inference
is your judgment or interpretation of
these cues
Health perception–health management pattern:
Describes patient’s selfreport
of health and well-being; how patient manages health (e.g., frequency
of health care provider visits, adherence to therapies at home);
knowledge of preventive health practices
Nutritional-metabolic pattern:
Describes patient’s daily/weekly pattern of
food and fluid intake (e.g., food preferences or restrictions, special diet,
appetite); actual weight; weight loss or gain
Elimination pattern:
Describes patterns of excretory function (bowel,
bladder, and skin)
Activity-exercise pattern
Describes patterns of exercise, activity, leisure,
and recreation; ability to perform activities of daily living
Sleep-rest pattern
Describes patterns of sleep, rest, and relaxation
Cognitive-perceptual pattern:
Describes sensory-perceptual patterns; language
adequacy, memory, decision-making ability
Self-perception–self-concept pattern:
Describes patient’s self-concept
pattern and perceptions of self (e.g., self-concept/worth, emotional patterns,
body image)
Role-relationship pattern:
Describes patient’s patterns of role engagements
and relationships
Sexuality-reproductive pattern
Describes patient’s patterns of satisfaction
and dissatisfaction with sexuality pattern; patient’s reproductive patterns;
premenopausal and postmenopausal problems
Coping–stress tolerance pattern:
Describes patient’s ability to manage
stress; sources of support; effectiveness of the patterns in terms of stress
tolerance
Value-belief pattern
Describes patterns of values, beliefs (including spiritual
practices), and goals that guide patient’s choices or decisions
An initial patientcentered
interview involves:
(1) setting the stage, (2) gathering
information about the patient’s chief concerns or problems and
setting an agenda, (3) collecting the assessment or a nursing health
history, and (4) terminating the interview
back channeling
Reinforce your interest in what the patient
has to say through the use of good eye contact and listening skills. includes active
listening prompts such as “all right,” “go on,” or “uh-huh.”
Open-Ended Questions
- Tell me how you are feeling.
- Tell me how your health has been.
- Describe how your wife has been helping you.
- Give me an example of how you get relief from your pain at home.
Closed-Ended Questions
- Do you think the medication is helping you?
- Who helps you at home?
- Do you understand why you are having the x-ray examination?
- Are you having pain now?
- On a scale of 0 to 10, how would you rate your pain?
Precipitating factors
What makes symptoms worse? Are there activities (e.g., exercise) that affect the symptoms
assessing these factors
• Location—Where is the symptom located?
• Onset and duration—When did it start? How long has it
lasted?
• Precipitating factors—What makes symptoms worse? Are
there activities (e.g., exercise) that affect the symptoms?
• Relieving factors—What does the patient do to become
more comfortable or relieve the symptoms?
• Quality—Have the patient describe what the symptom
feels like.
• Severity—Have the patient rate the severity on a scale of
0 to 10. This gives you a baseline with which to compare
in follow-up assessments.
• Concomitant symptoms—Does the patient experience
other symptoms along with the primary symptom? For
example, does nausea accompany pain?
