Prelims - Communication and History Taking PDF

RT 108: PHYSICAL ASSESSMENT AND ELECTROCARDIOGRAPHY Jehanna Nor, RMT, MD Data Collection The Patient Interview Process of communication that focuses on: Establishing rapport and trust (elicits accurate and meaningful information/ data) The Patient Interview Process of communic...

RT 108: PHYSICAL ASSESSMENT AND ELECTROCARDIOGRAPHY Jehanna Nor, RMT, MD Data Collection The Patient Interview Process of communication that focuses on: Establishing rapport and trust (elicits accurate and meaningful information/ data) The Patient Interview Process of communication that focuses on: Gathering information (to identify deviations that can be treated by independent or collaborative interventions) Developmental, psychologic, physiologic, sociocultural, and spiritual Phases of the Patient Interview Introductory Working Summary and Closure Introductory Phase Introducing self to the client Citing the purpose of the interview Discussion of the types of questions that may be raised Introductory Phase Explaining reason for writing down notes Assurance of con dentiality Ensure privacy fi Working Phase Gathers comments Biographic data Reasons for seeking care Present health concern, etc. Working Phase Listens and observes for cues Collaboration of both parties Summary and Closure Phase Summarizes sets of information Identi cation of possible plans (to resolve the problem and discuss) Clari cation is encourage about the above fi fi Types of Communication Types of Communication Non-verbal Appearance, demeanor, posture, facial expressions, attitude, etc. Verbal Basic necessity to gather information Uses communication strategies Non-Verbal Communication Appearance Present yourself professionally (neat clothes, hair, and name tag with credentials) Non-Verbal Communication Demeanor Upon entering the room, aim for composure Focus is towards the client When uncomfortable, best to maintain professional distance Never be too “touchy” or overwhelmingly friendly Non-Verbal Communication Demeanor NO: Laughing loudly Yelling with coworker Muttering under your breath  Non-Verbal Communication Facial Expression Often overlooked aspect of communication Re ects what you are truly thinking Regardless of what you are saying, keep it in check fl Non-Verbal Communication Attitude Non-judgmental (acceptance regardless of beliefs, ethnicity, lifestyle, and health practices) Means not preaching to client and imposing own ethics and morality One of the most important non-verbal skills to develop Non-Verbal Communication Silence Allows you and client to re ect and organize thoughts Facilitates more accurate reporting and data collection fl Non-Verbal Hindrances to Communication Excessive/Insu cient Eye Contact Distraction and Distance Standing ffi  Non-Verbal Hindrances to Communication Excessive/Insu cient Eye Contact Avoid extremes in eye contact (in moderation) i.e when client is speaking but look down at notes from time to time Cultural orientation may also a ect clients perception of eye contact with others ff ffi Non-Verbal Hindrances to Communication Distraction and Distance Being preoccupied with something else while asking questions (mentally distant) Gives idea that interview is not important to you Non-Verbal Hindrances to Communication Distraction and Distance Avoid physical distance more than 2-3 feet Rapport and trust are built when client senses your focus and concern entirely on him/her Proxemics Study of distance between people in their interactions Four (4) distances: 1. Intimate (0-1.5 feet) 2. Personal (1.5-4 feet) 3. Social (4-12 feet) 4. Public (>12 feet) Proxemics Proxemics Non-Verbal Hindrances to Communication Standing Puts concerned parties at di erent levels Healthcare-worker (higher level) may be perceived as superior Patient care should be a partnership Otherwise patient may not feel empowered ff Verbal Communication Open-Ended Questions Close-Ended Questions To elicit client’s feelings To obtain facts and zero-in and perceptions on speci c information Require more than a one- Important in keeping the word response interview on course “How?” or “What?” “When?” Or “Did?” fi The Interview Questions Types Description Limits the response that can be given When, Where, Who, What Closed/Close-ended Do (did, does) Is (was, are) Sometimes Open/Open-ended Invites clients to explore thoughts or feelings (elaborate, clarify, or illustrate) Neutral No direction or pressure from healthcare worker Leading Directs the client’s answer Therapeutic Communication Therapeutic Communication 1. Listening 2. Rephrasing 3. Broad Opening and General Statements 4. Clari cation 5. Focusing fi Therapeutic Communication Listening Actively and with mindfulness, using all the senses, paying attention to what the client says, does, and feels, as opposed to listening passively with just the ear Therapeutic Communication Rephrasing Actively listening for the basic message and repeating those thoughts in similar words Patient: “I couldn’t manage to eat any dinner last night - not even dessert.” Health-worker: “You had di culty eating yesterday.” Patient: “Yes, I was very upset when my family left.” ffi Therapeutic Communication Broad Opening and General Statements Using statements that: Encourage client to verbalize Choose a topic of conversation Facilitate continued verbalization Health-worker: “Where would you like to begin?” Therapeutic Communication Clari cation Makes client’s broad overall meaning