NUR2092 Health Assessment Exam Study Guide for .

NUR2092 Health Assessment Exam Study Guide for NUR2092: Health Assessment Exam Study Guide for Module 1: Chapter 1: Evidence Based Assessment Assessment: Point of Entry in an Ongoing Process Subjective data What patient says about himself or herself during history taking Objective data Observed when inspecting, percussing, palpating, and auscultating patient during physical examination Database Formed from these elements, plus patient’s record and laboratory studies Steps of the Nursing Process: 1. Assessment 2. Diagnosis 3. Outcome Identification 4. Planning 5. Implementation 6. Evaluation Nursing process: Critical Thinking systematically Assessment Diagnosis / analysis Plan Interventions Evaluations Nursing Process: Assessment Collection of data from multiple sources Review of clinical record Interview Health history Physical examination Functional assessment • Activities of daily living Cultural and spiritual assessment Consultation Review of the literature Nursing Process: Diagnosis Interpretation of data by identifying clusters of cues so as to make inferences Compare clusters of cues with definitions and defining characteristics Validation of inferences based on findings Identify related factors Document the diagnosis Nursing Process: Outcome Identification Identify expected outcomes related to patient individualization Ensure outcomes are realistic and measurable Specify short-term and long-term goal measurement criteria Nursing Process: Planning Establish priorities based on meeting identified patient care goals 51 Develop outcomes and set time frames for meeting proposed outcomes Identify relevant interventions and utilize interdisciplinary health care team members in the care planning process for the patient Document plan of care Question The nurse has a “hunch” that the patient’s elevated blood pressure is due to pain level; however, the patient received blood pressure and pain medication 45 minutes ago. What should the nurse consider in regards to this hunch? 1. Research supports that the pain and blood pressure medications will take 30 minutes to become effective. The nurse should wait until the next prescribed time and reevaluate pain level 2. The nurse should consider consulting with the pain management team to evaluate the effectiveness of the pain medication regimen. 3. The nurse should disregard the hunch because hunches are not effective at incorporating evidence-based practices 4. The nurse should administer pain medication based on the hunch Correct Answer: 2 Nursing Process: Implementation Determine patient readiness and involve patient(s) in health care process Review planned interventions with interdisciplinary health care team members to facilitate collaborative effort Utilize principles of delegation, being mindful of supervision and evaluation Counsel person and significant others Refer for continuing care Document care provided Nursing Process: Evaluation Refer to established outcomes Evaluate individual’s condition and compare actual outcomes with expected outcomes Summarize results of evaluation Identify reasons for failure to achieve expected outcomes Take corrective action to modify plan of care Document evaluation in plan of care Critical Thinking Principles Proceed through sequential steps from novice to expert Incorporation of experience provides foundation for development of clinical practice Utilize a multidimensional thinking approach to interpret data Use an organized, systematic assessment format Validate and confirm findings based on nonjudgmental interpretation of data Check and corroborate accuracy and reliability of data Cluster data information to support evidence as well as rule out inconsistent clinical findings in terms of differential diagnosis Distinguish relevant signs and symptoms Priority Problems Level First-level priority Emergent, life threatening, and immediate Second-level priority Next in urgency, requiring attention so as to avoid further deterioration Third-level priority Important to patient’s health but can be addressed after more urgent problems are addressed Collaborative problems Approach to treatment involves multiple disciplines Problems and Outcomes Identify patient outcomes and delineate measurable goals Qualify short-term and long-term goals that are realistic and patient centered Include evaluation methods that will allow for validation of results or adjustments to care planning Incorporation of planning methods is a critical element in the delivery of care Continuously evaluate the plan of care Analyze and implement changes as needed in order to maintain pathway toward goal achievement Comprehensive Plan of Care Evaluate and update plan Record revised plan and keep it up-to-date Communicate revised plans to multidisciplinary team Be aware that this is a legal document, and accurate recording is important for evaluation, insurance reimbursement, and research Evidence-Based Assessment Current and best clinical practice based on research standards focused on systematic reviews of randomized clinical trials (RCTs) Utilizing evidenced-based practice (EBP) in conjunction with provider experience will lead to better health outcomes for patients Fostering a “culture of EBP” at both the undergraduate and graduate levels will assist health educators to make EBP the “gold standard” of practice Question What is the best electronic resource for incorporating evidence-based practice into health assessment? 1. W 2. N. 3. M 4. WebMD.com Correct Answer: 2 Collecting Four Types of Data Complete total health database Includes complete health history and full physical examination Describes current and past health state and forms baseline to measure all future changes Yields first diagnoses Episodic or problem-centered database For limited or short-term problems Collect “mini” database, smaller scope and more focused than complete database Concerns mainly one problem, one cue complex, or one body system History and examination follow direction of presenting concern Collecting Four Types of Data (Cont.) Follow-up database Status of all identified problems should be evaluated at regular and appropriate intervals Note changes that have occurred Evaluate whether problem is getting better or worse Identify coping strategies being used Emergency database Rapid collection of data, often compiled concurrently with lifesaving measures Diagnosis must be rapid and comprehensive in nature Expanding the Concept of Health Assessment: collection of data about an individual’s health state A clear idea of health is important because it determines assessment data to be collected Holistic Model of Health Mind, body and spirit are interdependent and function as a whole Multifaceted basis of disease Individual and human environment are open systems Expanded assessment factors such as lifestyle behaviors, culture and values, family and social roles, self-care behaviors, job-related stress, developmental tasks, failures and frustrations of life Health promotion and disease prevention form the core of nursing Healthy People 2020 Web Site Review the tabs at the top of the website Healthy People 2020 Goals Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages Frequency of Assessment Interval of assessment varies with illness and wellness needs Ill people seek care because of pain or abnormal signs and symptoms This prompts an assessment: gathering a complete, episodic, or emergency database • Screening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices • Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental