Istinye University Overview

• Istinye University was established in 2015 by the 21st Century Anadolu Foundation
• It is supported by the 25-year knowledge and experience of the MLPCare Group
• MLPCare Group combines three separate hospital brands: Liv Hospital, Medical Park, and VM Medical Park
• A successful academic staff committed to education and research distinguishes the Istinye University
• It aims to be among the world's distinguished universities by contributing to the production of new information with education and research performance
• Uses a student-centered education approach in all the processes of the university
• Aligned with the vision of being a science and research center
• Aims to broaden the boundaries of science with the studies of faculty members
• Wants to implement the findings obtained from scientific developments for the welfare of society
• Also aims to provide quality and accessible health services to the public
• By conducting teaching, research, and community service activities at universal standards, students are presented with a learning environment and advancement that covers a wide-based range of information
• It also covers technology and art

Health story collection

• Health story collection is the first step for patient assessment
• Lecture: NUR111-Health Assessment
• Lecturer: Asst. Prof. Gizem Yağmur Yalçın
• Department: HSF /Nursing (English)
• E-posta: [email protected]

Phases of the Interview Process

• Pre-interaction Phase
• Beginning Phase
• Working Phase
• Closing Phase

Interview Process: Pre-interaction Phase

• The nurse collects data from the medical record
• Review the patient’s history of medical illnesses or surgeries, current medication list, and problem list before meeting with the patient

Interview Process: Beginning Phase

• The nurse introduces herself or himself by name
• The nurse states the purpose of the interview
• The nurse asks the patient his or her preferred name initially
• Ensure privacy is in place
• Pull drapes or close door before proceeding
• Confidentiality guidelines should be considered
• The beginning stage may continue with a discussion of neutral topics if the patient seems anxious

Interview Process: Working Phase

• The nurse asks specific questions.
• Each question has a purpose, which the nurse chooses to elicit appropriate responses
• Types of questions
• Closed-ended (direct) questions have answers, such as “yes” or “no”
• Open-ended questions provide responses in the patient’s own words that are broad
• They are key to understanding symptoms, health practices, and areas requiring intervention

Interview Process: Closing Phase

• The nurse ends the interview by summarizing and stating three important patterns
• Ask if the patients would like to mention or need anything else
• The nurse also thanks patients and family members for their time in taking time to provide information.

SUMMARY: THE INTERVIEW PROCESS

• Appropriate time
• Suitable interview environment
• Privacy
• Seating arrangement
• Lighting
• Temperature of the room

Nurse Tasks

• Introducing herself/himself
• Explain the purpose of the interview
• Good communication
• Getting an accurate and sufficient amount of history
• Keep records after the interview

Trust & Communication

• The nurse establishes trust with patients during history taking and interviewing
• The patient and the nurse work together to resolve problems through collaborative solutions with therapeutic communication
• As the nurse refines interviewing capabilities, conversation with patients becomes more comfortable, with smooth transitions between questions

Therapeutic communication techniques

• Therapeutic techniques or communication makes it easier for the individual to talk about feelings and thoughts, keep communication open

Active Listening

• Active listening is the ability to focus on patients and their perspectives
• Encouraging elaboration (facilitation) assists patients to more completely describe problems
• Responses encourage patients to say more, continue the conversation, and show patients that the nurse is interested
• Empathy means the ability to perceive understanding of another person’s feelings without criticism

Empathy

• Being able to see and feel the situation from the patient’s perspective, not the nurse’s

Examples:

• 12-year-old child feelings: "I am not given any say in the family, no one listens to me"
• Response: It makes you sad that they don't give you a say in the family, you want them to value you and listen to you

Therapeutic communication

• Facilitation-Support
• Using silence
• Confirm
• Clarification
• Explanation

Key considerations when asking questions

• Open-ended questions
• Closed-ended questions
• Be understandable
• Aim to clarify the situation
• Questions should be asked in a way that reveals all the details
• It shouldn't be intended to satisfy curiosity
• Do not ask more than one question at a time
• The answer to the question should not be in it

Principles of Story Taking

• Start with open-ended questions
• Ask specific and narrow questions that will eventually lead to a differential diagnosis
• Take your time
• Ask questions that will keep them talking, such as ‘’what else do you have’’ when an individual stops talking
• Maintain eye contact: show your openness with your body posture
• Show that you approve of it with your head gesture
• Allow the patient the opportunity to express themselves, stay silent
• Briefly summarize what the patient is saying, make sure it is true
• Generate a list by extracting complaints
• Talk about the same topic again and clarify the sequence of events if there is confusion in the sequence of events
• To reiterate patient's feelings "you look sad,....I understand that, it's annoying..." express that you understand
• Communicate care with the patient by sharing communication will be addressed

Nonverbal Communication

• Verbal message matters: "It’s not what you say but how you say it.”
• Real emotional content expressed with nonverbal communication

