Ems207 week2-chap10

NVCC EMS 207 - K Deal & E Stern

Health & Physical Assessment in Nursing

First Edition

Chapter 10

Health History

Donita D’Amicoand

Colleen Barbarito


Health History - Definition

A comprehensive accounting of the patients past and current health

• Two key focuses• General Medical

• Whole lifestyle• Affect of “activities of daily living”

(ADL)


Effective Communications



Communication - Exchange of Information Between Individuals



In a communications cycle, the “sender’s” idea (comment) is interpreted by the receiver and validated in one of many ways



Interactional Skills• Listening• Attending• Paraphrasing• Leading• Questioning• Reflecting• Summarizing



Listening - Paying Undivided Attention to What the Client Says and Does

I’m all ears!



Attending - Giving Full Attention to Verbal and Nonverbal Messages



Paraphrasing - Restating the Client’s Basic Message

“So what you’re saying Dad is that you and Mom are drug dealers?”



Leading - Encourages Open Communication• 3 Type of Leading Techniques

– Direct (Obtain specific info)• Let’s discuss the back pain

– Focusing (Zero in on a point)• How does it feel when your back hurts

– Questioning (seek specific info via a question)• What do you mean your back feels like it’s breaking



Reflecting - Repeating the Client’s Verbal or Nonverbal Message for the Client’s Benefit to Show that you have Empathy with their Thoughts, Feelings, or Experiences

So you’re saying you feel like you were adopted and it’s been difficult for you.



Questioning - Direct Way of Speaking with Clients to Obtain Subjective Data for Decision Making and Planning Care• Closed and open-ended

questions



Summarizing - The Process of Gathering the Ideas, Feelings, and Themes That Clients Have Discussed Throughout the Interview and Restating Them in Several General Statements


Barriers to Effective

Communications


Communication Barriers

Barriers to Effective Client Interactions• False reassurance• Interrupting or changing the subject• Passing judgment• Cross-examination• Using technical terms• Encountering sensitive issues



False Reassurance - Occurs When you Assure the Client of a Positive Outcome with No Basis for Believing in It

You’re Not You’re Not Going To Going To

Die!Die!



Interrupting or Subject Changing - Shows Insensitivity to the Client’s Thoughts and Feelings.

• May Occur When Distracted or you’re Not Comfortable with the Conversation



Passing Judgment - Conveys Messages to Clients That They Are Not Meeting Your Values



Cross - Examination - Asking Questions During the Interview May Cause the Client to Feel Threatened and Reveal Less Information



Technical Terminology - Should Be Avoided to Facilitate Client Understanding

• As Well as Jargon, Slang, etc



Encountering Sensitive Issues - May Make the Client Feel Uncomfortable or Defensive


Diverse Communications

Diversity and Impact on the Medic - Client Interactions

The Most difficult part of the job:

“Leave your judgment at the door and open your mind to the diversity of your community”


Box 10.1 Guidelines for Interviewing Clients Who Do Not Speak English


Figure 10.3 Differences in cultural or regional background may become barriers to effective communication.



Diversity and Impact on the Medic - Client Interactions• Factors

– Culture– Body language– Ethnicity– Religion



Diversity and Impact on the Medic - Client Interactions• Factors

– Nationality– Education– Health status– Level ofintelligence



Cultural Stereotypes


Diverse CommunicationsCultural Stereotypes


Diverse CommunicationsCultural Stereotypes



Patient Body Language



Your Body Language



Ethnicity

Things have changed and continue to change

“We must learn to live together as brothers or perish together as fools” (MLK)



Language


Figure 10.4 A Interpreter may help facilitate interaction with a client who does not speak English.

Interpreter vs Translator


Establishing theMedic - Client Relationship


Establishing the Relationship

Characteristics• Positive regard

• Empathy

• Genuineness

• Concreteness

Starts With a Simple Hand Shake



Positive Regard - Respect for Another’s Worth and Dignity



Empathy - Capacity to Respond to Another’s Feelings and Experiences as If They Were One’s Own



Genuineness - Ability to Present Oneself Honestly and Spontaneously



LEARNING OBJECTIVE FIVE

Concreteness - Speaking in Specific Terms

I need this for my report

I need this so I can document all of your medical history

What happened here?

When did you 1st notice the swelling in your ankles?


Health History Interview Phases



Health History Interview Phases• Preinteraction phase

• Initial interview

• Focused interview



Preinteraction Phase - Occurs Before You Meet the Client, When Data Is Collected from

Previous Records



Initial Interview - Meeting in Which You Gathers Information from the Client



Focused Interview - To Clarify Previously Obtained Assessment Data and Gather Missing Information


Health History Interview



Health History Interview - A ‘Planned, Formal’ Interaction Between You and the Client



Components of the Health History


Table 10.2 Health History Format



Components of the Health History• Biographical data• Present health–illness• Past history• Family history• Psychosocial history• Review of body systems


Health History InterviewBiographical Data

• Name• Address• Age• Date of birth• Birthplace• Gender• Marital status• Race• Religion• Occupation• Insurance coverage


Box 10.2 Cultural Assessment


Box 10.2 (continued) Cultural Assessment



The Present Health or Illness History• Past and current health problems and

concerns– Reason for seeking care– Health beliefs and practices– Health patterns– Medications



Past History• Childhood diseases• Immunizations• Allergies• Blood transfusions• Major illnesses• Injuries



Past History• Hospitalizations• Childbirths• Surgeries• Psychiatric problems• Use of alcohol, tobacco, and other

substances



Family History - Determines whether Genetic or Familial Patterns of Health Impact the Client’s Current or Future Health Status



Psychosocial History• Occupation• Education• Finances• Roles and relationships• Ethnicity and culture• Family• Spirituality• Self-concept



Review of Body Systems - Provides Subjective Information About Each Body System and Its Organs

• Includes questions about functional patterns the patient may experience

• Consider that EMS traditionally does a “focused assessment” instead of a full review


Box 10.3 Review of Body Systems

This is systems based vs the traditional EMS

“Head to Toe” review/assessment



Sources of Information for the Health History• Primary source

– Client

• Secondary sources– Other individuals– Client records and charts


Box 10.4 Narrative Recording of the Health History

SAMPLE


Box 10.4 (continued) Narrative Recording of the Health History SAMPLE


You Now Have the Power

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Ems207 week2-chap10