NR 509

Mid-Term

Exam

● Chapter 1

Basic and Advanced Interviewing Techniques

Basic maximize patient's comfort, avoid unnecessary changes in position, enhance

clinical efficiency, move head to toe, examine the patient from their right side

Active listening, empathic responses, guided questioning, nonverbal communication, validation,

reassurance, partnering, summarization, transitions, empowering the patient

Active Listening- closely attending to what the patient is communicating, connecting to the

patient’s emotional state and using verbal and nonverbal skills to encourage the patient to

expand on his or her feelings and concerns.

Empathic Responses-the capacity to identify with the patient and feel the patient’s pain as your

own, then respond in a supportive manner.

Guided Questioning- show your sustained interest in the patient’s feelings and deepest

disclosures and allows the interviewer to facilitate full communication, in the patient’s own

words, without interruption.

Non-verbal- includes eye contact, facial expression, posture, head position and movement such

as shaking or nodding, interpersonal distance, and placement of the arms or legs-crossed,

neutral, or open.

Validation- helps to affirm the legitimacy of the patient’s emotional experience.

Reassurance- an appropriate way to help the patient feel that problems have been fully

understood and are being addressed.

Partnering- building rapport with patients, express your commitment to an ongoing relationship.

Summarization- giving a capsule summary of the patient’s story during the course of the

interview to communicate that you have been listening carefully.

Transitions- inform your patient when you are changing directions during the interview.

Empowering the Patient- empower the patient to ask questions, express their concerns, and

probe your recommendations in order to encourage them to adopt your advice, make lifestyle

changes, or take medications as prescribed.

Advanced: Determine scope of assessment: Focused vs. Comprehensive: pg5

Comprehensive: Used for patients you are seeing for the first time in the office or hospital.

Includes all the elements of the health history and complete physical examination. A source

fundamental and personalized knowledge about the patient, strengthens the clinician-patient

relationship.

● Is appropriate for new patients in the office or hospital

● Provides fundamental and personalized knowledge about the

patient

● Strengthens the clinician–patient relationship

● Helps identify or rule out physical causes related to patient

concerns

● Provides a baseline for future assessments

● Creates a platform for health promotion through education

and counseling

● Develops proficiency in the essential skills of physical

examination

Flexible Focused or problem-oriented assessment: For patients you know well returning for

routine care, or those with specific “urgent care” concerns like sore throat or knee pain. You will

adjust the scope of your history and physical examination to the situation at hand, keeping

several factors in mind: the magnitude and severity of the patient’s problems; the need for

thoroughness; the clinical setting—inpatient or outpatient, primary or subspecialty care; and the

time available.

● Is appropriate for established patients, especially during

routine or urgent care visits

● Addresses focused concerns or symptoms

● Assesses symptoms restricted to a specific body system

● Applies examination methods relevant to assessing the

concern or problem as thoroughly and carefully as possible

Tangential lighting: JVD, thyroid gland, and apical impulse of heart.

Components of the Health History Jenna/Ashley

Initial information

Identifying data and source of the history; reliability

Identifying data- age, gender, occupation, marital status

Source of history- usually patient. Can be: a family member or friend, letter of referral, or clinical

record.

Reliability- Varies according to the patient’s memory, trust, and mood.

Chief Complaint

Chief Complaint- Make every attempt to quote the patient’s own words.

Present Illness

Complete, clear and chronological description of the problem prompting the patient visit

Onset, setting in which it occurred, manifestations and any treatments

Should include 7 attributes of a symptom:

● Location

● Quality

● Quantity or severity

● Timing, onset, duration, frequency

● Setting in which it occurs

● Aggravating or relieving factors

● Associated manifestations

-Differential diagnosis is derived from the “pertinent positives” and “pertinent negatives” when

doing Review of Systems that are relevant to the chief complaint. A list of potential causes for

the patients problems.

-Present illness should reveal patient’s responses to his or her symptoms and what effect this

has on their life.

-Each symptom needs its own paragraph and a full description.

-Medication should be documented, name, dose, route, and frequency. Home remedies, nonprescriptions drugs, vitamins, minerals or herbal supplements, oral contraceptives, or borrowed

medications.

-Allergies-foods, insects, or environmental, including specific reaction

Tobacco use, including the type. If someone has quit, note for how long

-Alcohol and drug use should always be investigated and is often pertinent to the Presenting

Illness.

Past history

-Childhood Illness: measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever,

scarlet fever, and polio. Also include any chronic childhood illness

-Adult illnesses: Provide information in each of the 4 areas:

● Medical: diabetes, hypertension, hepatitis, asthma and HIV;

hospitalizations; number and gender of sexual partners; and risk

taking sexual practices.

● Surgical: dates, indications, and types of operations

● Obstetric/gynecologic: Obstetric history, menstrual history,

methods of contraception, and sexual function.

● Psychiatric: Illness and time frame, diagnoses,

hospitalizations, and treatments.

-Health Maintenance: Find out if they are up to date on immunizations and screening tests.

Review Tb tests, pap smears, mammograms, stool tests for occult blood, colonoscopy,

cholesterol levels etc..

Family history

Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and

grandparents

Documents presence or absence of specific illnesses in family, such as hypertension, coronary

artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis,

tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide,

substance abuse, and allergies, and symptoms reported by patient.

Ask about history of breast, ovarian, colon, or prostate cancer

Ask about Genetically transmitted diseases

Personal or social history

Describes educational level, occupation, family of origin, current household, personal interests,

and lifestyle

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