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NR509 advanced physical assessment midterm week 1-4.
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NR509 advanced physical assessmentmidterm week 1-4
The interview process - ANS-Initiating the session
Gathering information
Physical examination
Explanation and planning
Closing the session
These steps are proving structure and building the relationship
interviewing techniques - ANS-Nonverbal communication
Empathy
Active listening
Validation
reassurance
partnering
summarize
Guided questioning
Empowerment
Setting the stage for examination - ANS-Explaining point for point what the examination
will entail, preparing, privacy, awareness of the setting in which the exam is taking
place, do not assume it is ok to have others in the room, being aware of disabilities.
Establishing Rapport - ANS-Earning trust, following through, showing empathy and
compassion, being knowledgeable of the information provided
Gender Pronouns - ANS-How a person would like to be referred to. Ex: "She/Her"
"He/Him" "They/Them" etc.
How would you describe your sexual identity
How would you describe your gender identity
What is the sex on your original birth certificate
FIFE model - ANS-Feelings
Ideas
Functioning
Expectations
Helps explore the patient's perspective about their health and illness
,Patient-centered medical care - ANS-Involving the patient in their care and coming up
with a plan with the provider. Provider must acknowledge their own personal biases
while being aware of what is the safest Sam's most effective plan for the patient
Fundamentals of skilled interviewing - ANS-Active listening, empathetic responses,
guided questioning, nonverbal communication, validation, reassurance, partnering,
summarization, transitions, empowering the patient
verbal communication - ANS-expressing ideas to others by using spoken words
nonverbal communication - ANS-communication using body movements, gestures, and
facial expressions rather than speech
Challenging Patient Situations and behaviors - ANS-Silent
Talkative
With confusing narrative
With altered state or cognition
With emotional lability
Angry or aggressive
Flirtatious
Discriminatory
With hearing loss
With low or impaired vision
With limited intelligence
Burdened by personal problems
Nonadherent
With low literacy
With low health literacy
With limited language proficiency
With terminal illness or dying
5 R's off cultural humility - ANS-Reflection— what did I learn?
Respect—did I treat everyone involved w respect?
Regard—did unconscious bias drive this encounter?
Relevance—how was cultural humility relevant?
Resiliency—how did my personal resilience affect this interaction?
Core Values of Medical Ethics - ANS-nonmaleficence,
beneficence,
, respect for autonomy,
decisional capacity,
confidentiality,
informed consent,
truth telling,
justice
Focused Health History - ANS-ALL components of the Complete Health History with the
focus on the specific reason the client is seeking care.
Comprehensive Health History - ANS-includes biographic data, reason for seeking care,
present health status, past medical history, family history, personal and psychosocial
history, and a review of all body systems
Psych
Obstetrics
Surgery c-section goes here
Hospital stays
Components of Health History - ANS-1) Demographic information
2) Source of history
3) Chief concern
4) History of present illness
——OLDCARTS
5) Past health history and current health status
6) Family history
7) Social history
8) Health promotion behaviors
9) ROS
——all subjective
Determining the Scope of patient assessment - ANS-The patient's symptoms, age, and
health history help determine the scope of the focused examination, as does your
knowledge of disease patterns.
seven attributes of a symptom - ANS-1. Location
2. Quality
3. Quantity or severity
4. Timing (including onset, duration, and frequency)
5. The setting in which it occurs
6. factors that have aggravated or relieved the symptom
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