Module 2 Flashcards
(138 cards)
1
Q
what is the purpose of a patient interview and who established it as the foundation of nursing practice?
A
Establish a therapeutic partnership and gather information. Introduced by Hildegard Peplau.
maintains privacy and confidentiality, while the nurse demonstrates professionalism, sensitivity, and nonjudgemental behavior
2
Q
during therapeutic communication, his information shared verbally or non-verbally?
A
Both.
3
Q
What are five dimensions of a patient centered assessment via therapeutic communication
A
- empathy
- unconditional regard (respect as a unique individual)
- genuine honesty/openness
- caring
- respect (maintains dignity)
4
Q
Define clear framework in therapeutic communication
A
CLEAR
Center- pause, focus, connect w/ compassion
Listen - being present
Empathize
Attention
Respect - honor differences
5
Q
what are you do to prepare for a patient interview
A
Review the patient’s medical record and ensure a distraction, private environment with good lighting and temperature
6
Q
during the interview, what should you do?
A
introduce yourself, explain the purpose, be on the same level as the patient either sitting or standing, reassure confidentiality. The patient remains clothed until the physical assessment begins. Don’t rush, don’t use medical jargon, and use language appropriate for the patients developmental level.
7
Q
An example of active listening
A
paying attention, verbal & nonverbal cues while maintaining eye contact
8
Q
broad opening question example
A
what can i do for you today
9
Q
example of clarification
A
What do you mean when you say, the rash comes and goes?
10
Q
What’s an example of confrontation?
A
you said you don’t drink but mention being arrested for a DUI can we discuss this?
11
Q
What’s an example of empathy
A
I’m sorry to hear about your pain. How is it affected your life?
12
Q
What’s an example of of showing respect?
A
You’ve shown great strength in caring for your children during this difficult time
13
Q
What’s an example of exploring?
A
Tell me more about your back pain
14
Q
what is the example of facilitation?
A
Using prompts like and then? Or. Mmmmhmm
15
Q
What’s an example of focusing?
A
How many stairs can you climb before feeling short of breath?
16
Q
What’s an example of reflection?
A
Patient: I might have breast cancer
Nurse: you seem upset. are you angry about missing the mammogram
17
Q
What’s an example of a transitional statement
A
now, let’s discuss your family history.
18
Q
What’s an example of silence?
A
Allow brief pauses for reflection for about 5 to 10 seconds each
19
Q
What’s an example of summarizing?
A
Let me summarize the key points we discussed.
20
Q
is it OK to record how you feel about the event when documenting?
A
no. Record observations without bias and should remain objective.
21
Q
what are some barriers to therapeutic communication from you?
A
- leading the patient and influencing their responses
- asking too many questions so they get overwhelmed
- not allowing enough time to respond
- using medical jargon
- assuming what the patient means
- using cliches (“you’ll feel better in the morning” which undermines their concerns)
- offering false reassurances
- Asking WHY questions (it can feel accusatory)
- changing the subject abruptly esp. if the discussion is uncomfortable
- giving opinions (only provide information)
- stereotyping (every patient should be treated as an individual)
- patronizing (dearie, sweetie, esp to older adults)
22
Q
how to communicate with hearing impaired patients
A
Ensure hearing is functional. Minimize background noise. Speak slowly clearly and face the patient. Use written communication if necessary and AVOID SHOUTING.
23
Q
how to communicate with visually impaired patients?
A
Introduce yourself and explain the sequence of an assessment. Describe the environment and physical set up. Ask permission before touching and guide the patient with descriptive cues. Let the patient know when you leave the room.
24
Q
How to communicate with aphasic patients?
A
definition: patient can’t communicate through speech or writing.
provide a quiet environment. Speak slowly clearly, and one at a time. Use pictures, writing, or drawing if necessary. Although extra time for responses and avoid rushing.
25
How to communicate with cognitively impaired patients?
Patient has difficulty with thinking, remembering or understanding.
Use simple focus questions. Repeat is necessary. Maintain eye contact and speak slowly. Gathering information from caregivers or family if necessary.
26
how to communicate with aggressive patients
Stay calm and empathic and reassuring. Less actively in avoid arguments. Speak softly and maintain a non-threatening posture. Ensure clear exit route.
