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NURSING: 1st QUARTER > History and Interviewing > Flashcards

History and Interviewing Flashcards

1
Q

What are the goals of history an interviewing?

A

Lead pt to maximum wellness
Discover info leading to diagnosis and management
Provide information about diagnosis
Share info with health care management
Education and prevention

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2
Q

Privileged Communication

A

Protects physicians, APNs or dentists from disclosing information against a patient on trial

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3
Q

Pitfalls in taking Hx

A

not appreciating cultural differences
judgmental
making medical model the only paradigm
bias and lack of personal awareness
medical jargon
failing to check for pt understanding

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4
Q

Patient Level Barriers

A

Lack of Assertiveness
Trust
Fund of Knowledge - Lack of understanding about dx

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5
Q

Provider Level Barriers

A

Lack of Cultural Competence
Stereotyping
Intersection of Patient and Provider Barriers

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6
Q

Ethical Context Respect and Flexibility

A

Autonomy
Beneficence
Utilitarinaism
Nonmaleficience
Fairness of Justice
Deontological

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7
Q

Factors that Enhance Communication

A

Courtesy
Comfort
Connection
Confirmation
Confidentiality
Patient Centered

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8
Q

Leading Questions

A

“Have you been taking your meds?”

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9
Q

Techniques to Enhance Communication

A

Facilitate - encourage to say more
Reflect - Repeat back
Clarify
Empathize
Confront - Address disturbing behavior
Interpret - Repeat back

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10
Q

Communication Tensions

A

Curiosity about you
Anxiety
Silence
Depression
Crying
Physical intimacy
Seduction
Anger
Avoidance of full story
Financial Considerations - Can they afford meds

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11
Q

Structure of Hx

A

Identifiers: name, date, time, age, gender, race, occupation, and referral source
Chief Complaint
History of present illness (HPI)
Past medical history (PMH)
Family history
Personal and social history (SH)
Review of Systems(ROS)

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12
Q

Building the History

A

Avoid medical jargon
Take notes sparingly
Avoid leading questions
Start with general concerns, then move to specific descriptions
Clarify responses (where, when, what, how, and why)
Verify and summarize

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13
Q

Goal of screening

A

Find out if a problem exists

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14
Q

CAGE Questionnaire

A

Cutting down
Annoyance by criticism
Guilty Feeling
Eye-opener

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15
Q

TACE Questionnaire

A

how many drinks does it TAKE to feel high?
ANNOYANCE by criticism
have you felt you ought to CUT down on drinking
do you take EYE-OPENER drinks in morning for hangovers

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16
Q

CRAFFT Questionnnaire

A

More so for adolescents
have you driven or ridden a CAR driven by someone under the influence?
do you ever take drugs to RELAX, feel better or fit in?
do you ever take drugs when you’re ALONE?
do you FORGET the things you did when using drugs?
do you have a FAMILY member or FRIEND tell you to cut down?
have you ever gotten into TROUBLE from using?

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17
Q

Three questions to detect partner violence

A

Have you been hit, kicked, punched or otherwise hurt by someone in the past year?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is making you feel unsafe now?

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18
Q

HITS questionnaire

A

Hurt you physically?
Insult or talk down to you?
Threaten you with physical harm?
Scream or curse at you?

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19
Q

FICA Questionnaire

A

Faith - spiritual heritage? writings important to you?
Importance - beliefs influence how you handle stress?
Community - belong to a spiritual community?
Address - do religious beliefs affect health decisions?

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20
Q

Gender neutral questions

A

Tell me about your living situation
Are you sexually active? In what way?

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21
Q

Different types of health history

A

Brief
Complete Inventory
Interim (see pt 6mo.-1yr)
PE (physical examination)

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22
Q

OLD CARTS for HPI

A

Onset
Location
Duration
Character - Stabbing or dull?
Aggravating/associated factors
Relieving factors
Temporal factors - continuous in the morning?
Severity

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23
Q

Chief Complaint

A

Note all significant complaints
What symptoms brought you here?
How long has problem been present?
Note age, gender, marital status, occupation and previous hospital admissions

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24
Q

HPI

A

Chronology of events
Health state before present problem
First symptoms
Exposure to infection or toxic agents
Typical attack
Illness impact on lifestyle
Stability of problem
Immediate reason for visit
Review of involved systems
Medications list
Complementary or alternative therapies
Chronology review
Problem list