of message and understandable. Used when paraphrasing is di cult or when communication is garbled. Health-worker: “I’m not sure I understand that. Would you please say that again?” fi ffi Therapeutic Communication Focusing Helps client expand on and develop a topic of importance Patient: “My wife says she will look after me, but I don’t think she can, what with the children to take care of, and they’re always after her about something — clothes, homework, what’s for dinner that night.” Health-worker: “Sounds like you are worried about how well she can manage.” Interview Considerations Gerontologic Considerations Age a ects and commonly slows body systems (esp. hearing and visual acuity) Slow physically but not mentally (less medical jargon, talk slower but do not talk down) Has more health concerns than younger patients (they may feel more vulnerable and scared) Not unusual for elderly patients to have health complaints ignored ff Cultural Considerations Willingness to openly express emotional distress or pain Reluctance to reveal personal information Ability to receive information Disease and illness Decision-making process Emotional Variations and Responses Patient’s Emotional State Proper and Professional Response Anxious Simple and organized information Explain role and purpose Angry Be reassuring, and adopt a calm manner Allow patient to ventilate feelings Avoid arguing Depressed Facilitate personal Express interest andspace understanding in a neutral manner Manipulative Structure and set limits Patient with sensitive issues Be aware of your own thoughts and feelings Collection of Data Health History Serves as groundwork for identifying problems Provides focus for the physical examination Commencement: “..so that I will be able to plan an individualized care plan with you.” Health History Components Biographical Data Chief Complaints Present Health History Past Health History Family History Health History Components Psychosocial History Lifestyle and Health Practices Review of Systems Biographical Data Personal Information Name, address, phone number, gender, informant, birthdate, social security number, medical record number, place of birth, nationality, ethnicity, marital status, educational level, occupation, and other similar data Chief Complaint Question Rationale What is your major health problem or concerns at Focus on signi cant health concern this time? Answers: “Why are you here?” How do you feel about having to seek healthcare? Encourages discussion of fears and other feelings toward healthcare provider fi Common Cardiopulmonary Symptoms Chest pain Di culty of breathing Cough Epigastric pain Wheezing ffi Present Health History Considers several aspects of the health problem Detailed description of the concern Symptom Treatments Precipitating factor Expectations (prognosis) Present Health History Examples: When did you rst notice the pain in your chest? How long have you experienced it? Has it become worse, better, or stayed the same since it rst occurred? fi fi Present Health History Factor Speci cs Character Feeling, look, sound, and smell Onset When did it begin? Location Where is it? Does it radiate? Duration How long does it last? Severity How bad is it? Grading? Pattern What makes it better or worse? Associated factors fi Past Health History Related to the client’s past until present condition Elicit data on client strength and weakness Points to trends of unhealthy behavior Information gained assists in identifying risk factors Past Health History Birth, growth and development, childhood diseases, immunizations, allergies, previous problems, hospitalizations, surgeries, pregnancies, deliveries, accidents, injuries, pain experiences Past Health History “Can you tell me how your mother described your birth? Where there any problems? As far as you know, did you progress normally as you grew to adulthood?” What illnesses or allergies have you had?” Have you ever been pregnant, and delivered a baby?” Family Health History Include as many blood relatives as can be recalled Vertical and horizontal relations Helps identify diseases with a genetic or familial pattern Family Health History Genogram tool used Includes at least three (3) generations Patient is known as the “proband/index patient” Has standard formats Male - Square (left side) Female - Circle (right side) Lines between relatives show relationship Sample Genogram Psychosocial Data Human responses Nutritional habits Activity and exercise patterns Typical daily patterns/regular exercise plan Psychosocial Data Sleep and rest Tell me about your sleeping patterns Do you have trouble falling or staying asleep Use of medications and other substances How much beer, or wine, do you drink on average? Self-concept and self-care activities What do you see as your talents or special abilities? Psychosocial Data Social and community activities Relationships Who is the most important person in your life? Values and belief systems What is the most important to you in life? What gives you hope and strength? Psychosocial Data Education and work Educational attainment, work experience Coping style Compensatory behaviors in dealing with stress Stress level Environment Review of Systems Speci c questions draw out current health problems from recent May still a ect the client (or may be recurring) Documentation - description of his or her health status for each body system and a notation of client’s comment to the question asked fi ff THANK YOU.