ATI - Chapter 26 Flashcards
Data collection includes obtaining _______ and _____ data from clients.
subjective and objective
The health history provides _____ data.
subjective
The physical examination and diagnostic tests provide ______ data.
objective
_______ are a framework for obtaining information about clients’ physical, developmental, emotional, intellectual, social and spiritual dimensions.
standardized formats
_______ for health assessment foster communication and create an environment that promotes an optimal health assessment/data collection experience.
therapeutic techniques
Therapeutic communication helps develop rapport with clients. The techniques encourage a _____ relationship, whereby clients feel comfortable telling their story.
trusting
Therapeutic communication begins with the purpose of the interview, gather information, and then conclude the interview by _________
summarizing the findings.
When using therapeutic communication introduce yourself and the various parts of the _____.
assessment
When using therapeutic communication determine what the client wants you to _____.
call him
When using therapeutic communication allow more time for responses from ______.
older adults
When using therapeutic communication make sure the client is ______.
comfortable (temp, chair, bed, etc)
When using therapeutic communication, when possible, start by asking for the health history, performing the general survey, and _______ to build rapport prior to moving on to more sensitive parts of the examination.
measuring vital signs
When using therapeutic communication reduce environmental noises (TV, radio, visitors talking) to enhance communication and eliminate ______.
distractions
When using therapeutic communication ensure understanding by obtaining ______ services for clients who have language or other communication barriers.
interpretive
When using therapeutic communication note the client’s ______ communication (body language, eye contact, tone of voice).
nonverbal
When using therapeutic communication avoid using ______, giving advice, ignoring feelings, and offering false reassurance.
medical/nursing jargon
Health History Components
Demographic info Source of history Chief concern History of Present Illness Past Health History and Current Health Status Family History Pscyhosocial History Health Promotion Behaviors
Demographic Information to Collect
Name, address, contact info Birth date, age Gender Race, ethnicity Relationship status Occupation, employment status Insurance Emergency contact info Family, others living at home Advance directives
Source of history can come from client, family members or close friends, other medical records, ______. The reliability of the historian must be taken into account.
other providers
A brief statement in the client’s own words of why is is seeking care is called the ______.
chief concern
A detailed, chronological description of why the client is seeking care is called the _________. Details about the manifestations, such as location, quality, quantity, setting, timing (onset and duration), precipitating factors, alleviating or ______ factors, associated phenomena (concomitant manifestations)
history of present illness
aggravating
Past health history and current health status include ______ illnesses, both communicable and chronic.
childhood
Past health history and current health status include medical, _____, obstetrical, gynecological, psychiatric history, including time frames, diagnoses, hospitalizations, and ______.
surgical
treatments
Past health history and current health status include ____ to medication, environment, food.
allergies