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NURS 5220: Module 1 Exam/160 Questions with Verified answers
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NURS 5220: Module 1 Exam/160 Questions with Verified answers
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NURS 5220: Module 1 Exam/160Questions with Verified answers
SOAP note - -SOAP note is both a process and a documentation format
-The Partnership with the Patient - -Getting to know your client:
Culture
Physical characteristics Influence on health and illness
Beliefs and behaviors Family relationships Preparing to be an effective health
care provider
-The History and Interviewing process - -The history and physical exam
begin the diagnostic and treatment process
The techniques you will learn are orderly but not rigid
To prevent misinterpretations and misperceptions, you must make every
effort to view the patient's perspective.
-GOALS - -Discover information leading to diagnosis and management
Provide information about diagnosis
Negotiate and share health care management
Counsel about disease prevention
-Autonomy - -Patient's self-determination
-Beneficence - -Do good for the patient
-Nonmaleficence - -Do no harm to the patient
-Utilitarianism - -Appropriate use of resources for the greater good
-Fairness and Justice - -Equitable treatment of all
-Deontological imperatives - -Care delivered according to traditions and in
cultural contexts
-Factors that Enhance Communication - -Establishing a positive patient
relationship depends on communication built on: Courtesy Comfort
Connection Confirmation Confidentiality
,Be Professional:
Attire & Response
-Enhancing Patient Responses - -Establish rapport and trust-Seek
connection
Open‐Ended Question-Allows patient discretion about the extent of an
answer
Direct Question-Seeks specific information
Leading Question
-May limit the information provided to what the patient thinks you want to
know
-If the patient does not understand what you are asking, remember to: - -
Facilitate: Encourage your patient to say more
Reflect: Repeat what you have heard.
Clarify: Ask "What do you mean?"
Empathize: Show understanding and acceptance.
Confront: Address disturbing patient behavior.
Interpret: Repeat what you have heard to confirm the patient's meaning.
-Communication TensionsLimit barriers - -curiosity about you
anxiety
silence
depression
crying
physical intimacy
emotional intimacy
anger
avoidance
financial considerations
-Setting for the Interview - -comfort
removal of physical barriers
good lighting
privacy
quiet
unobtrusive access to clock
, -Taking the history usually begins... - -your relationship with the patient
-Structure of the History - -Identifiers: name, date, time, age, gender, race,
occupation, and referral source
• Chief concern/complaint (CC)
• History of present illness (HPI)
• Past medical history (PMH)
• Family history (FH)
• Personal and social history (PH/ SH)
• Review of systems (ROS)
-Basic Rules for Building the History - -• Introduce yourself
• Address patient properly
• Be courteous
• Make eye contact
• Do not overtire patient
• Do not be judgmental
• Be flexible
Avoid medical jargon
• Take notes sparingly
• Avoid leading questions
• Start with general concerns, then move to specific descriptions.
• Clarify responses with where, when, what, how, and why questions.
• Verify and summarize what you have heard
-Building the History - -• Identify what the patient defines as problems.
• Establish patient's reliability.
• Consider intentional or unintentional suppression or underreporting of
information.
• Evaluate patient's words and behaviors.
• Adapt to the modifications that age, pregnancy, and physical and
emotional handicaps mandate
-Approaching Sensitive Issues - -• Ensure privacy.
• Be direct and firm.
• Do not apologize for broaching the issue.
• Do not preach.
• Use language that is understandable.
• Do not push too hard.
-Sensitive Issues - -• Alcohol and drug use
• Domestic violence
• Spirituality
• Sexuality
-CAGE Questionnaire - -- Cutting down
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