Health history model 1

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Health history model 1 by Mind Map: Health  history model 1

1. Verbal skills : includes questions

1.1. Closed or Direct Questions

2. The elements of the health history

2.1. Biographic data

2.1.1. Personal information includes name, address,phone number,ets.

2.2. Source of history

2.2.1. Record of who furnishes the information ( the best source is the person himself or herself

2.3. Reason for seeking care

2.3.1. This is a brief spontaneous in the person’s own words that describes the reason for the visit

2.3.1.1. Sign

2.3.1.2. Symptoms

2.4. Present health or history of present illness

2.4.1. This is a short statement about the general state of health

3. Health

3.1. a state of complete physical, mental , and social wellbeing and not merely the absence of disease or infirmity.

4. Assessment

4.1. Collection of data about individual’s health state

5. Health assessment

5.1. A health assessment is a set of questions answered by patient

5.2. Evaluation of the health state of an individual using physical examinations technique

5.3. It’s involve collecting data

5.4. First step of nursing process

6. The process of communication

6.1. Interview is a necessary tool to obtain data.

6.2. Communication is all behavior, conscious and unconscious, verbal and nonverbal.

7. Data

7.1. Types S\O

7.1.1. Subjective data \ based on what the patient says

7.1.2. Objective data \ observation

7.1.2.1. Vital signs

7.2. Types of databases

7.2.1. Complete (total health) data base

7.2.1.1. Health history and full physical examination

7.2.1.2. Certain and past health state

7.2.1.3. First diagnosis

7.2.2. Focused or problems centred database

7.2.2.1. The main one problem and the more complex

7.2.3. Follow up database

7.2.3.1. Surviving the client healthy state and risk factors of particular health problem

7.2.3.2. This is for a limited or short-term problem

7.2.3.3. Used in all sitting to follow up short-term or chronic health problems ,identified problems and appropriate intervals.

7.2.4. Emergency database

7.2.4.1. Rapid collection of data

7.2.4.2. Swift and sure questions are done. Emergency need of the patient

8. Purposes of health assessment

8.1. Undetected Diseases. Risks, screening for specific diseases such as diabetes,determining functional impact of diseases, evaluation the effectiveness of health care plan.

9. Three health assessment component

9.1. Part one interviewing techniques

9.2. Part two physical examination

9.3. Party three evaluates the client nutritional state

10. Phases of the interview

10.1. Introducing the interview (orientation phase )

10.2. The working phase

10.2.1. data-gathering phase

10.3. Closing the interview (closure phase)

10.3.1. that eases the closing of the interview and d sums it up

11. Factors of interview

11.1. Internal Factors

11.1.1. Internal\ it’s particular to the examiner, it’s what’s the examiner to bring into the interview.

11.1.1.1. liking other

11.1.1.2. Empathy

11.1.1.3. Ability to listen

11.1.1.4. Mini database more targeted than the complete database

11.2. External Factors

11.2.1. External\proper the physical setting.

11.2.1.1. Privacy

11.2.1.2. Environment physical

11.2.1.3. Interruption

12. Ten Traps Of Interviewing

12.1. Providing False Reassurance

12.2. Giving Unwanted Advice

12.3. Using Authority

12.4. Using Avoidance Language

12.5. Engaging in Distancing

12.6. Thank the client

12.7. Using Professional Jargon

12.8. Using Leading or Biased Questions

12.9. Talking too much

12.10. Interrupting

12.11. Using “why” questions.

13. Nonverbal Skills

13.1. Physical Appearance

13.2. Posture

13.3. Gestures

13.4. Facial Expressions

13.5. Eye Contact

13.6. Voice

13.7. Touch

14. The Complete Health History

14.1. a combination of the objective data from the physical examination and laboratory studies to form a database.

14.1.1. It provides a complete picture of the person’s past and present health

14.1.1.1. Describes the individual as a while and how the person interacts with the environment.

15. Difference between Nursing health history and Medical health history

15.1. Medical health history: symptoms and progression of diseases

15.2. Nursing health history: focuses on the client’s functional health patterns

16. Data documentation

16.1. Major part of a complete health history

16.2. The nurse should record subjective data in the client own words

17. Review of records

17.1. Medical diagnosis

17.2. Nursing notes

17.3. Laboratory and diagnostic studies performed

17.4. Referral notes

18. Closing the interview

18.1. Discuss only specific points

18.1.1. It concludes what the client and nurse agree the health state to be

18.2. Signal that the interview is about to end

18.2.1. Don’t introduce any new topic

18.3. Request validation of the patient/client perception

18.4. End the interview/conclusion brings it to close

18.5. Offer the client chance for final addition

18.6. Explain the next steps.plan can be made for the future

19. Responses-Assisting the narrative

19.1. Facilitation

19.1.1. This response encourage the patient to say more, to continue with the story

19.1.2. These responses show the person the interviewers’ interest and will to listen further

19.2. Silence

19.2.1. Is golden after open ended questions.

19.2.2. Silent attentiveness communicates that the patient has time to think, organize what to say without interruption from the interviewer.

19.3. Reflection

19.3.1. This response echoes the patient’s words.

19.3.2. It is repeating part of what the person has just said; it helps express feelings behind a person’s words

19.4. Empathy

19.4.1. This response recognizes a feelings and puts it into words

19.5. Clarification

19.5.1. used when the patient’s word choice is ambiguous or confusing

19.5.2. Also used to summarize the person’s words, simplify the words to make them clearer.

19.6. Confrontation

19.6.1. these responses now include your own thoughts and feelings.

19.6.2. The interviewer has observed a certain action, feeling or statement and you now focus the person’s attention to it.

19.7. Interpretation

19.7.1. the responses are based on the inference or conclusion.

19.7.2. t links events, makes association or implies cause.

19.8. Explanation

19.8.1. This response is informing the person, sharing factual and objective information.

19.9. Summary

19.9.1. is the final review of what the interviewer understand the person has said

19.9.2. Condense the facts and present a survey of how health problem is perceived.

20. Use this mnemonic PQRSTU to help remember all patients to ask.

20.1. PQVRSTU

20.1.1. Provocative or palliative

20.1.2. Quality or quantity

20.1.3. Region or radiation

20.1.4. Severity

20.1.5. Timing

20.1.6. Understanding of patient perception