health Frequency of Assessment (Cont.) Routine periodic examination might include the following services for preventive health care: Screening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental health Immunizations Chemoprophylaxis for multivitamin with folic acid for females capable of or planning pregnancy Frequency of Assessment (Cont.) For well persons, opinions are changing about assessment intervals Annual checkup is vague: What does it constitute? Is it necessary? Does it sometimes give an implicit promise of health and thus provide false security? Timing of formerly accepted procedures is now variable: for example, annual Pap tests Same annual routine physical examination cannot be recommended for all persons because health priorities vary among individuals, age groups, and risk categories Assessment through the Life Cycle Age-specific charts for periodic health examinations are a positive approach to health assessment Define lifetime schedule of health care, organized into packages for four specific age groups Each chart lists a frequency schedule for periodic health visits and preventive services for age group • These services include screening factors to gather during the history, and age-specific items for physical examination and laboratory procedures, counseling topics, and immunizations Assessment through the Life Cycle (Cont.) Age-specific charts focus on major risk factors specific for each age group based on lifestyle, health needs, and problems Shift emphasis from an annual physical examination toward rational and varying periodicity Incorporate health promotion and disease prevention at every health visit, not just at one annual physical examination Health education and counseling are highlighted as means to promote health Cross-Cultural Care Concepts A holistic model of health care assessment must include culture Inclusion of heritage assessment is of paramount importance to gather meaningful data and intervene with culturally sensitive and appropriate care With the rapid increases in numbers of individuals from diverse cultural backgrounds in the United States, a concern for the cultural beliefs and practices of people is increasingly important in health care Cross-Cultural Care Principles A serious conceptual problem arises as nurses and physicians are expected to know, understand, and meet health needs of people from culturally diverse backgrounds without formal preparation for doing so International interchanges are increasing among nurses and physicians, making attention to cultural aspects of health and illness an even greater priority High-Level Assessment Skills Attention to life cycle, holism, and culture must not detract from the importance of assessment skills themselves Assessment skills require hands-on expertise refined to a high level The nurse is the first and often only health professional to see an individual in many communities The nurse is the only health professional continually present at bedside in hospitals Cost Containment Principles Efforts at cost containment result in hospital populations composed of people with increased acuity, shorter stays, and earlier discharges than in the past Nurses must make faster, more efficient assessments Nurses required to go people’s homes for follow-up assessment and diagnosis First-rate assessment skills grounded in holistic approach and knowledge of age-specific problems are required H A BOLD new initiative from the USDHHS, Center for Disease Control, Centers for Medicaid and Medicare, Food and Drug Administration and NIH. to help Americans live longer, better and healthier lives. advances NIH-supported research has led to: Death rates from heart disease and stroke fell by 40% and 51%, respectively, between 1975 and 2000. Overall 5-year survival rate for childhood cancers rose to nearly 80% during the 1990s from under 60% in the 1970s. Number of AIDS-related deaths fell by about 70% between 1995 and 2001. Sudden infant death syndrome rates fell by more than 50% between 1994 and 2000. Infectious diseases—such as rubella, whooping cough, and pneumococcal pneumonia—that once killed and disabled millions of people are now prevented by vaccines. more advances Quality of life Americans suffering with depression has improved due to more effective medication and psychotherapy. The sequencing of the human genome set a new course for developing ways to diagnose and treat diseases like cancer, Parkinson's Disease and Alzheimer's Disease. In response to the anthrax attacks of 2001, the NIH launched and expanded research to prevent, detect, diagnose, and treat diseases caused by potential bioterrorism agents. What else have we done? New and improved imaging techniques let scientists painlessly look inside the body and detect disease in its earliest stages when it is often most effectively treated. Progress in understanding the immune system may lead to new ways to treat and cure diabetes, arthritis, asthma and allergies. New, more precise ways to treat cancer are emerging, such as drugs that zero in on abnormal proteins in cancer cells. Novel research methods are being developed that can identify the causes of outbreaks, such as Severe Acute Respiratory Syndrome (SARS), in weeks rather than months or years Lab Book Practice Questions: 1. The concept of health and healing has evolved in recent years. Which is the best description of health? a. Health is the absence of disease. b. Health is a dynamic process toward optimal functioning. c. Health depends on an interaction of mind, body, and spirit within the environment. d. Health is the prevention of disease. 2. Which would be included in the database for a new patient admission to a surgical unit? a. All subjective and objective data gathered by a health practitioner from a patient b. All objective data obtained from a patient through inspection, percussion, palpation, and auscultation c. A summary of a patient’s record, including laboratory studies d. All subjective and objective, and data gathered from a patient and the results of any laboratory or diagnostic studies completed 3. You are reviewing assessment data of a 45-year-old male patient and note pain of 8 on a scale of 10, labored breathing, and pale skin color on the electronic health record. This documentation is an example of: a. Hypothetical reasoning b. Diagnostic reasoning c. Data cluster d. Signs and symptoms 4. A patient is in the emergency department with nausea and vomiting. Which would you include in the database? a. A complete health history and full physical examination b. A diet and GI history c. Previously identified problems d. Start collection of data in conjunction with lifesaving measures 5. A patient has recently received health insurance and would like to know how often he should visit the provider. How do you respond? a. “It would be most efficient if you visit on an annual basis.” b. “There is no recommendation for the frequency of health care visits.” c. “Your visits may vary, depending on your level of wellness.” d. “Your visits will be based on your preference.” 