27
how to communicate with someone who has a language barrier. Meaning they have a little understanding of English.
Hire trained interpreter instead of family members. Speak directly to the patient and not to the interpreter. Ask simple clear questions. Ensure the patient’s language preferences are respected.
28
how to speak to a patient with low health literacy?
Use simple language, and avoid medical jargon. Incorporate, pictures, models, or diagrams. Verify understanding by asking patient to explain the information back. A.k.a. teach back method.
29
what to keep in mind while speaking to a patient with a different culture?
realize that they may have discomfort when discussing private issues. variable physical closeness and touching. preference for the same gender sometimes. allow modesty and realize that direct eye contact may be disrespectful. avoid generalizations.
30
what are examples of open ended questions?
Encourage patient to express her thoughts and provide detailed answers.
How do you remember to take all of your medication?
Tell me more about how you are feeling?
What brings you in today?
31
what are examples of closed ended questions?
did you ever try to lose weight weight?
Useful for clarifying details after starting with open ended questions.
Typically a yes, or no answer.
32
What is full preparation for a patient interview entail?
* Review the patient’s medical record (if available).
* Organize your thoughts and plan how to collect the data.
* Set goals for the interview.
* Assess professional appearance and demeanor.
* Create a comfortable, private environment.
* Wash your hands in front of the patient to follow standard precautions.
* If family members are present, clarify their relationship to the patient and ask for permission for their involvement.
* Document who was present during the interview.
33
What are three phases of a patient interview?
Intro, working, summarization
34
What is the introduction phase of an interview?
“Hello Mrs. Mangos, my name is Trisha, and I am a registered nurse. I will be asking you questions about your health before Dr. Brown sees you. This will take about 20–25 minutes. I’ll take some notes as we talk. Are you comfortable?”
## Footnote
Introduce yourself, explain your role, and establish rapport and trust.
State the purpose of the interview, expected duration, and note-taking.
Ensure the patient is comfortable and address them respectfully (use Mr., Mrs., Ms., or Dr., unless told otherwise).
35
What is the working phase of an interview?
* Collect information using a combination of open- and closed-ended questions.
* Encourage self-reporting and be attentive to nonverbal communication.
* Identify patient problems and goals.
* Allow the patient to ask questions.
36
What is the summarization phase of an interview?
* Summarize the patient’s report to confirm accuracy and shared understanding.
* Clarify any remaining concerns or questions.
* Validate goals with the patient.
37
What is the health history?
A patient provides critical pertinent information.
Includes ROS as a subcategory. ROS goes over all 11 body systems and asks them about symptoms they are having in each. This info is subjective.
38
What are three types of health histories?
1. Comprehensive
2. Focused
3. Follow up
39
What is a comprehensive health history and when do you perform one?
* Reviews the whole patient and **all body systems**.
* Common during **annual physical exams or first-time visits**
* Example: Head-to-toe review of systems.
40
What is a focused/problem based health history and when do you perform one?
* Addresses a **specific problem** or symptom. For example, shortness of breath. This would cause the encounter to focus on respiratory system and other systems that could cause shortness of breath.
* Common in urgent care or emergency settings.
* Example: A patient with breathing difficulty focuses on the respiratory and cardiac systems.
41
What is a follow up history and when do you do one?
* **Reviews new data since the last visit.**
* Example: Evaluating treatment effectiveness for heart palpitations during a follow-up appointment.
42
Explain a primary source of data?
Information comes from the patient being assessed. most reliable.
43
Explain a secondary source of data?
* Family members, significant others, or medical records.
* Used when the patient cannot communicate due to sensory deficits, physical limitations, or cognitive disabilities.
* Example: “Patient is unreliable; report by patient’s son.”
44
How do you determine if the patient is reliable historian? aka info is accurate
if the patient provides accurate info, they should be able to tell you answers that you yourself can confirm.
Verify with confirmable questions (e.g., “What is your date of birth?" Where are you? What season is it? Who is the president”).
For unreliable sources, rely on secondary sources and document appropriately.
45
Do you document subjective or objective data?
Both
| objective data is physically observable.
subjective data is told by pt.
