NUR 3065 Exam 1
Identify the components of the health history.
-- biographical data/ Demographics
-- chief Complaint (CC)/ Reason for seeking care
Brief statement in person's own words describing reason for visit, write
this in "quotes"
-- history of present illness/ present health
-- past health/past medical and surgical history
-- family history
-- functional assessment
social history
activities of daily living (ADLs)
-- review of Symptoms (ROS)
Identify the components of the functional/social history
--sometimes referred to as psycho-social assessment and ADLs
--activities of daily living: cooking, eating, dressing, toileting, bathing, etc.
-- activity/exercise M(moving around inside and outside, any limitations,
etc.
-- sleep/rest- how many hours/day, napping, aids, etc.
-- nutrition/elimination- adequate diet, specific diet, beverages/water,
able to get groceries, able to get to the BR: (specific questions about
voiding, incontinence, BMs, constipation/diarrhea, teeth/dentures,
swallowing are with the ROS)
-- self-esteem, self-concept
--interpersonal relationships/resources
,-- spiritual resources
-- coping and stress management
Consider the role of culture as a key element in health assessment.
-- touch: use sparingly, but in some cultures may relay meaning. It is
dependent on your level of familiarity with a client.
-- cultural Considerations-You must modify your actions based upon the
client's culture. For instance, eye contact is thought of as rude in some
cultures
Non-verbal communication:
-- physical appearance
-- facial expression
-- posture
-- gestures
-- eye contact
-- voice
-- touch
Verbal Communication
-- affirmation:
use of verbal cues to show you are paying attention. "is that right?"
-- restating:
-- clarification:
-- presenting reality:
-- humor:
-- redirecting: Refocusing the client on the topic at hand "Now lets get
back to the problem with your boyfriend....it is the reason you're
here...isn't it?"
, -- sharing perceptions: Sharing what you perceive to determine the
meaning that the client attributes to the situation. "I feel like your
insinuating that you may hurt yourself or someone else?".
Communicating with different ages across the life cycle: infants
(gentle handling; quiet and calm voice; face them directly)
communicating with different ages across the life cycle: toddlers and
preschoolers
(answer "why" questions; provide choices when possible; short, simple
sentences; concrete language)
verbal communication
facilitation
responses designed to facilitate more information sharing.
verbal communication: reflection
Repeating a portion of a clients statement in order to gain greater
meaning "you say your getting tired of my lecture?"
verbal communication
restating
restating the main point to see if you really wonder what the client is
saying. "So your really angry because your dinner was late?"
verbal communication: clarification
Asking the client to expand on a topic to increase your understanding.
verbal communication: presenting reality
Identify the components of the health history.
-- biographical data/ Demographics
-- chief Complaint (CC)/ Reason for seeking care
Brief statement in person's own words describing reason for visit, write
this in "quotes"
-- history of present illness/ present health
-- past health/past medical and surgical history
-- family history
-- functional assessment
social history
activities of daily living (ADLs)
-- review of Symptoms (ROS)
Identify the components of the functional/social history
--sometimes referred to as psycho-social assessment and ADLs
--activities of daily living: cooking, eating, dressing, toileting, bathing, etc.
-- activity/exercise M(moving around inside and outside, any limitations,
etc.
-- sleep/rest- how many hours/day, napping, aids, etc.
-- nutrition/elimination- adequate diet, specific diet, beverages/water,
able to get groceries, able to get to the BR: (specific questions about
voiding, incontinence, BMs, constipation/diarrhea, teeth/dentures,
swallowing are with the ROS)
-- self-esteem, self-concept
--interpersonal relationships/resources
,-- spiritual resources
-- coping and stress management
Consider the role of culture as a key element in health assessment.
-- touch: use sparingly, but in some cultures may relay meaning. It is
dependent on your level of familiarity with a client.
-- cultural Considerations-You must modify your actions based upon the
client's culture. For instance, eye contact is thought of as rude in some
cultures
Non-verbal communication:
-- physical appearance
-- facial expression
-- posture
-- gestures
-- eye contact
-- voice
-- touch
Verbal Communication
-- affirmation:
use of verbal cues to show you are paying attention. "is that right?"
-- restating:
-- clarification:
-- presenting reality:
-- humor:
-- redirecting: Refocusing the client on the topic at hand "Now lets get
back to the problem with your boyfriend....it is the reason you're
here...isn't it?"
, -- sharing perceptions: Sharing what you perceive to determine the
meaning that the client attributes to the situation. "I feel like your
insinuating that you may hurt yourself or someone else?".
Communicating with different ages across the life cycle: infants
(gentle handling; quiet and calm voice; face them directly)
communicating with different ages across the life cycle: toddlers and
preschoolers
(answer "why" questions; provide choices when possible; short, simple
sentences; concrete language)
verbal communication
facilitation
responses designed to facilitate more information sharing.
verbal communication: reflection
Repeating a portion of a clients statement in order to gain greater
meaning "you say your getting tired of my lecture?"
verbal communication
restating
restating the main point to see if you really wonder what the client is
saying. "So your really angry because your dinner was late?"
verbal communication: clarification
Asking the client to expand on a topic to increase your understanding.
verbal communication: presenting reality