Communication Process

• Facial expressions and voice matter: 93%
• Words: 7%

Health History, Subjective Data Collection

• The points below pertain to preparing the care plan
• Take health histories and collect subjective data
• Assess the patient’s health status and provide therapeutic communication
• Sections review the elements of a complete comprehensive health history

Components

• Sources
• Components

Sources

• The individual patient is considered the primary data source
• Charts and family members are considered secondary data sources

Elements of a Complete Comprehensive History

• Demographical Data
• Reason for Seeking Care
• History of Present Illness
• Past Health History
• Current Medications and Indications
• Family History
• Functional Health Assessment
• Review of Systems

Components: Demographical Data

• Should check before interview
• Name, age, gender
• Educational status, marital status (whom live with?)
• Address, employment, income and insurance details

Components: Reason for Seeking Care

• This brief statement in the patient’s own words, establishes why they are making the visit

Components: History of Present Illness

• Begins with open-ended questions, and asks patients to explain symptoms
• Complete description, essential
• Questions about symptoms in six to eight categories assist patients to be more specific and complete

Categories for Present

• Illness - location
• Intensity
• Duration
• Description
• Aggravating factors
• Pain goal
• Alleviating factors
• Functional impairment

History of Present Illness (PQRST)

• Onset
• Location
• Duration
• Character
• Aggravating/Relieving factors
• Timing
• Severity

Components: Past Health History (Background)

• Includes the patient’s history of medical and surgical problems along with treatments and outcomes
• Some problems are acute, others resolve, and others are chronic

Current Medications and Indications

• Includes - names, purpose of each, doses, routes

Components: History

• If confusion about any medication exists, ask family members to bring in pill bottles.
• For hospitalized patients, reconcile all medication lists
• The nurse verifies allergies with patients and compares findings against legal records
• The nurse notes the type of allergic response and differentiates allergies from side effects or adverse reactions to medications

Components: Family History

• Questions about the health of parents, grandparents, siblings, and children help identify those diseases for which patients may be at risk
• Important familial conditions noted

Familial Conditions

• High blood pressure
• Coronary artery disease
• High cholesterol
• Stroke, cancer
• Diabetes mellitus
• Obesity, alcohol or drug addiction
• Mental illness
• Genetic conditions

Functional Health Assessment

• Functional health patterns are the focus
• Effects of health or illness on quality of life
• Using this approach, the nurse can assess the strengths of patients, as well as areas needing improvement

Functional Health Patterns

1. Health perception/health management
2. Nutrition/metabolic
3. Elimination
4. Activitiy/exercise
5. Cognition/perception
6. Sleep/rest
7. Self-perception/self-concept
8. Role/relationship
9. Sexuality/reproductive
10. Coping/stress tolerance
11. Values/beliefs

Health Assessment Examples

• Health perception/health management: Perceived health and well-being and how health is managed
• Nutrition/metabolic: Food to metabolic need and indicators of local nutrient supply
• Elimination: Excretory function (bowel, bladder, and skin)
• Activitiy/exercise: Exercise, activity, leisure, and recreation
• Cognition/perception: Sensory perceptions and thought patterns
• Sleep/rest: Sleep, rest, and relaxation
• Self-perception/self-concept: Self-concept, body comfort, body image, and feeling state
• Role/relationship: Role engagements and relationships
• Sexuality/reproductive: Satisfaction and dissatisfaction with sexuality and reproductive patterns
• Coping/stress tolerance: General coping pattern and effectiveness in terms of handling stress
• Values/beliefs: Values, beliefs (including spiritual), or goals that guide choices or decisions

Review of Systems

• A series of questions about all body systems that helps to reveal concerns or problems
• Asking questions related to each body system systematically before proceeding to the physical assessment
• Integrating questions while physically examining each region

Systems to Review

• General Health State
• Skin, Hair, and Nails
• Head and Neck, regional lymph nodes
• Eyes
• Ear, nose, mouth and throat
• Thorax and Lungs
• Cardiovascular system
• Heart and Neck Vessels
• Peripheral Vascular
• Abdominal-Gastrointestinal
• Neurological
• Sequence and format vary with setting, urgency of the problem, and style of the nurse

Cardiovascular System Sample Questions

• Have you ever had any pain or pressure sensations in your chest, neck or arm?
• Do you have shortness of breath during exercise?
• Have you ever woken up at night with shortness of breath?
• Can you lie flat without shortness of breath?
• Do you have swelling in your ankles?
• Have you ever felt irregularities or stuttering in your heartbeat?
• Have you had a sudden blackout without any complaints?
• Have you felt tired in your legs during exercise?
• Have you had coldness and blueness in your hands or feet?
• Have you had a rheumatic fever or heart attack?
• Do you have high blood pressure (hypertension)?