46
What is an overview of health history
key purposes of the Health History
* Create a database of past and current medical history, including:
* Chronic conditions, surgeries, hospitalizations.
* Document family health history.
* Identify psychosocial influences on health.
* Assess self-care and health promotion practices.
* Recognize patient strengths and weaknesses.
* Determine educational and discharge needs.
* Plan case management or referrals as necessary.
47
At the very beginning of the health history, what do you establish?
Reason for being here
48
Reason for being here overview
also called chief compliant (CC) or presenting problem.
Either an annual physical, some condition, or a main symptom they complain about.
Always begin with an open ended question. Later will ask focused questions.
## Footnote
On average it takes a patient three minutes to tell you what they want to say.
49
What is an HPI?
A history of present illness. It usually includes only pertinent information. An HPI should tell you everything important you should know to understand a patient's situation.
Common mneumonics for this is OLDCARTS and LMNOPQRSTUV. You only have to pick one or the other.
## Footnote
I prefer OLDCARTS because it flows the best with conversation
50
OLDCARTS?
* Onset: When did the symptom begin?
* Location: Where is the symptom felt? Does it radiate?
* Duration: Is it constant or intermittent? How long does it last?
* Characteristics: Describe the sensation or appearance.
* Aggravating/Alleviating Factors: What makes it better or worse?
* Related Symptoms: Are other symptoms present (e.g., nausea)?
* Treatment: What treatments have been tried? Were they effective?
* Severity: Rate the intensity (1 to 10) or impact on daily life.
51
LMNOPQRST?
* Location: "Can you point to where it hurts?"
* Mechanism: "What do you think caused the problem?"
* New: "Is this a new issue for you?"
* Onset: "When did the symptoms begin?"
* Palliative/Provocative: "What makes it better or worse?"
* Quality: "How would you describe the sensation (e.g., sharp, dull)?"
* Radiation: "Does the symptom spread anywhere else?"
* Severity: "On a scale of 1–10, how intense is the symptom?"
* Timing: "Does it occur at specific times or is it constant?"
* Unusual Symptoms: "Have you noticed anything unusual?"
* Valid: "Do the symptoms feel real to you?"
* Work: "Have these symptoms affected your daily activities or work?"
52
Example of a pertinent positive?
Located in the HPI.
Patient complains of coughing, wheezing, shortness of breath, pinpoint chest pain, nausea, and vomiting.
53
Example of a pertinent negative?
Located in the HPI?
Denies rhinorrhea, facial pain, trouble with swallowing, malaise, body aches, fever, fatigue, weight loss.
54
Summary of some key points (just read this)
* Holistic Approach: The health history integrates physical, psychological, social, and cultural dimensions of health.
* Patient-Centered Communication: Build rapport, ensure confidentiality, and adapt to the patient’s needs.
* Systematic Inquiry: Use mnemonics like OLDCARTS to gather detailed symptom information.
* Documentation: Accurately record subjective data, including pertinent positives and negatives, and verify source reliability.
55
What is done in biographical data?
- assess patient as a reliable source.
* Name, address, date of birth (DOB), birthplace.
* Age, gender, race, religion.
* Primary and secondary languages.
* Marital status and occupation.
* Health insurance.
* Allergies (drug, environmental, food).
* Reaction Documentation: Include type of reaction (e.g., "Pollen—watery eyes").
* Emergency contact information.
56
What is done in the military history section?
* "When and where did you serve, and in what branch?"
* "What type of work did you do in the service?"
* "Did you experience any illnesses, injuries, or hospitalizations during your service?"
* "Were you exposed to chemicals, viruses, radiation, or combat situations?"
** Special Considerations:**
* Address sensitive topics like unwanted sexual experiences, living situation, PTSD, depression and exposure to hazardous materials.
* Provide information about Veterans Affairs (VA) services and resources for military-related healthcare needs.
## Footnote
depending on the war, they are exposed to war specific things.
57
Key info in medications section
* Include: Name, dose, route, frequency.
* OTC, herbal, supplements, vitamens
*prescription medicaitons
can also educate patients about the purpose, actions, and side effects of their medications.
