Midterm Health ASSESSMENT via book ALL SOLUTION 2024/25 EDITION GUARANTEED GRADE A+
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Course
Mdterm Health ASSSSMENT via book
Institution
Mdterm Health ASSSSMENT Via Book
The nurses role in health promotion
The nurse documents and retrieves assessment data through many ways.
Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
A.D.P.I.E
Assessment
Diagnosis
Planning
Implementation
Evaluation
Generic framework for health assessment in...
6512 Midterm Exam LATEST EDITION
2024/25 GUARANTEED GRADE A+
·Communication techniques used to obtain a patient's health history
Courtesy, Comfort, Connection, Confirmation
Courtesy Communication Technique
• Knock before entering a room.
• Address, first, the patient formally (e.g., Miss, Ms., Mrs., Mr.)
It is all right to shake hands.
• Meet and acknowledge others in the room and establish their roles
and degree of participation.
• Learn their names.
• Ensure confidentiality.
• Be in the room, sitting, with no effort to reach too soon for the
doorknob.
• If taking notes, take notes sparingly; note key words as reminders
but do not let note-taking distract from your observing and listening.
• If typing in the electronic medical record, type briefly and
maintain eye contact with patient, if possible.
• Respect the need for modesty.
• Allow the patient time to be dressed and comfortably settled after
the examination. Follow-up discussion with the patient still "on the
table" is often discomfiting.
Comfort Communication Technique
• Ensure physical comfort for all, including yourself.
• Try to have a minimum of furniture separating you and the patient.
• Maintain privacy, using available curtains and shades.
• Ensure a comfortable room temperature or provide a blanket—a cold
room will make a patient want to cover up.
• Ensure good lighting.
• Ensure necessary quiet. Turn off the television set.
• Try not to overtire the patient. It is not always necessary to do
it all at one visit.
Confirmation Communication Technique
• Ask the patient to summarize the discussion. There should be clear
understanding and uncertainty should be eased.
• Allow the possibility of more discussion with another open-ended
question: "Anything else you want to bring up?"
• If there is a question that you cannot immediately answer, say so.
Be sure to follow up later if at all possible.
• If you seem to have made a mistake, make every effort to repair it.
, Candor is important for development of a trusting partnership. Most
patients respect it.
Connection Communication Technique
• Look at the patient; maintain good eye contact if cultural
practices allow.
• Watch your language. Avoid professional jargon. Do not patronize
with what you say.
• Do not dominate the discussion. Listen alertly. Let the patient
order priorities if several issues are raised.
• Do not accept a previous diagnosis as a chief concern. Do not too
readily follow a predetermined path.
• Find out whether the patient has turned from other healthcare
providers to come to you.
• Take the history and conduct the physical examination before you
look at previous studies or tests. Consider first what the patient
has to say.
• Avoid leading or direct questions at first. Open-ended questions
are better for starters. Let specifics evolve from these.
• Avoid being judgmental.
• Respect silence. Pauses can be productive.
• Be flexible. Rigidity limits the potential of an interview.
• Assess the patient's potential as a partner.
• Seek clues to problems from the patient's verbal behaviors and body
language (e.g., talking too fast or too little).
• Look for the hidden concerns underlying chief concerns.
• Never trivialize any finding or clue.
• Problems can have multiple causes. Do not leap to one cause too
quickly.
• Define any concern completely: Where? How severe? How long? In what
context? What soothes or aggravates the problem?
SOAP Notes
S Subjective data—the information, including the absence or presence
of pertinent symptoms, that the patient tells you
O Objective data—your direct observations from what you see, hear,
smell, and touch and from diagnostic test results
A Assessment—your interpretations and conclusions, your rationale,
the diagnostic possibilities, and present and anticipated problems
P Plan—diagnostic testing, therapeutic modalities, need for
consultants, and rationale for these decisions
Ethical Considerations
• Autonomy: The patient's need for self-determination. Autonomy
suggests that choices exist, and a patient may choose between
alternatives. Uncertainty exists when the patient is a child or is
cognitively impaired. Parents, guardians, family, or other
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