NR 509 Basic and Advanced Interviewing Techniques Study Guide

Chapter 1 Basic and Advanced Interviewing Techniques Basic maximize patient's comfort, avoid unnecessary changes in position, enhance clinical efficiency, move head to toe, examine the patient from their right side A ...

Chapter 1 Basic and Advanced Interviewing Techniques Basic maximize patient's comfort, avoid unnecessary changes in position, enhance clinical efficiency, move head to toe, examine the patient from their right side Active listening, empathic responses, guided questioning, nonverbal communication, validation, reassurance, partnering, summarization, transitions, empowering the patient Active Listening- closely attending to what the patient is communicating, connecting to the patient’s emotional state and using verbal and nonverbal skills to encourage the patient to expand on his or her feelings and concerns. Empathic Responses-the capacity to identify with the patient and feel the patient’s pain as your own, then respond in a supportive manner. Guided Questioning- show your sustained interest in the patient’s feelings and deepest disclosures and allows the interviewer to facilitate full communication, in the patient’s own words, without interruption. Non-verbal- includes eye contact, facial expression, posture, head position and movement such as shaking or nodding, interpersonal distance, and placement of the arms or legs-crossed, neutral, or open. Validation- helps to affirm the legitimacy of the patient’s emotional experience. Reassurance- an appropriate way to help the patient feel that problems have been fully understood and are being addressed. Partnering- building rapport with patients, express your commitment to an ongoing relationship. Summarization- giving a capsule summary of the patient’s story during the course of the interview to communicate that you have been listening carefully. Transitions- inform your patient when you are changing directions during the interview. Empowering the Patient- empower the patient to ask questions, express their concerns, and probe your recommendations in order to encourage them to adopt your advice, make lifestyle changes, or take medications as prescribed. Advanced: Determine scope of assessment: Focused vs. Comprehensive: pg5 Comprehensive: Used for patients you are seeing for the first time in the office or hospital. Includes all the elements of the health history and complete physical examination. A source fundamental and personalized knowledge about the patient, strengthens the clinician-patient relationship. ● Is appropriate for new patients in the office or hospital ● Provides fundamental and personalized knowledge about the patient ● Strengthens the clinician–patient relationship ● Helps identify or rule out physical causes related to patient concerns ● Provides a baseline for future assessments ● Creates a platform for health promotion through education and counseling ● Develops proficiency in the essential skills of physical examination Flexible Focused or problem-oriented assessment: For patients you know well returning for routine care, or those with specific “urgent care” concerns like sore throat or knee pain. You will adjust the scope of your history and physical examination to the situation at hand, keeping several factors in mind: the magnitude and severity of the patient’s problems; the need for thoroughness; the clinical setting—inpatient or outpatient, primary or subspecialty care; and the time available. ● Is appropriate for established patients, especially during routine or urgent care visits ● Addresses focused concerns or symptoms ● Assesses symptoms restricted to a specific body system ● Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible Tangential lighting: JVD, thyroid gland, and apical impulse of heart. Components of the Health History Jenna/Ashley Initial information Identifying data and source of the history; reliability Identifying data- age, gender, occupation, marital status Source of history- usually patient. Can be: a family member or friend, letter of referral, or clinical record. Reliability- Varies according to the patient’s memory, trust, and mood. Chief Complaint Chief Complaint- Make every attempt to quote the patient’s own words. Present Illness Complete, clear and chronological description of the problem prompting the patient visit Onset, setting in which it occurred, manifestations and any treatments Should include 7 attributes of a symptom: ● Location ● Quality ● Quantity or severity ● Timing, onset, duration, frequency ● Setting in which it occurs ● Aggravating or relieving factors ● Associated manifestations -Differential diagnosis is derived from the “pertinent positives” and “pertinent negatives” when doing Review of Systems that are relevant to the chief complaint. A list of potential causes for the patients problems. -Present illness should reveal patient’s responses to his or her symptoms and what effect this has on their life. -Each symptom needs its own paragraph and a full description. -Medication should be documented, name, dose, route, and frequency. Home remedies, nonprescriptions