58
Immunizations section
* "What immunizations have you had?"
* Include dates/years if available.
* Educate about immunizations they are due for.
59
What is the Health Prevention and Promotion for?
Have you gotten x screening done? When was the last one?
Examples: Last annual physical exam, cancer screenings, cholesterol tests, X ray for smokers,
60
PMH / past medical history section
* Childhood Illnesses: (e.g., measles, chickenpox, rheumatic fever).
* Adult Illnesses: (e.g., diabetes, hypertension, cancer, STIs).
* Accidents/Injuries.
* Serious/Chronic Illnesses: (e.g., autoimmune diseases, arthritis).
* Hospitalizations: Include medical, surgical, obstetric, psychiatric, or rehabilitative.
* Surgeries: Year and type of procedure.
* Mental/Emotional Illnesses: (e.g., anxiety, depression).
61
Family history section
* Focus on **first-degree relatives** (parents, siblings, children).
* Extend to grandparents, aunts, uncles, and cousins if relevant.
* **Genogram** (Pedigree):
* Visual representation of **three generations.**
* Include relationships, causes of death, and health/illness histories.
* Identifies hereditary conditions (e.g., heart disease, cancer).
62
What is a psychosocial assessment?
Lifestyle, behavior, social relationships, employment, functional capacity, environmental factors.
63
behavioral questions
Questions:
What are your daily habits?
What healthcare practices do you follow regularly?
Describe your daily activities.
64
environmental questions
* Describe your physical and social environment.
* Are there allergens or hazards in your home (e.g., asbestos, poor water quality)?
* Are you exposed to harmful substances at work or home?
65
Social questions
* How would you describe your social interactions and relationships?
* Do you participate in any community or cultural activities?
* Do you practice a particular spirituality or religion?
66
financial and economic questions
* Are you financially secure and able to support yourself?
* How do you manage your household finances?
67
Education questions
* What is your highest level of education?
* Do you have a college or graduate degree? What was your major?
68
Occupational questions
* Are you employed outside the home? What do you do for a living?
* Do you have medical benefits through work?
* Does your job require sitting for long periods, using machinery, or exposure to hazards (e.g., fumes, loud noise)?
69
Housing or environmental questions
* What type of housing do you live in? How would you describe your neighborhood?
* What type of transportation do you use?
70
Exercise questions
* Do you exercise regularly? What type of exercise and for how long?
71
Sleep/rest questions
* How many hours of sleep do you get each night?
* Do you have difficulty falling asleep or staying asleep?
* Have you been diagnosed with sleep apnea?
72
Safety questions
* Do you use seat belts, helmets, or other protective gear?
* Do you have smoke or carbon monoxide detectors at home?
73
Tobacco use questions
* Do you smoke cigarettes, cigars, or use e-cigarettes? How many per day?
* Pack year history
* Do you chew tobacco?
74
How do you calculate the pack year history? (math)
Pack-Years History:
* Formula: (Cigarettes per day ÷ 20) × years smoked.
* Example: 15 cigarettes daily for 21 years = 16 pack-years.
75
Support system/home life questions
* Who lives with you? Describe your family and support system.
76
Stress and coping mechanism questions
* Do you feel stressed? What are your stressors?
* How do you relieve stress?
77
What is the BATHE assessment technique?
* BATHE Assessment Technique:
* Background: “What is going on in your life?”
* Affect: “How do you feel about that?”
* Trouble: “What troubles you most?”
* Handling: “How are you handling it?”
* Empathy: “That must be difficult.”
## Footnote
responding to when someone feels stress
78
Domestic violence section
* Definition: Pattern of abusive behavior to maintain power or control over a partner.
* Screening Questions:
* Have you been hit, slapped, or otherwise hurt by someone in the past year?
* Do you feel safe in your current relationship?
* Do you feel threatened or controlled by someone?
* HITS screening
79
What is the HITS screening tool? What is a positive result?
HITS Screening Tool:
* Measures frequency of behaviors (e.g., being hurt, insulted, threatened, or screamed at).
* Score ≥10 indicates positive screening.
80
Alcohol assessment questions
* How often do you drink? What type of alcohol?
* How many drinks per day or week?