6. You are reviewing concepts related to steps in the nursing process for determining prioritization and developing patient outcomes. To what are these actions attributed? a. Planning b. Assessment c. Implementation d. Diagnosis 7. Which best describes evidence-based nursing practice? a. Combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient’s values and circumstances b. Appraising and looking at the implications of one or two articles as they relate to the culture and ethnicity of the patient c. Completing a literature search to find relevant articles that use nursing research to encourage nurses to use good practices d. Finding value-based resources to justify nursing actions when working with patients of diverse cultural backgrounds 8. What can be determined when the nurse clusters data as part of the critical- thinking process? a. This step identifies problems that may be urgent and require immediate action. b. This step involves making assumptions in the data. c. The nurse recognizes relevant information among the data. d. Risk factors can be determined so the nurse knows how to offer health teaching. 9. A patient says she is very nervous and nauseated, and she feels like she will vomit. This data would be what type of data? a. Objective b. Reflective c. Subjective d. Introspective 10. The expert nurse differs from the novice nurse by acting without consciously thinking about the actions. This is referred to as: a. Deductive reasoning b. Intuition c. The nursing process d. Focus assessment 11. Which would be considered a risk diagnosis? a. Identifying existing levels of wellness b. Evaluating previous problems and goals c. Identifying potential problems the individual may develop d. Focusing on strengths and reflecting an individual’s transition to higher levels of wellness 12. Which would be included in a holistic model of assessment? a. Nursing goals for the patient b. Anticipated growth and development patterns c. A patient’s perception of his or her health status d. The nurse’s perception of disease related to the patient 13. The nurse uses health promotion activities with a new patient. What would this focus include? a. The nurse would try to change the patient’s perceptions of disease. b. The nurse would search for identification of biomedical model interventions. c. The nurse would help to identify negative health acts of the patient. d. The nurse would empower the patient to choose a healthier lifestyle. 14. Which is an example of objective data? a. Patient’s history of allergies b. Patient’s use of medications at home c. Last menstrual period 1 month ago d. 2- × 5-cm scar present on the right lower forearm 15. During the evaluation phase of the nursing process, which action would be included? a. Validating the nursing diagnosis b. Establishing priorities related to patient care c. Providing information to the patient and family members d. Establishing a timeline for planned outcomes Chapter 2: Cultural Competence Cultural Assessments • Is cultural assessment still relevant today? • What questions does the hospital admission form ask? Is it enough to truly get to know the family? Culture Descriptors Culture is learned. It is neither instinctive or innate. Culture is taught over the generations socially through families Culture is adaptive. Customs and beliefs adapt to the environment. Culture is satisfying. Habits persist if satisfying. Culture is difficult to articulate. Is this why some family’s answer “No” to everything asked about cultural needs? Cultural Competency Questions Who are you meeting for the first time? Where does the patient come from? What is his or her heritage? What is his or her cultural background: ethnicity and religion? Does the patient understand, speak, and read English? What language does he or she understand, speak, and read? What are his or her health and illness beliefs and practices? Objectives Demographic profile of United States National standards for culturally and linguistically appropriate services Background of heritage assessment Methods for conducting heritage assessment Traditional health and illness beliefs and practices Steps to cultural competence Health and Illness Health Balance of a person is a complex, interrelated phenomenon • Within one’s being: physical, mental, spiritual • In outside world: natural, communal, metaphysical Illness Loss of a person’s balance • Within one’s being: physical, mental, spiritual • In outside world: natural, communal, metaphysical Demographic Profile of United States Total population passed 311 million in 2011 Greater than one third of U.S. residents were other than non-Hispanic Whites Minority, or emerging majority, populations total 114.5 million people Hispanics: largest and fastest growing group Blacks: second largest population Asians, American Indians, Alaska Natives, Native Hawaiians, and other Pacific Islanders make up the third largest part of the population Emerging Minority Group Trends Differences noted in age, poverty level, and household composition Emerging majority groups tend to be as follows: Younger with lower median ages Higher proportions under 18 years old All ethnic and racial minority groups exceed the national poverty level Family size and multigenerational families are more evident in minority groups Immigration and Health Care Concerns Status of immigrants entering the health care system Legal permanent residents Naturalized citizens Undocumented aliens Refugees, requesting asylum, and parolees Legal nonimmigrant residents Many new immigrants have only minimal understanding of the following: Modern health care delivery system Modern medical and nursing practices and interventions English language It is imperative that the nurse’s care be tailored to meet the person’s perceived needs National Cultural and Linguistic Standards First and landmark standard Health care organizations should ensure that patients receive from all staf f members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language National Cultural and Linguistic Standard Components Effective care: positive outcomes and satisfaction for patient Respectful care: considers values, preferences, and expressed needs of patient Cultural and linguistic competence: congruent behaviors, attitudes, and policies that come together in a system among professionals that enables work in cross-cultural situations Linguistic Competence Title VI of Civil Rights Act of 1964 Services cannot be denied to people of limited English proficiency In 2012, over 21% of Americans over 5 years of age speak a language other than English in their homes Most common non-English language is Spanish Patients who have limited English proficiency (LEP) are at risk for poor health care outcomes due to the barrier that language presents during health care delivery interactions Health care facilities may have established interpreters who can assist with therapeutic communication. Cultural Competence Culturally sensitive Possessing basic knowledge of and constructive attitudes toward diverse cultural populations Culturally appropriate Applying underlying background knowledge necessary to provide the best possible health care Culturally competent Understanding and attending to total context of patient’s situation including the following: • Immigration status • Stress and social factors • Cultural similarities and differences Steps to Cultural Competence Understand one’s own heritage-based values, beliefs, attitudes, and practices Identify meaning of “health” to patient Understand how health care system works Acquire knowledge about social backgrounds of patients Become familiar with languages, interpretive services, and community resources available to nurses and patients Conveying Cultural Competent Care Caregivers attend to the holistic situation; they have an awareness of immigration status, stress factors, social factors, and cultural needs Question What must the nurse assess first when providing culturally competent health care to an Asian American patient? 