NURS 612 – Exam 1 CHEATS Weeks 1 – 4 Seidel Book Notes

NURS 612 – Exam 1 CHEATS Weeks 1 – 4 Seidel Book Notes

Key Point to Review Student Notes
What are the concepts in
developing a relationship
with the patient?
• Seek connection without bias – modify interactions to fit each patient
• Do not assume relationships – ask non-conforming questions and allow them to fill in the blanks
What are some effective
communication strategies
when obtaining a health
history?
• Open-ended questions – allow them to answer
• Courtesy – knock, learn names, take notes sparingly
• Comfort – maintain privacy, physical comfort
• Connection – maintain good eye contact if culturally allowed, avoid jargon, listen (do not dominate
discussion), avoid leading or direct questions at first, avoid judgement, be flexible
• Confirmation – ask patient to summarize the discussion, allow for questions or further
discussion
What is a patient-centered
question? Give examples.
Patient centered care is defined as: “respecting and responding to patients’ wants, needs and
preferences, so that they can make choices in their care that best fit their individual circumstances” Pt centered
questions are:
• How would you like to be addressed?
• How are you feeling today?
• What would you like for use to do today?
• What do you think is causing your symptoms?
• How do you feel about your illness?
• How are you coping with your illness?
• How important to you is “quality of life”?
• How do you define “quality of life”?
What are some potential
barriers of patient and
provider communication?
• Language barriers
• Curiosity about you as a person (i.e. personal questions)
• Anxiety
• Silence – do not fear this and overwhelm the pt. by forcing them to talk when they are not ready
• Depression – can be situational or secondary to other medications. Must be addressed
• Crying and compassionate moments – allow pt. to cry and resume interview/assessment when
they are ready
• Physical & emotional intimacy – respect modesty where able. Be clear and communicate. Do not
skip needed assessments
• Seduction – excessive flattery or manipulation toward provider. Firm boundaries are
necessary
• Anger – name their emotion, stay calm, avoid being defensive. Apologize only when
appropriate.
• Avoiding the full story – pts may not tell whole story or may avoid the truth, either on purpose
or subconsciously. Allow interview to continue but come back to a topic with further
questioning to illicit more thorough answer.
• Financial considerations – talk with candor and accurate information. Provide resources.
What is the structure and
the components of a patient
history? What kind of patient
information is obtained in
• Why is this happening to this particular patient at this particular time?
• Chief Complaint (CC)
o Brief statement about why patient is seeking care – quotes are helpful here
o Can include duration of problem here if desired
2 each section? • History of present illness (HPI)
o Ask pt. ‘when did you last feel well?’
o Specify characteristics of presenting symptoms:
â–ª Location, duration, intensity, description/character, aggravating factors, alleviating
factors
o If presenting problem is intermittent or has happened before – have them describe a
typical attack – is this time different and how?
o Possible exposure to infection, toxic agents, or environmental hazards
o How has it impacted daily life?
o Immediate reason that prompted pt. to seek care – especially if this is a longstanding problem (why now)?
o Appropriate/relevant system review
o Meds: current & recent – include Rx and non-Rx, home remedies and herbal
o Review above with patient to confirm accuracy
o Repeat process with each problem
• Past medical History (PMH)
o General health
o Gender identity
o Childhood illnesses – measles, mumps, whooping cough, etc.
o Major adult illnesses or chronic diseases – TB, hepatitis, DM, CVA, etc.
o Immunizations – dates and any unusual reactions
o Surgical history
o Serious injuries
o Limitations in functional abilities due to past events
o Medications – past, current, and recent meds (include dosage)
o Allergies and what reaction pt. has
o Transfusion history
o Recent screening tests – cholesterol, pap smear, colonoscopy, etc.
o Emotional status – mood d/o, etc.
• Family history (FH) – blood relatives in the immediate or extended family with illnesses similar
to patient’s presenting concern
o Include:
â–ª Asthma, heart disease, HTN, CA, TB, stroke, sickle cell disease, CF,
epilepsy, DM, gout, kidney disease, thyroid disease, forms of arthritis, blood
diseases, STIs, familial hearing or visual issues
â–ª CA – determine whether isolated or has occurred in multiple family
members
â–ª Note age and outcome of any illness
â–ª Note ethnic/racial background of family
â–ª Note age and health of patient’s spouse/partner or the child’s parents
• Personal and social history (SH)
o Personal status – home environment, where raised
o Habits – nutrition, sleep, substance use (caffeine, cigarettes, ETOH, etc)
o Self-care – use of home, herbal, natural remedies
o Sexual history
o Home conditions
o Occupation
o Environment – travel and other possible exposure to illness
o Military record
o Religious and cultural preferences
o Access to care
o Social needs
• Review of systems (ROS)
o General – pain, fever, chills, fatigue, night sweats, sleep pattern, weight changes
o HEENT
o Lymph nodes
o Chest and lungs
o Breasts
o Heart & vessels
o Peripheral vasculature
o GI -
â–ª Diet – restrictions
o Endocrine
o GU
o Musculoskeletal
o Psych

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