NR509 Chapter 1 Midterm Study Guide.pdf

NR 509 Midterm Study Guide Chapter 1Approach to the Clinical Encounter The interviewing process 1. Initiating the encounter o Setting the stage/preparation o Greeting the patient and establishing initial rapport 2. Gathering i...

NR 509 Midterm Study Guide Chapter 1Approach to the Clinical Encounter The interviewing process 1. Initiating the encounter o Setting the stage/preparation o Greeting the patient and establishing initial rapport 2. Gathering information o Initiating information gathering o Exploring patient’s perspective of illness o Exploring biomedical perspective of disease including relevant background and context 3. Performing the physical examination 4. Explaining and planning o Provide correct amount and type of information o Negotiate plan of action o Shared decision making 5. Closing the encounter Interviewing techniques o Active listening o Empathy o Guided questioning o Nonverbal communication o Validating o Reassuring o Partnering o Summarizing o Transitioning o Empowerment: § Empowering clients to ask questions and express their concerns increases the chances that they will adopt your advice, make lifestyle changes, or take medications as prescribed. [ch1] The clinical interview needs to incorporate both the clinician’s and the patient’s views of reality, disease, and illness. Begin with open-ended questions that allow full freedom of response: Setting the stage for the examination Establishing rapport [Box 1-4] Box 1-4. Establishing Rapport with Patients with Physical and Sensory Disabilities Based on 2010 global population estimates more than a billion people (15% of the world’s population) are estimated to live with some form of disability. In the United States, it is estimated that the overall rate of people with disabilities in 2016 was 12.8% of the population.  Patients Who Are Blind or Have Low Vision o Always verbally identify yourself when you approach and introduce other people in the room. o Do not leave without letting the patient know. o Ask before you help. Always ask how the patient would like to be assisted. o Be prepared to provide written materials in an auditory, tactile, or electronic format of the patient’s preference (audio file, Braille, large print). o Explain what is about to happen before beginning the encounter and ask if the patient has any questions. o Tell the patient where personal effects (clothes and other belongings) are in the room and do not move them without telling the patient. o Staff should be welcoming and describe the physical environment (doors, steps, ramps, bathroom location, etc.). o Never distract or touch a service animal without asking the owner. Patients Who Are Hard of Hearing o Ask how best to communicate. o Be prepared to give written materials as long as they are not the primary form of communication. o Inform patients that sign language interpreting and real-time captioning services are available. o If requested, promptly provide sign language interpreting or real-time captioning service for effective communication. o Do not talk at a distance from the patient or from another room. o Look directly at the patient when speaking so your mouth is visible. o Speak normally and clearly. Do not shout, exaggerate mouth movements, or speak rapidly. o Minimize background noise and glare. Patients Who Are Deaf o Ask how best to communicate. o Inform patients that sign language interpreting and real-time captioning services are available. o If requested, promptly provide sign language interpreting or real-time captioning service for effective communication. o Family members should not be used to interpret. o Address the patient, not the interpreter. o Be prepared to give written materials as long as they are not the primary form of communication. Patients Who Use Wheelchairs o Make sure there is a path of access to the room. o Respect personal space, including wheelchair and assistive devices. o Do not propel the wheelchair unless asked to do so. o Provide accessible equipment as needed. o Provide assistance as needed, such as by clearing obstacles from the path of travel or helping patients transfer to equipment if accessible equipment is unavailable. o Do not separate patients from their wheelchairs Gender pronouns Clinicians should ask all patients their preferred name and gender pronouns, ideally at the beginning of the visit and/or on an intake questionnaire.  Patient-centered medical care o Clinician centered care: symptoms/disease focus o Patient centered care: patient expressions, emotions, perceptions, feelings, attitudes towards disease focus o Emphasizes shared decision-making model o Disease: clinician explanation for symptoms o Illness: patient experience of symptoms o FIFE o o Use “people-first” language especially when referring to patients with disabilities (e.g., person who is blind, person who uses a wheelchair, person with hearing loss) o The patient-centered approach “recognizes the importance of patients’ expressions of personal concerns, feelings, and emotions” and evokes “the personal context of the patient’s symptoms and disease.” Experts have defined patient-centered interviewing as “following the patient’s lead to understand their thoughts, ideas, concerns and requests, without adding additional information from the clinician’s perspective Structure of clinical encounter o Initiate the session o Gathering information o Physical examination o Explanation and planning o Closing the session The FIFE model o F = feelings, o I = ideas, o F = functional effect, o E = expectations § Helps to explore patient’s perspective about/illness Box 1-9 Learn to respond attentively to emotional cues using techniques like reflection, feedback, and “continuers” that convey support. A mnemonic for responding to emotional cues is NURSE: Name: “That sounds like a scary experience” Understand or legitimize: “It’s understandable that you feel that way” Respect: “You’ve done better than most people would with this” Support: “I will continue to work with you on this” Explore: “How else were you feeling about it?” Box 1-13 three dimension of cultural humility 1 Self-awareness. Learn about your own biases; we all have them. 2 Respectful communication. Work to eliminate assumptions about what is “normal.” Learn directly from your patients; they are the experts on their culture and illness. 