drugs, vitamins, minerals or herbal supplements, oral contraceptives, or borrowed medications. -Allergies-foods, insects, or environmental, including specific reaction Tobacco use, including the type. If someone has quit, note for how long -Alcohol and drug use should always be investigated and is often pertinent to the Presenting Illness. Past history -Childhood Illness: measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever, and polio. Also include any chronic childhood illness -Adult illnesses: Provide information in each of the 4 areas: ● Medical: diabetes, hypertension, hepatitis, asthma and HIV; hospitalizations; number and gender of sexual partners; and risk taking sexual practices. ● Surgical: dates, indications, and types of operations ● Obstetric/gynecologic: Obstetric history, menstrual history, methods of contraception, and sexual function. ● Psychiatric: Illness and time frame, diagnoses, hospitalizations, and treatments. -Health Maintenance: Find out if they are up to date on immunizations and screening tests. Review Tb tests, pap smears, mammograms, stool tests for occult blood, colonoscopy, cholesterol levels etc.. Family history Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents Documents presence or absence of specific illnesses in family, such as hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, and symptoms reported by patient. Ask about history of breast, ovarian, colon, or prostate cancer Ask about Genetically transmitted diseases Personal or social history Describes educational level, occupation, family of origin, current household, personal interests, and lifestyle Capture the patients personality and interests, sources of support, coping style, strengths, and concerns Includes lifestyle habits that promote health or create risk, such as exercise and diet, safety measures, sexual practices, and use of alcohol, drugs, and tobacco Expanded personal and social history personalizes your relationship with the patient and builds a rapport Review of systems pg 11-13 Documents presence or absence of common symptoms related to each of the major body systems Understanding and using Review of Systems questions may seem challenging at first. These “yes-no” questions should come at the end of the inter- view. Think about asking a series of questions going from “head to toe.” It is helpful to prepare the patient by saying, “The next part of the history may feel like a hundred questions, but it is important to make sure we have not missed anything.” Most Review of Systems questions pertain to symptoms, but on occasion, some clinicians include diseases like pneumonia or tuberculosis. Note that as you elicit the Present Illness, you may also draw on Review of Systems questions related to system(s) relevant to the Chief Complaint to establish “pertinent positives and negatives” that help clarify the diagnosis. For example, after a full description of chest pain, you may ask, “Do you have any history of high blood pressure . . . palpitations . . . shortness of breath . . . swelling in your ankles or feet?” or even move to questions from the Respiratory or Gastrointestinal Review of Systems The Review of Systems questions may uncover problems that the patient has overlooked, particularly in areas unrelated to the Present Illness. Significant health events, such as past surgery, hospitalization for a major prior illness, or a parent’s death, require full exploration. Keep your technique flexible. Remember that major health events discovered during the Review of Systems should be moved to the Present Illness Past History in your write-up. Some experienced clinicians do the Review of Systems during the physical examination, asking about the ears, for example, as they examine them. If the patient has only a few symptoms, this combination can be efficient. If there are multiple symptoms, however, this can disrupt the flow of both the history and examination, and necessary note taking becomes awkward The Review of Systems: Pg. 12-13 ROS Chart Copied from online book General: Usual weight, recent weight change, clothing that fits more tightly or loosely than before; weakness, fatigue, or fever. Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles. Head, Eyes, Ears, Nose, Throat (HEENT): Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased, use or nonuse of hearing aids. Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble. Throat (or mouth and pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness. Neck: “Swollen glands,” goiter, lumps, pain, or stiffness in the neck. Breasts: Lumps, pain, or discomfort, nipple discharge, self-examination practices. Respiratory: Cough, sputum (color, quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (pleuritic pain), last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis. Cardiovascular: “Heart Trouble”; high blood pressure; rheumatic fever; heart murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea breathing (paroxysmal nocturnal dyspnea); swelling in the hands, ankles, or feet (edema); results of past electrocardiograms or other cardiovascular tests. Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea. Bowel move-ments, stool color and size, change in bowel habits, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble; hepatitis. Peripheral vascular: Intermittent leg pain with exertion (claudication); leg cramps; varicose veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness. Urinary: Frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling. Genital Male: Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infections and their treatments. Sexual habits, interest, function, satisfaction, birth control methods, condom use, and problems. Concerns about HIV infection. Female: Age at menarche, regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension. Age at menopause, menopausal symptoms, postmenopausal bleeding. If the patient was born before 1971, exposure to diethylstilbestrol (DES) from maternal use during pregnancy (linked to cervical carcinoma). Vaginal discharge, itching, sores, lumps, sexually transmitted infections and treatments. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy, birth-control methods. Sexual preference, interest, function, satisfaction, any problems, including dyspareunia. Concerns about HIV infection. Musculoskeletal: Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness. Psychiatric: Nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts. Past counseling, psycho-therapy, or psychiatric admissions. Neurologic: Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, black-outs; weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles”. Subjective vs Objective Data Subjective- symptoms or what the patient tells you. Apparent only to the person affected; includes client’s perceptions, feelings, thoughts, and expectations. Cannot be directly observed and can be discovered only asking questions. Examples: low back pain, fatigue, immunizations, weight gain, stomach cramps. Objective- signs or what you observe. Detectable by an observer or can be tested against acceptable standard; tangible; observable facts; includes observation of client behavior, medical records, lab and diagnostic tests, data collected by physical exam. Examples: blood pressure, heart rate, wound appearance, lung sounds, ambulation description. Subjective Data (symptoms) Objective Data (signs) What the patient tells you What is observed during physical examination Patients history, from Chief Complaint through Review of Systems Laboratory information, test data DocumentationDocumentation needs to be CLEAR, CONCISE, COMPREHENSIVE. -think order and readability, amount of detail. - Record: history, PE, and lab findings - describe what's observed not what was done -SOAP (subjective, objective, assessment, & plan) note is used for providers of various backgrounds/specialties to communicate with each other Chapter 2 Clinical Decision Making ashley Clinical decision making should be evidence based. The FNP should draw on a full range of knowledge and experience, and read widely. Clinical decision making is when the reading about diseases and abnormalities is most useful. By consulting the clinical literature, you are embarking on evidence-based decision making and clinical practice. There are five steps to generating a clinical hypotheses 1. Select the most specific and critical findings to support your hypothesis 2. Match findings against all the conditions that can produce them. 3. Eliminate the diagnostic possibilities that fail to explain findings. 4. Weigh the competing possibilities and select the most likely diagnosis 5. Give special attention to potentially life-threatening conditions Once the hypothesis is made it should be tested, this may include further history taking, testing or physical examination. The next step is to establish a working diagnosis such as “bacterial meningitis, pneumococcal”. The final step is developing a plan. The plan should make reference to diagnosis, treatment and patient education. It is important to discuss your assessment with the patient prior to finalizing the plan to ensure the patient is onboard. Critical Thinking and Reasoning Critical thinking- the mental process of actively and skillfully perception, analysis, synthesis and evaluation of collected information through observation, experience and communication that leads to a decision for action. The main critical thinking skills in which nursing students should be exercised during their studies are critical analysis, introductory and concluding justification, valid conclusion, distinguish between facts and opinions, evaluation the credibility of information sources, clarification of concepts and recognition of conditions. Critical thinking is an essential process for the safe, efficient and skillful nursing practice. The nursing education programs should adopt attitudes that promote critical thinking and mobilize the skills of critical reasoning. Critical thinking is the disciplined, intellectual process of applying skillful reasoning as a guide to belief or action. In nursing, critical thinking for clinical decision-making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care. Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought and the competent use of thinking skills and abilities for sound clinical judgments and safe decisionmaking. Differential Diagnoses (obtained from book and week 1 review) - A list with potential causes of patient specific problem/CC -A chief complaint must be identified first. -Includes all medical diseases that may possibly explain problem/ CC. -The differential diagnosis list should begin with the most likely explanation or etiology for the problem/CC. EX: C/O vomiting blood: 1. Peptic ulcer 2.Cirrhosis with bleeding esophageal varices 3. Acute hemorrhagic gastritis -Differential diagnostic procedures are used by clinicians to diagnose the specific disease in a patient, or, at least, to eliminate any imminently life-threatening conditions. The differential diagnosis list is similar to, but different from, the problem list. -The differential diagnosis includes all of the medical diseases that may possibly explain the patient’s chief complaint or principal problem -A differential diagnosis list is focused on providing an explanation for a specific complaint. -In order to develop a differential list versus a problem list, you must first identify the chief complaint. Each differential diagnosis should offer an explanation or etiology for the same chief complaint. Pathological and Physiological Processes Pathologic Process- patient complaints often stem from a pathologic process involving diseases of a body system or structure. Common Classified: congenital, inflammatory or infectious, immunologic, neoplastic, metabolic, nutritional, degenerative, vascular, traumatic, and toxic. Example: Possible pathological causes of a headache include- sinus infection, concussion from trauma, subarachnoid hemorrhage, or brain tumor. Problem List -After you complete the clinical record, it is good clinical practice to generate a problem list that summarizes the patient’s problems that can be placed in the front of the office or hospital chart. -List the most active and serious problems first and record their date of onset. - Helps to individualize the patient’s care. On follow-up visits, provides a quick summary of the patient’s clinical history and a reminder to review the status of problems the patient may not mention. -An accurate Problem List allows better population management of patients, by using EHRs to track patients with specific problems, recall patients who are behind on appointments, and follow up on specific issues. -Allows other members of the health care team to learn about the patient’s health status at a glance. For example, in a patient who is vomiting blood and is known to have migraines and to be diabetic, the problem list might read: 1. Hematemesis 2. Diabetes Mellitus 3. Migraine 4. Recent divorce 5. Poverty Prioritization Generate problem list with all problems noted, differential diagnoses should cover all possible causes of chief complaint. Prioritize which complaints/problems are highest priority (urgent) for this visit. (i.e., Tina has diabetes, htn, and a slew of other issues, but utmost importance is her foot wound and ankle pain) Chapter 3 **Interpretation and Analysis (Area is lacking information) Heather and Stacy The clinician must focus on the patient to elicit the full story of the patient's symptoms, but the clinician must also interpret key information to reach an assessment and plan. Patient-centered interviews recognize the importance of patients' expressions of personal concerns, feelings, and emotions and evoke the personal context of the patient's symptoms and disease Sensitivity- true positive. The probability that a person with disease as a + test. Specificity- True negative. SnNOUT- a sensitive test with a negative result rule OUT disease SpPIN- a specific test with a positive result rules IN disease Bayes Theorem- one way to use likelihood ratios to revise probabilities for disease Natural frequencies- represents the joint frequency of two events, such as the number of patients with disease and the number who have a positive test result. Kappa score- reproductivity. Measures the amount of agreement that occurs beyond chance. Precision-reproductivity. Being able to apply the same test to the same unchanged person and obtain the same results. Logical Sequence pg 73 In general, an interview moves through several stages. Throughout this sequence, as the clinician you must remain attuned to the patient’s feelings, help the patient express them, respond to their content, and validate their significance. As a student, you will concentrate primarily on eliciting the patient’s story and creating a shared understanding of the patient’s concerns. Later on, as a practicing clinician, reaching an agreement on a plan for further evaluation and treatment becomes more important. Whether the interview is comprehensive or focused, pay close attention to the patient’s feelings and affect, always working on strengthening the relationship as you move through the typical sequence that follows. Including the patient’s feelings, ideas, and expectations leads to therapeutic interventions best suited to the patient’s needs, coping skills, and life circumstances.