1. The tradition of the Asian American culture and the health care practices related to health and wellness 2. The nurse’s heritage-based cultural values, beliefs, attitudes, and practices. 3. Any differences between the nurse’s culture and the Asian American culture 4. The attitudes of Asian American cultures to the health care system in the United States Correct Answer: 2 Related Concepts Four basic concepts of culture Learned, shared, adapted, and dynamic Race and ethnicity Self-identification and social group Acculturation Assimilation is one dimensional, and biculturalism/integration is bidimensional Acculturative stress Losses and changes associated with integration of new beliefs Religion and spirituality Organized system of beliefs versus individual’s unique experience Culture Thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups Characteristics of culture Learned Shared Adapted Dynamic Ethnicity Describes a group united by the following: Common geographic origin Migratory status Religion Race Language Shared values, traditions, or symbols Food preferences Religion Belief in divine or superhuman power, or powers to be obeyed and worshipped as creator/ruler of universe System of beliefs, practices, and ethical values Shared experience of spirituality Socialization Process of being raised within a culture and acquiring characteristics of that group Related terms: Acculturation: process of adapting to and acquiring another culture Assimilation: process of developing a new cultural identity and becoming like members of dominant culture Biculturalism: dual pattern of identification and often of divided loyalty (having two different backgrounds, either from mom vs. dad, or multiple generations) Health-Related Beliefs and Practices Balance and beliefs about causes of illness Biomedical or scientific theory Naturalistic or holistic theory Yin and yang Hot and cold Magicoreligious perspective Traditional beliefs and health healers Disease Causation Theories Biomedical Assumes cause and effect Views the body as a machine Life can be divided into parts Endorses germ theory Naturalistic Forces of nature must be kept in balance Embraces idea of opposing categories or forces • Yin and yang, hot and cold Disease Causation Theories (Cont.) Magicoreligious Supernatural powers predominate in area of health and illness • Examples include voodoo, witchcraft, and faith healing Healing and culture In addition to seeking help from health care providers, patients may also seek help from folk or religious healers Hispanics or American Indians may believe that cure is incomplete unless healing is carried out for the body, mind, and spirit Health-Related Behaviors Affected by Religion Meditating Exercising/physical fitness Sleep habits Vaccinations Willingness to undergo physical examination Pilgrimage Truthfulness about how patient feels Maintenance of family viability Hoping for recovery Coping with stress Genetic screening and counseling Living with a disability Caring for children Differing Views Related to Health Beliefs Differing views of epilepsy Uganda: contagious, untreatable Greece: source of family shame Mexican-American community: evidence of physical imbalance Hutterites: evidence of having endured trial by God Developmental Competence Beliefs and values across life cycle Dominant culture beliefs Traditional Treatments and Folk Healers Folk healers Hispanic: curandero, espiritualista, yerbo, or sabedor Black: hougan, spiritualist, old lady American Indian: shaman, medicine woman, medicine man Asian: herbalists, acupuncturists, bone setters Amish: braucher Developmental Competence Culture affects choices parents make for children regarding the following: Presumed cause of illness First treatment tried Acceptability of treatments offered by clinicians For older patients, culture is likely to do the following: Define their family responsibilities Affect their view and knowledge of health care systems used by dominant culture Transcultural Expression of Illness Transcultural expression of pain Expectations, manifestations, and management of pain are all embedded in a cultural context Pain has been found to be a highly personal experience, depending on cultural learning, the meaning of the situation, and other factors unique to the person Silent suffering has been identified as the most valued response to pain by health care professionals Culture-Bound Syndromes Condition that is culturally defined Some have no equivalent in a biomedical, scientific perspective Anorexia nervosa and bulimia are examples of cultural aspects of illness in dominant cultural population in North America Steps to Cultural Competency Culturally sensitive Caregivers possess basic knowledge and understanding Culturally appropriate Caregivers apply knowledge to improve health outcomes Culturally competent Caregivers apply a universal concept of understanding to all contextual aspects of care Cultural care Provision of health care across cultural boundaries in consideration of context Cultural Formation Model Categories Cultural identity of the individual Cultural explanation of the individual’s illness Cultural factors related to psychosocial environment and levels of functioning Cultural elements of the relationship between the individual and clinician impact of culture on diagnosis and care Heritage Consistency Concepts Heritage consistency Degree to which a person’s lifestyle reflects his or her traditional heritage Heritage consistency continuum Traditional: living within norms of traditional culture Modern: acculturated to norms of dominant society Indicators of Heritage Consistency Childhood occurred in country of origin or immigrant neighborhood of like ethnic group Extended family support of traditional activities Frequent visits to old country or old neighborhood Family home within ethnic community to which they belong Participation in ethnic cultural events Raised in extended family setting Indicators of Heritage Consistency (Cont.) Regular contact with extended family Name not anglicized Educated in parochial school Social activities primarily with members of ethnic community Knowledge of language and culture of origin Expresses pride in heritage Culture and Treatment First effort at treatment is often self-care Home treatment attractive for accessibility, particularly for people from rural or sparsely populated areas Home treatment may mobilize person’s social support network and provide a caring environment in which to convalesce Alternative or complementary interventions are gaining recognition from health care professionals in health care system Culture and Disease Prevalence Disparity continues in deaths and illnesses experienced by racial and ethnic populations Diseases are not distributed equally among all segments of population Abnormal biocultural variations may be genetic or acquired Information about disease prevalence for racial and ethnic groups provides focus for assessment regarding increased probability that particular conditions may occur Nurses must be certain that they have gathered data needed to support or refute suspicions Culture and Respect Realize you must know heritage of yourself and patient Examine patient within cultural context Select simple questions and speak slowly Pace questioning throughout exam Encourage patient to discuss meaning of health and illness with you Check patient’s understanding and acceptance of recommendations Touch patient within boundaries of his or her heritage Question Which of these is a necessary tool for building cultural competence? 