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Identify the guidelines for the patient interview.

1. The nurse uses therapeutic communication
techniques when conducting the interview.
2. Don’t overuse professional jargon or language.
3. Don’t use biased questions such as “you don’t
use drugs do you?”
4. Use positive non-verbal communication
5. Be aware of how the patient is responding
during interviewing.


What topics should you include in a health history?

*biographical data
*reason for seeking health care
*patient expectations
*present illness or health concerns
*health history
*family history
*environmental history
*psychosocial history
*spiritual health
*review of systems (ROS)
*documentation of history findings


What are some methods of data collection for a patient history?

*open-ended questions
*back channeling or repeating
*probing (getting more info)
*closed-ended questions


Discuss the purposes of physical assessment

*Triage for emergency care
• Routine screening to promote wellness &
preventive healthcare measures
• Determine eligibility for health insurance
• For hospital or LTC admission


What are the different types of physical assessment?

• Initial or Comprehensive assessment
• Focused assessment
• Interval assessment


what are the levels of consciousness?

*alert, oriented x3
*memory intact
*uses logic and judgement
* understands questions


what is the McCaffery definition of pain?

“Pain is whatever the
experiencing person says it
is, existing whenever the
experiencing person says it


What are the characteristics of a pain assessment?

• location
• onset, duration
• variations, rhythms
• what relieves the pain
• what increases the pain
• manner of expressing pain
• effects of pain
• quality
• intensity


What are the characteristics of pain? (PQRST)

*P- Palliative factors/ Provocative factors
*R- Radiation/Region
*T- Temporal factors


What is an important pain intensity question to ask?

–What is an acceptable level of
pain for you?


define health

“a state of complete physical, mental, & social well-being, not merely the
absence of disease or infirmity” (WHO, 1948)
• Individual variability
• A dynamic state of being in which the developmental and behavioral potential
is realized to the fullest extent possible (ANA, 1980)
• Not just the absence of illness


define health promotion

The process of equipping people to have control over, and to
improve physical, emotional, and social health.


what are internal variables influencing health?



what are external variables influencing health?

Cultural beliefs
Standards of Living
Social support networks


what are the levelsof preventative care?

*primary prevention
*secondary prevention
*tertiary prevention


activities that decrease the probability of illness or disease

primary prevention


activities of early diagnosis and treatment

secondary prevention


activities aimed at restoring the person to optimum functioning
through rehabilitation

tertiary prevention


what are some examples for active strategies for health promotion?

*weight reduction
*smoking cessation


what are some examples for passive strategies for health promotion?

*fortified milks and cereals
*fluoride in drinking water
*trans fat bans
*GMO debates


• Identify risk factors that could make an individual vulnerable to developing an acute or
chronic illness.

• Anything that can increase the vulnerability of an individual, family, or
community to develop an acute or chronic illness.
• Risk factors may or may not be controllable.
• Genetic – i.e. diabetes and heart disease
• Age – i.e. more children die from accidents, cancer risk increases with age
• Environment – air-water-earth
• Lifestyle – diet, alcohol, smoking, etc


Explain the role of the nurse in health promotion.

• Understand your patient’s perception of health & wellness
• Acknowledge influences
• Identifying their areas of risk
• Identifying their stage of change and readiness to learn
• Identifying the topic with the highest need
• Areas addressed by the nurse in health promotion:
• nutrition
• physical fitness
• weight control
• avoidance of tobacco and alcohol
• avoidance of substance abuse
• enhancing holistic care
● An important role of the nurse is to be an advocate.


Discuss examples of complementary alternative medicine (CAM).

• Traditional Chinese medicine
• Native American healing
• Botanical Healing- herbals, aromatherapy, homeopathy
• Nutritional Therapy
• Healing with the hands-Chiropractic, massage, acupuncture
• Mind-Body Therapies –Yoga, meditation, hypnotherapy, guided imagery
• Biofeedback
• Spiritual therapy
• Music, pet therapy


Discuss Healthy People 2020 and the health promotion goals for those in the United

4 broad goals:
•Increase quality and years of healthy life
•Eliminate health disparities
•Create environments that promote health
•Promote healthy behaviors


What is your General Survey?

• An observation or appraisal of the patient’s behavior and
• An overall review or first impression of the patient’s well being
• Generally a visual observation


Identify patient care equipment and assistive
devices in the patient room.

• IV pumps
• Portable O2
• O2 flow meters attached to wall
• Call light
• Beds, side rails
• Bedside tables
• Catheter drainage bag
• SCD’s
• Compression stockings
• Wall suction


What are some potential problems that you can come across during your survey?

*Call light
*bedside table
*catheter drainage bag
*chest tubes
*nasogastric tubes


What do you need to assess before taking vital signs?

*Comfort level
*Equipment needed to perform the skills


What are the 5 Vital Signs?

*Blood pressure


What are the advantages of using an oral thermometer?

*easily accessible
*comfortable for patient
*reflects rapid change in core temp