* Have you ever been arrested for driving under the influence?
* Define “social drinking” if mentioned by the patient.
CAGE
81
How many drinks per day is moderate drinking?
How many drinks per week is hazardous drinking?
Moderate Drinking Guidelines:
* Men: 2 drinks/day.
* Women/Older Adults 65+: 1 drink/day.
Hazardous Drinking:
* 14 drinks/week (men)
* 7 drinks/week (women)
82
Street drug section questions?
* Do you take recreational drugs? At what age did you start?
* Do you use prescription pain medication regularly?
83
What is the screening tool used for alcohol misuse?
What is a positive score?
CAGE (think trapped in a cage if addicted)
* “Have you ever felt you needed to cut down on drinking/drug use?”
* “Have people annoyed you by criticizing your drinking/drug use?”
* “Have you ever felt bad/guilty about drinking/drug use?”
* “Have you ever had a drink/drug first thing in the morning?”
Scoring: 1+ positive response indicates a possible issue.
84
What is an alternative alcohol screening and why would we use it instead of CAGE
sensitive to **current** drug and alcohol disorders rather than **lifetime** abuse.
TICS
* In the past year, have you used drugs/alcohol more than you meant to?”
* “Have you wanted or needed to cut down?”
## Footnote
remember TICS because you are compelled by a 'TIC' of drinking alcohol
85
Why collect a sexual history?
* Identifies potential risks, such as sexually transmitted infections (STIs) and unintended pregnancies.
* Provides an opportunity for patient education and addressing concerns.
* Helps reduce stigma and promotes access to quality STI care (aligned with Healthy People 2030 goals).
86
What is essential while collecting a sexual history
gender neutral language like partner or spouse, nonjudgemental, treat conversation as routine.
87
What is good to say before collecting a sexual history?
* “I’m going to ask you some questions about your sexual health and practices. These questions are very personal, but they are important for your overall health.”
* “I ask all adult patients these questions, regardless of age, gender, or marital status. Your responses are confidential. Do you have any questions before we begin?”
88
What questions do you ask during a detailed sexual history
General Sexual History:
* Tell me about your sexual history.
* Is there someone special in your life?
* Are you sexually involved with anyone?
Gender of Partners:
* Do you have sex with men, women, or both?
Safe Sex Practices:
* Are you practicing safe sex?
* Do you and your partner use protection against STDs? What kind of protection? How often?
* If "sometimes," in what situations or with whom do you use protection?
STI Testing and Prevention:
* Have you ever been tested for HIV or other STDs?
* Do you have any questions about protection from STDs?
Current Sexual Health Concerns:
* Are you or your partner experiencing any sexual difficulties?
Female-Specific Questions:
* Do you experience pain during intercourse (dyspareunia)?
* Do you have vaginal itching or unusual discharge?
Male-Specific Questions:
* Do you have difficulty ejaculating or maintaining an erection?
* Do you have any unusual-colored discharge from your penis?
## Footnote
Provide tailored education on STI prevention, testing, and treatment options.
89
What is a functional assessment?
Evaluates a patient’s ability to perform Activities of Daily Living (ADLs) and identifies the level of independence or need for assistance.
90
Name the type types of ADLs
Basic ADLs:
* Bathing
* Dressing
* Eating
* Walking
Instrumental ADLs (IADLs):
* Housekeeping
* Meal preparation
* Shopping
* Driving
91
Questions to ask during functional assessment?
* Can you perform [specific ADL] independently, or do you need assistance?
* If assistance is needed, who helps you and how often?
* Are there any activities you have difficulty with due to health or environmental factors?
92
Describe a cultural assessment
**Cultural Competence:**
* Nurses must develop awareness of cultural similarities and differences.
* Provide care holistically by considering cultural preferences and respecting diversity.
* Access resources like the National Center for Cultural Competence for guidance.
**Patient-Centered Care:**
* Establish trust by displaying warmth, respect, and active listening.
* Avoid assumptions; ask questions to understand the patient’s cultural norms.
93
What are some key questions for a cultural asssessment?
* What is your ethnic background, and how does it influence your health beliefs?
* Are there cultural practices or traditions that affect your healthcare preferences?