1. Cultural Competency Assessment Tool 2. Health Risk Assessment Tool 3. Ethnic Identity Tool 4. Heritage Assessment Tool Correct Answer: 4 Lab Book Practice Questions: 1. Which statement best describes religion? a. An organized system of beliefs concerning the cause, nature, and purpose of the universe b. Belief in a divine or superhuman spirit to be obeyed and worshiped c. Affiliation with one of the 1200 recognized religions in the United States d. The following of established rituals, especially in conjunction with health- seeking behaviors 2. The major factor contributing to the need for cultural care nursing is: a. An increasing birth rate b. Limited access to health care services c. Demographic change d. A decreasing rate of immigration 3. The term culturally competent implies that the nurse: a. Is prepared in nursing. b. Possesses knowledge of the traditions of diverse peoples. c. Applies underlying knowledge to providing nursing care. d. Understands the cultural context of the patient’s situation. 4. You are the triage nurse in the emergency department and perform the initial intake assessment on a patient who does not speak English. Based on your understanding of linguistic competence, which action would present as a barrier to effective communication? a. Maintaining a professional respectful demeanor b. Allowing for additional time to complete the process c. Providing the patient with a paper and pencil so he or she can write down the answers to the questions that you are going to ask d. Seeing if there are any family members present who may assist with the interview process 5. Which culture would describe illness as hot and cold imbalance? a. Asian-American heritage b. African-American heritage c. Hispanic-American heritage d. American Indian heritage 6. Of what does the patient believe the amulet is protective? a. The evil eye b. Being kidnapped c. Exposure to bacterial infections d. An unexpected fall 7. Which statement best illustrates the difference between religion and spirituality? a. Religion reflects an individual’s reaction to life events whereas spirituality is based on whether the individual attends religious services. b. Religion is characterized by identification of a higher being shaping one’s destiny while spirituality reflects an individual’s perception of one’s life having worth or meaning. c. Religion is the expression of spiritual awakening whereas spirituality is based on belief in divine right. d. Religion is the active interpretation of one’s spirituality. 8. The first step to cultural competency by a nurse is to: a. Identify the meaning of health to the patient. b. Understand how a health care delivery system works. c. Develop a frame of reference to traditional health care practices. d. Understand your own heritage and its basis in cultural values. 9. Which statement is true in regard to pain? a. Nurses’ attitudes toward their patients’ pain are unrelated to their own experiences with pain. b. The cultural background of a patient is important in a nurse’s assessment of that patient’s pain. c. A nurse’s area of clinical practice is most likely to determine his or her assessment of a patient’s pain. d. A nurse’s years of clinical experience and current position are a strong indicator of his or her response to patient pain. 10. Which factor is identified as a priority influence on a patient’s health status? a. Poverty b. Lifestyle factors c. Legislative action d. Occupational status 11. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient? a. “Are you of the Christian faith?” b. “Do you want to see a medicine man?” c. “How often do you seek help from medical providers?” d. What cultural or spiritual beliefs are important to you?” 12. Which statement best describes ethnocentrism? a. The government’s description of various cultures b. A central belief that accepts all cultures as one’s own c. The tendency to view your own way of life as the most desirable d. The tendency to impose your beliefs, values, and patterns of behaviors on an individual from another culture 13. Which category is appropriate in a cultural assessment? a. Family history b. Chief complaint c. Past medical history d. Health-related beliefs 14. Which health belief practice is associated with patients who are of American Indian heritage? a. Wearing bangle bracelets to ward off evil spirits b. Eating compatible foods in one’s diet c. Using swamp root as a traditional home remedy d. Believing in a shaman as a traditional healer 15. Which statement best reflects the Magicoreligious causation of illness? a. Each being is but a part of a larger structure in the world of nature as it relates to health and illness. b. Causality relationship exists leading to expression of illness. c. Belief in the struggle between good and evil is reflected in the regulation of health and illness. d. Illness occurs as a result of disturbances between hot and cold reactions. Module 2: Chapter 3: Interview The Interview Subjective data collection Patient perception of health First step in the therapeutic relationship Interview Goal Identification Identify health strengths and problems as bridge to physical examination First and most important part of data collection Collects subjective data: what person says about his or her perceived health state Individual knows everything about his or her own health state, and nurse knows nothing Successful Interview Characteristics Gather complete and accurate data about person’s health state, including description and chronology of any symptoms of illness Establish rapport and trust so person feels accepted and free to share all relevant data Teach person about health state so that he or she may participate in identifying problems Build rapport to continue therapeutic relationship and to facilitate future diagnoses, planning, and treatment Begin teaching for health promotion and disease prevention The Interview Contract Contract consists of spoken and unspoken rules for behavior What person needs and expects from health care and what health professional has to offer Mutual goal is optimal health for patient The Interview Contract Terms Time and place of interview and physical examination Introduction of and explanation of health care provider’s role Purpose of interview How long it will take Expectation of participation for each person Presence of others (family, etc.) Confidentiality and to what extent it may be limited Any costs that the patient must pay Process of Communication: Sending Communication is behavior, conscious and unconscious, verbal and nonverbal All behavior has meaning Body language: posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair Process of Communication: Receiving Awareness of messages you send is only part of process o Words and gestures must be interpreted in a specific context to have meaning Receiver attaches meaning determined by his or her past experiences, culture, self-concept, and current physical and emotional state Successful communication requires mutual understanding by sender and receiver Patients’ health problems intensify communication because patients depend on you to get better Communication can be learned and polished when you are a beginning practitioner Communication is a tool, as basic to quality health care as tools of inspection or palpation Process of Communication: Internal Factors Awareness of internal and external factors and their influence allows you to maximize communicating skill Internal factors o Liking others o Empathy o Ability to listen Process of Communication: External Factors o Ensure privacy o Refuse interruptions o Physical environment o