3 Collaborative partnerships. Build your patient relationships on respect and mutually acceptable plans. Box1-14 the 5 Rs of cultural humility Box 1-14. The 5Rs of Cultural Humility Reflection: Clinicians will approach every encounter with humility and understanding that there is always something to learn from everyone. Ex: What did I learn from each person in that encounter? Respect: Clinicians will treat every person with the utmost respect and strive to preserve dignity at all times. E.x., Did I treat everyone involved in that encounter respectfully? Regard: Clinicians will hold every person in their highest regard, be aware of, and not allow unconscious biases to interfere in any interactions. Ex: Did unconscious biases drive this interaction? Relevance: Clinicians will expect cultural humility to be relevant and apply this practice to every encounter. Ex: How was cultural humility relevant in this encounter? Resiliency: Clinicians will embody the practice of cultural humility to enhance personal resiliency and global compassion. Ex: How was my personal resiliency affected by this interaction? Self-reflection and self-critique to realize cultural understandings and self limitation/bias o Reflection o Respect o Regard o Relevance o Resilience ACE: Aid to Capacity Evaluation, can be perform in less than 30 min, and uses the patient’s clinical scenario in the evaluation. Chapter 2 Interviewing, Communication, and Interpersonal Skills. Fundamentals of skilled interviewing Box 2-1. Skilled Interviewing Techniques o Active or attentive listening o Guided questioning (open-ended progress to close-ended) § Box 2-2 technique of guided questioning o Empathic responses § “You have lost your father. What has that been like for you? o Summarization §. You have not had a fever or felt short of breath, but you do feel congested, with difficulty breathing through your nose.” Following with an attentive pause or asking, “Anything else? o Transitions (help patient know what to expect) § Before we move on to reviewing all your medications, was there anything else about past health problems?” “Now I would like to examine you o Partnering § Make patients feel that no matter what happens, you will continue to provide their care o Validation  § “Your accident must have been terrifying. Car accidents are always unsettling because they remind us how vulnerable we are. Perhaps that explains why you still feel upset,” o Empowering the patient [49 Box 2-3] § When you empower patients to ask questions, express their concerns, and probe your recommendations, they are most likely to adopt your advice, make lifestyle changes, or take medications as prescribed. o Reassurance § The first step to effective reassurance is simply identifying and acknowledging the patient’s feelings. § o Appropriate nonverbal communication Verbal and nonverbal communication Box 2-5 Forms of nonverbal communication o Body orientation toward and physical proximity to patient o Gaze orientation (eye contact) toward patients o Head nodding with facial animation o Head nodding with gesture o Posture o Tone and use of voice o Use of silence o Use of touch (haptics Challenging patient situations and behaviors o Silent patients: therapeutic, allow for reflection o Talkative: allow to talk for 5-10 min, redirect, never show impatience o Confusing narrative: summarize, clarify, assess for cognition o Emotional lability: therapeutic, empathy, reassurance o Angry/aggressive: validate if warranted, set clear boundaries o Flirtatious: set clear boundaries o Discriminatory: assess illness acuity of patient, patient, cultivate therapeutic alliance, o Establish supportive learning environment/set boundaries o Hard of hearing: face patient, allow for lip reading, lower frequency, normal volume Guided questioning o Open ended: encourage telling the story o Progress too close ended/focused questioning o People-first language: “person with diabetes” NOT diabetic Constitutional symptoms o Fatigue o Weakness o Fever/chills o Weight gain/weight loss o Pain Chapter 3 Health History. Focused and comprehensive health histories o For new patients, in most settings, you will do a comprehensive health history. o For patients seeking care for specific concerns, for example, cough or painful urination, a more limited interview tailored to that specific problem may be indicated; this is sometimes known as a focused or problem-oriented history. Box 3-1 Patient assessment : comprehensive or focused Comprehensive patient assessment Focused patient assessment Is appropriate for new patients in the office or Is appropriate for established patients, especially hospital during routine or urgent care visits Provides fundamental and personalized Addresses focused concerns or symptoms knowledge about the patient Strengthens the clinician–patient relationship Assesses symptoms restricted to a specific body system Helps identify or rule out physical causes related Applies examination methods relevant to to patient concerns assessing the concern or problem as thoroughly and carefully as possible 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 o Comprehensive for initial visit and transitional care § Includes CC, HI, PMH, PFSH, full ROS o Focused for established patients with specific concerns, ER visits § Incudes CC, HPI, pertinent PMH and ROS SOAP Subjective o CC, HPI, PMH, PFSH, ROS Objective o Physical exam, labs, imaging o Pertinent positives (abnormal that confirms disease) pertinent negatives (normal findings that rules out disease) Assessment o Medical diagnoses Plan: o e.g., F/U in 1 week o medications, orders (diagnostic, referrals, etc.) HPI includes OLDCARTS o Give as much detail as necessary for CC PMH includes ongoing medical problems, significant childhood illness, vaccinations, surgical obstetric, psychiatric, allergies, medications. PFSH past family social hx): living condition, occupation, smoking, history, alcohol use, drug use, family hx, sexual orientation and gender identity, sexual hx, spiritual, nutritional, exercise, safety, ADLs Determining the scope of the patient assessment o 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. The seven attributes of a patient’s principal symptoms 1) Location 2) Quality 3) Quantity or severity 4) Timing including: a. Onset, duration, frequency 5) Setting in which it occurs 6) Modifying factors 7) Associated manifestations Subjective versus objective data o The clinical record from the Chief Complaint (CC) through the Review of Systems is considered subjective information, whereas all physical examination, laboratory information and test data are objective information. Modifying of the clinical interview for various clinical settings o Ambulatory care clinic: § Focus your information gathering not only on the CC (if there is one) but also chronic health issues and any changes to them since their last visit/ o Emergency care: § you should ensure that your pt is stable before initiating a detailed but focused interview. o Intensive care unit: § clinical information will need to come from a family member, other clinicians, or prior documentation in the HER. o Nursing Home: § attempt to obtain history from the resident first § if pt has cognitive dysfunction, may need to confirm certain information with family or the clinical staff o Home: § when obtaining the health history try to focus on level of function § Evaluate the environment (environment hazards, level of cleanliness, etc) FICA: Faith or belief; Importance and Influence; Community; Address Week 2. Chapter 4 Physical Examination. Determining the scope of the physical examination