* Do you have any dietary restrictions or preferences related to your culture or health condition?
* What are your feelings about physical touch or eye contact during care?
* How does your family participate in healthcare decisions?
* Are there any topics or activities that you avoid because of cultural beliefs?
94
Cultural assessment demographics section
Name, address, date of birth.
Ethnic origin.
Primary and secondary languages.
Need for an interpreter.
95
Family and social dynamics cultural section
* Name and relationship of significant others.
* Family living arrangements and roles within the family.
* Main decision-maker in the family.
* Support systems and individuals responsible for health concerns.
96
Health beliefs cultural section
* Special health beliefs and practices.
* Perception of illness and preferred methods of treatment.
* Previous medical assistance sought and its effectiveness.
97
Religious beliefs cultural assessment
* Religious practices, requirements, or restrictions affecting care.
* Impact of religious beliefs on health decisions.
98
Culture assessment preferences and sensitivities
* Taboos or topics the patient is unwilling to discuss.
* Activities the patient avoids due to cultural customs or taboos.
* Personal feelings regarding touch and eye contact.
* Time orientation (past, present, or future focus).
99
Bioethical considerations (cultural assessment)
* Illnesses or nutritional deficiencies common in the patient’s cultural group (e.g., hypertension in African Americans, lactose intolerance in Asian Americans).
* Dietary preferences or restrictions related to culture or illness.
100
Cultural assessment biocultural considerations
Patient’s usual response to:
* Anxiety
* Anger
* Loss or change
* Pain
* Fear
101
Cultural assessment foods and nutrition section
* Favorite foods and foods requested or refused due to cultural beliefs or illness.
102
Spiritual Assessment
103
How can spirituality impact patients?
Spirituality influences perceptions of health, illness, and recovery.
It promotes positive health outcomes, especially in chronic conditions (more hope)
104
How does spirituality differ from religion?
* Religion: Organized system of beliefs, practices, rituals, and worship shared by a group.
* Spirituality: Broader and individualized, related to meaning, purpose, and life direction.
105
What do you do as a nurse in regards to someone's religion/spirituality?
* Praying with the patient (if appropriate and requested).
* Offering a sacred or calming space.
* Listening empathetically and attentively.
* Avoiding judgment or bias regarding a patient’s spiritual or religious beliefs.
106
What is a spiritual assessment tool?
FICA Spiritual Assessment Tool
Developed by Dr. Christina Puchalski to guide healthcare professionals in addressing spiritual concerns.
107
What does the F stand for in FICA?
F: Faith, Belief, and Meaning
* Purpose: Identify if the patient has spiritual beliefs or practices that provide support or meaning in life.
* “Do you consider yourself spiritual?”
* “Do you have spiritual beliefs, practices, or values that help you cope with stress or difficult times?”
* If the response is “No”:
* “What gives your life meaning?”
* Common responses include family, career, or nature.
108
What does the I stand for in FICA?
I: Importance and Influence
* Purpose: Understand the significance of spirituality in the patient’s life and its impact on healthcare decisions.
* “What importance does spirituality have in your life?”
* “Has your spirituality influenced how you take care of yourself, particularly regarding your health?”
* “Does your spirituality affect your healthcare decision-making?”
109
What does the C stand for in FICA?
C: Community
* Purpose: Determine if the patient has a community for spiritual or emotional support.
* “Are you part of a spiritual community?”
* “Is your community supportive to you, and how?”
* For non-religious patients:
* “Is there a group of people you deeply care for or rely on?”
110
What does the A stand for in FICA?
A: Address and Action in Care
*Purpose: Collaborate with the patient to integrate spirituality into their care plan.
*“How would you like me, as your healthcare provider, to address these issues in your healthcare?”
111
ROS general status
* What is your current state of health?
* When was your last physical exam or visit to a healthcare provider?
* Do you experience fever, chills, night sweats, weight changes, weakness, fatigue, or mood changes?
112
HEENT ROS
* Head, Eyes, Ears, Nose, and Throat (HEENT)
*Head:
* Have you experienced headaches, dizziness, or head injuries?
*Eyes:
* When was your last eye exam? Do you have vision changes or eye pain?
