Assessment data used to diagnose disease

Assessment data (used to diagnose a patient's response to actual or potential health problems)- pain, altered skin integrity, ineffective coping, etc.

• Medical diagnoses: asthma
• - Plan (prescribe drug therapy)
• Nursing diagnoses: impaired gas exchange (the patient's response to illness)
• - Plan: teach methods to improve gas exchange (e.g. smoking cessation, proper use of medications, etc.)

• 1. Complete (health history and physical examination)
• - e.g. 1st appointment in primary care, hospital admission

• 2. Episodic (mini data base concerning one problem)
• - e.g., acute illness [common cold]

3. Follow-up (to assess progress)

• 4. Emergency (rapid and focused data collection)
• - e.g. chest pain (do you have a history of heart trouble, MI, PUD, hiatal hernia?)
• - The type of data collection may quickly increase/decrease the level of suspicion for a certain type of problem.

• 1) Allows for collection of subjective data (e.g. health history, symptoms)
• 2) Assists the patient in identifying areas of concern and perceptions of health status.
• 3) Identifies person's problems and strengths
• 4) Establishes rapport and trust for an ongoing working relationship
• 5) Provides a comfortable bridge to the physical examination
• 6) Provides an opportunity for education

• 1) Purpose (clarify)- Why are you here?
• - it may not always be apparent.

2) Time (set time limits in the beginning)

• 3) Presence of others (other caregivers, family, friends, translator, etc.)
• - Affects communication (positive or negative effect)
• - May be unable to speak freely about issues (abuse, sexual problems,etc.)
• - May help with information acquisition.
• - interpreter e.g. violates confidentiality; risk of misinterpretation.

• 4) Confidentiality
• - avoid conversations of public places
• - don't discuss patients with friends/family; don't refer to patient by name
• - builds patient trust/decreases litigation

• Verbal:
• - tone, words, speed, vocalizations, what you don't say

• Nonverbal:
• - posture, gestures, facial expression, eye contact, body position, location in the room)- sometimes conveys more than verbal communication (SMILE)

• 1) Acceptance of others
• - tolerance for weaknesses
• - convey warmth, caring and acceptance
• - respect for other's health care decisions (may be different from yours)
• 2) empathy (to convey understanding for how the patient feels)
• 3) active listening (give the patient full attention)

• 1) Environment
• - attempt to achieve a comfortable setting (temperature, lighting, noise reduction, etc.)
• - control interruptions
• - sit 4-5 ft from pt and slightly to the side (allows pt to avoid eye contact if desired by looking straight ahead)
• - avoid standing (implies haste and superiority)

2) Professional Dress (e.g. good hygiene, keeping clothes and shoes neat and clean, and wearing a name tag)

3) Ensure physical or psychological privacy (private room or pull curtain)

• 1) impedes eye contact
• 2) attention shifting
• 3) interrupts patient's narrative flow
• 4) impedes observation of nonverbal behavior
• 5) can be threatening

- Introduction (Always introduce yourself and your title)- explain your role.

- Address patient by surname (Mr./Mrs./Ms.)- unless permission given to use 1st name

• - Open ended questions
• - requires narrative responses
• - used to begin interview
• - allows for description, leads to more info

• - Close ended questions
• - requires 1-2 word answers or yes/no responses
• - used to fill in omitted info or to get specific facts
• - ask only one question at a time

• 1) Facilitation (encourages patient to say more)- "uh huh" or "go on"
• 2) Silence (gives the patient time to think, helps him/her focus)
• 3) Reflection: (echoes the response; help patient elaborate)- ...you're telling me that it hurts when you cough
• 4) Empathy (shows understanding and acceptance)- "I can understand why your test results would upset you"
• 5) Clarification (describe what you mean by "upset stomach")
• 6) Confrontation: (use this technique if the history is inconsistent)
• - inconsistency may occur in one visit or over time
• - situation: obese male over 300 lbs
• - "before you told me that you rode your bike 10 miles/day, now you say you ride 25 miles/day"
• 7) Interpretation: (links events and associations; your impression of what patient has said)- "It seems as though every time you have a deadline to meet at work, you develop stomach pain"
• 8) Explanation (providing objective info)
• 9) Summary(final review of what the patient has said; surveys what we perceive the health problems/concerns to be)

• 1) Providing False Assurance (may lead to disappointment and lack of trust)- "I'm sure you will be all right"
• 2) Giving Advice
• - Don't shift accountability for decision making from the patient to you.
• - present patient with the facts and allow him/her to make an informed decision.
• 3) Using Authority "Your doctor knows best"
• 4) Avoiding Difficult Topics
• - Don't avoid discussion (allow the pt to discuss fears/dying etc.)
• 5) Engaging in Distancing: e.g. saying "the breast" instead of "your breast"
• 6) Using Professional Jargon (use language at the patient's level of understanding)
• 7) Using Leading or Biased Questions (you may not get honest or objective response)- You don't smoke do you?
• 8) Talking Too Much (you can't learn for yourself)
• 9) Interrupting (breaks pt train of thought)- may miss important info
• 10) Asking "Why" questions may put the pt on the defensive; too challenging; implies blame)
• - "why did you wait so long to bring your child to the hospital?"
• - It is better to teach regarding future behavior

• 1) Physical appearance (ill/well, student/professional, well groomed/poor hygiene, etc.)
• 2) Posture (relaxed/tense)
• 3) Gesture(agreement/anger/pain)
• 4) Facial expression (alert/relaxed/anxious)
• 5) Eye-contact (shy/withdrawn/depressed)
• 6) Voice (anxious/hearing impaired/sarcasm)
• 7) Touch

• 1) Hearing impaired- raising your voice increases the pitch and makes hearing worse
• 2) Acutely ill
• 3) Substance abuse
• 4) Personal questions (redirect conversation to the pt) [not obligated to divulge personal info]
• 5) Sexually aggressive (don't tolerate; confront) "your behavior makes me uncomfortable"
• 6) Crying (allow expression of emotions; don't change the subject)
• 7) Anger (deal with this emotion before going on with the interview)
• 8) Those who threaten violence-be sure that you are safe and don't hesitate to seek assistance from others around you
• 9) anxious

• 1) eye-to-eye contact
• 2) hand shaking
• 3) touch (may or may not be acceptable to the pt)
• 4) personal space and interview distance

• 1) Social Distance: 4-12 feet, Interview range
• 2) Personal Distance: 1.5-4 feet, Distance for most physical assessment
• 3) Intimate Zone: 0-1.5 feet, Some physical assessment (e.g. HEENT exam)