NR 509 Mid-term study guide

        Basic and Advanced Interviewing Techniques Basic o Gather a sensitive and nuanced hx. o Perform thorough and accurate exam o Improve pt. rapport o Focus your assessment o Sent guideposts that direct clinical decision making o Avoid interpreting your findings- may be premature. o Warn pt. that your assessment may take longer but that doesn’t mean negative findings Advanced o With time and practice- able to integrate: o Empathetic listening o Ability to interview pts of all ages, genders, races, ethnicities, etc. o Improved techniques to examine different body systems o Differentiate level of sick vs. not sick o Improved process of clinical reasoning leading to diagnosis and plan o Will grow and begin clinical reasoning from first impression of meeting pt. o ID Sx. And abnormal findings, linking underlying pa xtho o Establish and test explanatory hypotheses Components of the Health History Identifying data – age, gender, marital status, occupation o Source of hx. - usually pt. but could be family or friend, letter of referral or clinical record o Establish the source of referral is necessary Reliability- pt. memory, trust, mood Chief Complaint- one or more symptoms or concerns causing pt. to seek care o Try and keep this in patients own words “my stomach feels awful” Present illness- amplifies CC o **Complete, clear and chronologic description of the problems prompting the pts. Visit including onset, setting it developed how it manifests and tx. To date o Includes pt. thoughts and feelings about illness o *pertinent positives and pertinent negatives* o May include meds, allergies, tobacco, ETOH... o Seven attributes of a symptom 1. Location 2. Quality 3. Quantity or severity 4. Timing (onset, duration, frequency) 5. Setting it occurs 6. Factors that aggravate or relieve 7. Associated manifestations o Consider placing PMHx in this area to support potential problem (hx. Of CAD with pt. presenting with CP) o How these sx are affecting ADLs o Medications taking to help or than may exacerbate