*Ears:
* Have you noticed hearing loss, ringing (tinnitus), or discharge?
*Nose:
* Do you experience nasal congestion, loss of smell, or nosebleeds?
*Throat:
* Have you had difficulty swallowing, hoarseness, or dental issues?
112
ROS skin hair nails
Skin:
* Have you noticed rashes, lesions, itching, or bruising?
* Do you use sunscreen or visit tanning salons?
Hair:
* Have you experienced hair loss, itching, or changes in hair texture or distribution?
Nails:
* Have you noticed changes in nail color, thickness, or texture?
113
Respiratory system ROS
Do you experience coughing, wheezing, or shortness of breath?
Have you ever had a chest X-ray or tuberculosis test?
114
Cardiovascular ROS
* Do you have chest pain, palpitations, or swelling in your extremities?
* When was your last electrocardiogram (EKG)?
115
Gastrointestinal GI ROS
* Have you had nausea, vomiting, or changes in bowel habits?
* Have you noticed blood in stool or abdominal pain?
115
Genitourinary (GU) ROS
* Do you experience frequent or painful urination?
* For men: Do you have difficulty starting urination?
* For women: Do you perform Kegel exercises?
116
Musculoskeletal ROS
* Do you have joint or muscle pain?
* Have you experienced falls or used assistive devices like a cane or walker?
117
Neurological ROS
* Have you experienced memory loss, balance issues, or seizures?
* Do you have changes in coordination or senses (vision, hearing, touch)?
118
Peripheral Vascular ROS
* Do you have numbness, tingling, or swelling in your extremities?
* Have you noticed changes in skin color?
118
Hematological (blood) ROS
Do you experience bruising, bleeding, or anemia?
119
Endocrine ROS
* Have you noticed increased thirst, hunger, or urination?
* Do you have issues with heat or cold intolerance?
120
Reproductive System ROS
Women:
* When was your last menstrual period, Pap smear, or mammogram?
* Do you experience menopausal symptoms or changes in libido?
Men:
* Have you had issues with erectile function or prostate health?
121
Psychological ROS
* Key Questions:
* Have you been experiencing stress, depression, or anxiety?
* Do you feel safe at home and in your relationships?
121
Is ROS subjective or objective?
Subjective
122
Mental health assessment
appearance, speech patterns, orientation, cognition/memory, behavior, mood, affect
123
Appearance includes?
grooming, hygiene, clothing appropriate to weather. posture and body language
124
Speech patterns include?
clarity, coherence, volume, articulation
125
orientation includes?
Person, Place, Time, Situation
what is your name?
where is your current location?
What day is it?
Why are you being assessed?
126
Cognition and memory includes?
- Immediate term memory (repeat these words..)
- Short term memory (do you recall x event recently)
- Long term memory (can you recall x past event)
127
Behavior and mood includes?
Cooperation, mistrust, hostility, emotion expression such as sad, indifferent, happy, or anxious.
128
What does affect include?
Blunted affect is a reduced emotional response.
Flat affect is an absence of any emotion response (sometimes in schizophrenia patients)
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What depression screening are asked
PHQ
Over the last 2 weeks, have you felt down depressed or hopeless?
Have you felt little interest or pleasure in doing things?
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Suicide Risk Assessment
Have you wished you were dead?
What you had thoughts of ending your life?
Have you thought about how?
Have you worked out the details of ending your life?
Have you prepared or started doing anything to end your life?
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After the suicide assessment risk, and they answer yes, what do you do?
Never leave the patient alone and arrange for immediate evaluation by a mental health professional
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What is the cognitive assessment tool?
Mini Mental State Examination (MMSE) evaluates:
1. orientation: time and place
2. registration: name three objects in this room
3. attention and calculation (spell a word backwards and perform arithmetic)
4. recall: can you remember the three things I said 3 minutes ago?
5. language: name objects, repeat phrases, and follow written or verbal instruction
max of 30. positive is any score 23+.
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What and how should you document during a mental health assessment?
Use exact quotes often. Include speech, behavior, and mood. Record results of cognitive and depressive screenings.
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What are resources for mental health?
American psychiatric association
national institute of mental health
suicide prevention lifeline