25
PMH
General health Childhood illnesses Major adult illnesses Hospitalizations Serious injuries Accidents Disability Immunizations Past medication Blood transfusions Allergies Recent Screening Tests Emotional Health
26
Social History
Socioeconomic status Access to care Occupation Living conditions Drugs Smoking Intimate Partner Violence Spiritual Sexual hx Military hx Living or traveling abroad Home Conditions Safety - guns, seat belts or helmets
27
Obstetric Hx
GTPAL - gravida, term, preterm, abortions, living
28
Menstrual hx
age of menarche, frequency, duration, amount of flow, pain or other problems, LMP (last menstrual period) , LNMP (last normal menstrual period)
29
Family Hx
Blood relatives with similar illness Blood relatives with hx of major disease Determine if any cancers have been multiple, bilateral, occuring more than once and occuring at a young age (less than 50 y/o) Note age and outcome of illnesses Ethnic and racial background Note the age and health of spouse or patients parents
30
ROS
General constitutional symptoms, Skin, hair and nails Head and neck Lymph nodes Chest and lungs Breasts Heart and blood vessels Peripheral vascular Hematologic GI Diet Endocrine Genitourinary Musculoskeletal Neurological Psychiatric Concluding questions
31
General Constitutional Symptoms
Fever, chills, malaise, fatigability, night sweats, sleep patterns, Weight - average, preferred, present, change
32
Skin, hair and nails
rash, eruption, itching pigmentation excessive sweating abnormal nail or hair growth
33
Head and Neck: General
Headaches, dizziness, syncope, head injuries, Loss of Conciousness
34
Head and Neck: Eyes
Acuity, blurring, diplopia, photophobia, pain, vision changes, glaucoma, trauma
35
Head and Neck: Ears
Hearing loss, pain, discharge, tinnitus, vertigo
36
Head and Neck: Nose
Sense of smell, colds, obstruction, epistaxis, postnasal discharge, sinus pain
37
Head and Neck: Throat and Mouth
Hoarseness or change in voice, sore throats, bleeding gum, tooth abscesses, extractions, soreness or ulcers of tongue/mucosa, taste changes
38
Lymph Nodes
Enlargement, tenderness, suppuration (pus forming)
39
Chest and Lunga
Pain, dyspnea, cyanosis, wheezing, cough, sputum, hemoptysis, night sweats, exposure to TB, last chest radiograph
40
Breasts
Development, pain, tenderness, discharge, lumps, galactorrhea, mammograms (screening and diagnostic), self-awareness, self-examination
41
Heart and Blood Vessels
Chest pain, palpitations, dyspnea, orthopnea, edema, claudication, hypertension, previous MI, exercise tolerance, date of last ECG, other cardiac tests
42
Peripheral Vascular
Claudication - frequency, severity Tendency to bruise or bleed Thromboses Thrombophlebitis
43
Hematologic
Anemia, blood cell abnormalities, past transfusions
44
GI
Appetite, digestion, food intolerance, dysphagia, heartburn, N/V/D, hematemesis, regularity of bowels, constipation, change in stools, hemorrhoids, jaundice, previous imaging studies
45
Diet
Appetite, likes and dislikes, diet restrictions, cultural constraints, vitamins and other supplements, caffeine, dietary recall
46
Endocrine: General
Thyroid enlargement or tenderness, heat/cold intolerance, weight change, diabetes, polydipsia, polyuria, changes in facial or body hair, increased hat or glove size, skin striae
47
Endocrine: Female
Menses, discharge, itching, lasp pap smear, libido, intercourse, birth control, infertility, pregnancy, menopause
48
Endocrine: Male
Puberty onset, erections, emissions, testicular pain, libido, infertility
49
Genitourinary
STIs, dysuria, pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, dribbling, loss in force of stream, passage of stone, edema of face, stress incontinence, hernias
50
Musculoskeletal
Joint stiffness, pain, restriction of motion, swelling, redness, heat, bony deformity
51
Neurologic
Syncope, seizures, weakness or paralysis, abnormalities of sensation or coordination, tremors, loss of memory
52
Psychiatric
Depression, mood changes, difficulty concentrating, nervousness, tension, SI, irritability, sleep disturbances
53
Concluding Questions
Is there anything else you think would be important for me to know? What problem concerns you most?
54
Considerations for Children
Mother's gestational history, pregnancy, and birth Child's neonatal period, feeding, and development Child's school adjustment, habits and home life Review systems for child-specific conditions
55
HEEADSSS
For adolescents Home environment Education Eating Activities, affect, ambitious, anger Drugs Sexuality Suicide/depression Safety
56
PACES
For adolescents Parents, peers Accidents (alcohol/drugs) Cigarettes Emotional issues School, sexuality
57
Considerations for Pregnant Women
Current pregnancy and obstetric hx exposure to environmental/occupational hazards family genetic conditions/congenital personal and social issues of pregnancy and parenting Reproductive, CV, endocrine, resp. focus Risk factors that threaten mother and fetus
58
Older Adults
Watch age-related changes like sensory loss, visual impairment, cognitive impairment, or memory loss Draw on persons cumulative lifetime experience
59
Health history of older adults
Multiple overlapping health problems Chronic symptoms Complete drug assessment Assessment of functional capacity

NURSING: 1st QUARTER (9 decks)

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