Dress o Note-taking may be unavoidable ▪ Cannot rely completely on memory for details of previous illnesses or review of body systems o Tape and video recording Question Which of the following would be the best way to refer to an adult patient when initiating the interview? a. Hello Mr. Jones, what brought you to the emergency department today? b. Hello James, what brought you to the emergency department today? c. Hi, I’m nurse John, what brought you into the hospital today Jim? d. Hi Mr. J., what’s up? Why are you here today? Correct Answer: Challenges of Note-Taking Breaks eye contact too often Shifts attention away from person, diminishing his or her sense of importance 51 Interrupts patient’s narrative flow Impedes observation of patient’s nonverbal behavior May be threatening to patient’s discussion of sensitive issues Techniques of Communication Introducing the interview Working phase o Data-gathering phase o Verbal skills include questions to patient and your responses to what is said o Two types of questions ▪ Open-ended ▪ Closed ▪ Each has a different place and function in interview Open-Ended Questions Ask for narrative responses State topic only in general terms Use them in the following situations: o To begin interview o To introduce a new section of questions o Whenever the patient introduces a new topic Closed or Direct Questions Ask for specific information Elicit short one- or two-word answers, a yes or no answer, or a forced choice Use them in the following situations: o After opening narrative to fill in details person may have left out o When you need many specific facts about past health problems or during review of systems o To move the interview along Question Which of the following questions would likely warrant the best response? Why did you come in today? Where does it hurt? Have you been checking your blood pressure? When was the last time you were seen by a doctor? Responses: Assisting the Narrative Facilitation encourages patients to say more and shows you are interested and will listen further Silent attentiveness o Gives patient time to think and organize what to say without interruption from you o Gives you a chance to observe person unobtrusively and note nonverbal cues Reflection o Echoes patient’s words, repeating what person has just said, focuses further attention on a specific phrase, and helps person continue in his or her own way Types of Verbal Responses Empathy 51 Recognizes a feeling and puts it into words Names the feeling and allows expression of it Patient feels accepted and can deal with feeling openly Clarification Use when person’s words are ambiguous or confusing Used to summarize person’s words and to simplify them to make them clearer You are asking for agreement, and the person can then confirm or deny your understanding Types of Verbal Responses (Cont.) Confrontation Frame of reference shifts from patient’s perspective to yours May focus on discrepancy or inconsistency in person’s narrative You have observed a certain action, feeling, or statement and now focus person’s attention on it You give honest feedback about what you see or feel Types of Verbal Responses (Cont.) Interpretation Based on your inference or conclusion It links events, makes associations, implies cause, ascribes feelings Helps person understand his or her own feelings in relation to the verbal message If your inference is incorrect, the patient may correct it and thus prompt further discussion of topic Types of Verbal Responses (Cont.) Explanation These statements inform the person; you share factual and objective information, offering reasons for requirements or actions Summary Final review of what person has said; it condenses facts and presents your view of health problem Is a type of validation that person can agree with or correct; both you and patient should participate Occurring at the end of the interview, it signals that termination of the interview is near Ten Traps of Interviewing 1) Providing false assurance or reassurance 2) Giving unwanted advice 3) Using authority 4) Using avoidance language 5) Engaging in distancing 6) Using professional jargon 7) Using leading or biased questions 8) Talking too much 9) Interrupting 10) Using “why” questions Elements of the Interview Process Nonverbal skills Physical appearance Posture Gestures Facial expression Eye contact Voice Touch Closing the interview Developmental Competence Interviewing the caregiver o Communicating with different ages across the life cycle o Infants o Toddlers and preschoolers o School-age children o Adolescents o Adults and older adults Interviewing People with Special Needs Hearing impaired Acutely ill Under influence of street drugs or alcohol Those who must be asked personal questions Sexually aggressive Crying Angry and threatening violence Anxious Culture and Genetics Gender Being aware of maintaining cultural norms during interview and examination process Maintaining privacy and modesty Sexual orientation Maintaining neutrality related to patient’s presentation by being mindful of communication patterns Being aware of your own personal bias and baggage Cross-Cultural Care o Probability of miscommunication increases when two people are from different cultural backgrounds o Cultural backgrounds of both health care professional and patient influence verbal and nonverbal communications o Cultural perspectives on professional interactions o Etiquette o Space and distance Overcoming Communication Barriers ▪ Working with and without interpreters ▪ Nonverbal cross-cultural communication ▪ Touch o Touching patients is a necessary component of comprehensive assessment o Physical contact with patients conveys various meanings cross- culturally 51 ▪ Patient’s significant others may exert pressure on nurses by enforcing culturally meaningful norms in health care setting Nonverbal Behaviors Five types of nonverbal behaviors convey information about person Vocal cues: pitch, tone, and quality of voice, including moaning, crying, and groaning Action cues: posture, facial expression, and gestures Object cues: clothing, jewelry, and hairstyles Personal space: interpersonal transactions and care of belongings Touch: involves use of personal space and action Health Literacy ▪ This is more than just the ability to read but rather includes understanding and following directions that lead to effective communication between the patient and the health care provider ▪ A patient may be literate but not have health literacy ▪ Involves the use of quantitative measurement and memory aspects ▪ Tools for determining literacy Test of Functional Health Literacy (TOFHLA) Rapid Estimate of Adult Literacy in Medicine (REALM) Newest Vital Sign (NVS) Techniques to Improve Health Literacy Oral teaching Use of written materials based on standard educational levels Teach back or use of return demonstration Use of an Interpreter Choosing an Interpreter • Before locating an interpreter, identify the language the person speaks at home. Be aware that it may differ from the language spoken publicly (e.g., French is sometimes spoken by well-educated and upper-class members of certain Asian, African, or Middle Eastern cultures, but it is not the language spoken in the home). • Whenever possible, use a trained interpreter, preferably one who knows medical terminology. • Avoid interpreters from a rival tribe, state, region, or nation (e.g., a Palestinian who knows Hebrew may not be the best interpreter for a Jewish person). • Be aware of gender differences between interpreter and client. In general the same gender is preferred. • Be aware of age differences between interpreter and client. In general an older, more mature interpreter is preferred to a younger, less experienced one. • Be aware of socioeconomic differences between interpreter and client. Strategies for Effective Use of an Interpreter • Plan what you want to say ahead of time. Meet privately with the interpreter before the interview. Avoid confusing the interpreter by backing up, hesitating, or inserting a proviso. • Ask the interpreter to provide a line-by-line verbatim account of the conversation. Ask for a detailed interpretation when provided with brief summaries of longer exchanges between interpreter and client. • Be patient. When using an interpreter, interviews often take 2 to 3 times longer. • Longer-than-expected explanatory exchanges are often required to convey the meaning of words such as stress, depression, allergy, preventive medicine, and physical therapy because there may not be comparable terms in the language that the client understands. • When discussing diagnostic tests such as mammograms, magnetic resonance imaging (MRI), computed tomography (CT) scans, or those involving body fluids such as blood, urine, stool, spinal fluid, or saliva, be sure to clarify the nature of the test to the interpreter. Indicate the purpose of the test, exactly what will happen to the client, approximately how long the test will take, whether the procedure is invasive or noninvasive, and which part(s) of the body will be tested. • Be aware that the interpreter may modify or edit some aspects of the conversation, especially if he or she thinks you might not understand the cultural context of the client's response (e.g., traditional or folk beliefs and practices related to healing). • Avoid ambiguous statements and questions. Refrain from using conditional or indefinite phrasing such as “if,” “would,” and “could,” especially for target languages such as Khmer (Cambodia) that lack nuances of conditionality or distinctions of time other than simple past and present. Conditional statements may be mistaken for actual agreement or approval of a course of action. • Avoid abstract expressions, idioms, similes, metaphors, and medical jargon. • To ensure confidentiality and privacy, avoid using as interpreters children or strangers who may be visiting other clients. • Be aware that an interpreter who is a nonrelative may seek compensation for services rendered. Be sure to negotiate fees ahead of time. Recommendations for Institutions • Maintain a current, computerized list of interpreters who may be contacted as needed. • Network with area hospitals, colleges, universities, and other organizations that may serve as resources. • Use over-the-telephone interpretation services provided by telephone companies. For example, since 1989 AT&T has operated the Language Line Services, which provides interpretation in more than 140 languages. Services are available around the clock every day of the year. Call (800) 628-8486 or visit for further information on services and charges. Tools for Assessing Health Literacy TOOL DESCRIPTION EXAMPLE QUESTIONS Test of Functional Health Literacy (TOFHLA) • Designed for use in research • Measures reading comprehension and numeracy • Uses actual client instructions and forms • Takes approximately 22 minutes Do not eat a. appointment b. walk-in c. breakfast d. clinic Rapid Estimate of Adult Literacy in Medicine (REALM) • Designed for use in clinical setting • Person reads 66 medical terms aloud • Score based on Words include: flu, smear, stress, gallbladder, inflammatory, diagnosis, potassium TOOL DESCRIPTION EXAMPLE QUESTIONS number of words read and pronounced correctly • Takes 2-3 minutes to administer Newest Vital Sign (NVS) • Assesses numeracy and comprehension • Uses nutrition label that clients must read and interpret • Total of six questions related to label provided • Takes approximately 3 minutes Give client the nutrition label and ask: • If you eat the entire container, how many calories will you eat? • If you usually eat 2,500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving? Lab Book Practice Questions: 1. The practitioner, entering the examining room to meet a patient for the first time, states: “Hello, I’m M.M., and I’m here to gather some information from you and to perform your examination. This will take about 30 minutes. D.D. is a student working with me. If it’s all right with you, she will remain during the examination.” Which of the following must be added to cover all aspects of the interview contract? a. A statement regarding confidentiality, patient costs, and the expectations of each person b. The purpose of the interview and the role of the interviewer c. Time and place of the interview and a confidentiality statement d. An explicit purpose of the interview and a description of the physical examination, including diagnostic studies 2. is exhibiting an accurate understanding of the other person’s feelings within a communication context. a. Empathy b. Liking others c. Facilitation d. A nonverbal listening technique 3. You conduct an admission interview. Because you are expecting a phone call, you stand near the door. Which would be a more appropriate approach? a. Arrange to have someone page you so you can sit on the side of the bed. b. Have someone else answer the phone so you can sit facing the patient. c. Use this approach given the circumstances. d. Arrange for a time free of interruptions after the initial physical examination is complete. 4. A patient asks the nurse, “May I ask you a question?” This is an example of: a. An open-ended question b. A reflective question c. A closed question d. A double-barreled question 5. Which statement best describes interpretation as a communication technique? a. Interpretation is the same as clarification. b. Interpretation is a summary of a statement made by a patient. c. Interpretation is used to focus on a particular aspect of what the patient has just said. d. Interpretation is based on the interviewer’s inference from the data that have been presented. 6. Which demonstrates a good understanding of the interview process? a. The nurse stops the patient each time something is said that is not understood. b. The nurse spends more time listening to the patient than talking. c. The nurse is consistently thinking of his or her next response so the patient will know he or she is understood. d. The nurse uses “why” questions to seek clarification of unusual symptoms or behavior. 7. During an interview, a patient denies having any anxiety. The patient frequently changes position in the chair, holds his arms folded tight against his chest, and has little eye contact with the interviewer. The interviewer should: a. Use confrontation to bring the discrepancy between verbal and nonverbal behavior to the patient’s attention. b. Proceed with the interview. Patients usually are truthful with a health care practitioner. c. Make a mental note to discuss the behavior after the physical examination is completed. d. Proceed with the interview and examination as outlined on the agency assessment form. The patient’s behavior is appropriate for the circumstances. 8. For what or with whom should touch be used during the interview? a. Only with individuals from a Western culture b. As a routine way of establishing contact with the person and communicating empathy c. Only with patients of the same gender d. Only if the interviewer knows the personwell 9. Children usually come for health care with a parent. At about what age should the interviewer begin to question the child himself or herself regarding presenting symptoms? a. 5 years b. 7 years c. 9 years d. 11 years 10. Because of adolescents’ developmental level, not all interviewing techniques can be used with them. Which techniques should be avoided? a. Facilitation and clarification b. Confrontation and explanation c. Empathy and interpretations d. Silence and reflection 11. Knowledge of the use of personal space is helpful for the health care provider. Personal distance is generally considered to be: a. 0to112 feet. b. 112 to 4 feet. c. 4 to 12 feet d. 12 or more feet. 12. Mr. B. tells you, “Everyone here ignores me.” You respond, “Ignores you?” This technique is best described as: a. Clarification. b. Selective listening. c. Reflecting. d. Validation. 13. What does active listening NOT include? a. Taking detailed notes during the interview b. Watching for clues in body language c. Repeating statements back to the person to make sure you have understood d. Asking open-ended questions to explore the person’s perspective 14. When interviewing a patient who does not speak English, the examiner should: a. Take advantage of family members who are readily available and willing to assist. b. Use a qualified medical interpreter who is culturally literate. c. Seek as much information as possible and then continue with the physical examination. d. Wait until a qualified medical interpreter is available before starting the interview. 15. With older adults, how should the examiner proceed with the interview? a. Proceed in a more organized and concise manner. b. Consider the fatigue of the older person and break the interview into shorter segments. c. Ask a family member to complete some of the records while moving ahead with the interview. d. Raise your voice if the patient does not appear to hear you. Chapter 4: The Complete Health History The Health History Sequence Biographical data Source of history Reason for seeking care Present health or history of present illness Past health Family history Review of systems Functional assessment including activities of daily living (ADLs) Biographical Data Name Address and phone number Age and birth date Birthplace Sex Marital status Race Ethnic origin Occupation: usual and present Source of History o Record who furnishes information, usually the person, although source may be relative or friend o Judge reliability of informant and how willing he or she is to communicate ▪ A reliable person always gives same answers when questions are rephrased or are repeated later in interview o Note any special circumstances, such as use of interpreter Reason for Seeking Care o Brief spontaneous statement in person’s own words describing reason for visit o Symptom: subjective sensation person feels from disorder ▪ What person says is reason for seeking care is recorded and enclosed in quotation marks to indicate person’s exact words o Sign: objective abnormality that can be detected on physical examination or in laboratory reports Present Health or History of Present Illness (HPI) Location Character or quality Quantity or severity Timing Setting Aggravating or relieving factors Associated factors Patient’s perception PQRSTU Mnemonic P = Provocative or palliative Q = Quality or quantity R = Region or radiation S = Severity scale: 1 to 10 T = Timing or onset U = Understand patient’s perception of problem Question Which of the following is a good example of a well-written chief complaint? a. Patient complaining of chest pain for about 3 days that is worse with activity and relieved with rest. b. Pain is a 10/10. c. Patient complaining of chest pain. R/O MI. d. Patient states “I don’t know what this pain is. This is the worst I have ever felt.” Question Answer: Past Medical History Childhood illnesses Accidents or injuries Serious or chronic illnesses Hospitalizations Operations Obstetric history Immunizations Last examination date Allergies Current medications Family History Age and health or cause of death of relatives Health of close family members Family history of various conditions such as heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease, and tuberculosis Family tree (genogram) to show this information clearly and concisely Cross-Cultural Care Implications Additional questions for new immigrants Biographical data Spiritual resource and religion: assess if certain procedures cannot be done Past health: what immunizations, if any Health perception How does person describe health and illness How does person see problems he or she is now experiencing Nutrition: taboo foods or food combinations Review of Systems General overall health state Skin Hair Head Eyes Ears Nose and sinuses Mouth and throat Neck Breast Axilla Respiratory system Cardiovascular Peripheral vascular Gastrointestinal Urinary system Functional Assessment: ADLs Self-esteem, self-concept Activity and exercise Sleep and rest Nutrition and elimination Interpersonal relationships and resources Spiritual resources Coping and stress management Personal habits Illicit or street drugs Environment and work hazards Intimate partner violence Occupational health CAGE Test Have you ever thought you should Cut down your drinking? Have you ever been Annoyed by criticism of your drinking? Have you ever felt Guilty about your drinking? Do you drink in the morning, an Eye opener? Perception of Health Ask questions such as the following: How do you define health? How do you view your situation now? What are your concerns? What do you think will happen in the future? What are your health goals? What do you expect from us as nurses, physicians, or other health care providers? Question Which of the following statements by the patient would indicate a substance abuse problem? a. “I have a glass of wine each day with dinner.” b. “My wife keeps nagging me to cut down on drinking.” c. “I love to have a few drinks around the holidays.” d. “I have a few drinks on the weekend when my friends get together.” Correct answer: Developmental Competence Child Health history adapted to include information specific for age and developmental stage of child o Biographic data o Source of history ▪ Person providing information and relation to child ▪ Your impression of reliability of information ▪ Any special circumstances (e.g., use of an interpreter) o Reason for seeking care Developmental Competence: Child (Cont.) History of present Illness Severity of pain: note effect on usual behavior (e.g., does it stop child from playing?) Associated factors, such as relation to activity, eating, and body position Parent’s intuitive sense of problem often accurate; even if proven otherwise, this gives an idea of parent’s area of concern Parent’s coping ability and reaction of other family members to child’s symptoms or illness Past Health History: Child Prenatal status Labor and delivery Postnatal status Childhood illnesses Serious accidents or injuries Serious or chronic illnesses Operations or hospitalizations Immunizations and allergies Medications Past Health History: Child (Cont.) Developmental history Growth Milestones Current development for children 1 month through preschool age School-age child Nutritional history Family history Review of Systems: Child General overall health state Skin Hair Head Eyes Ears Nose and sinuses Mouth and throat Neck Breast Axilla Respiratory system Cardiovascular Peripheral vascular Gastrointestinal Urinary system Functional Assessment: Child Including ADLs Interpersonal relationships Activity and rest Economic status Home environment Environmental hazards Coping and stress management Habits Healt