Patient Assessment 2
Terms
undefined, object
copy deck
- Biophysical
- pertaining to the science dealing with the application of physical methods and theories to biological problems.
- chief complaint
- the reason the patient is seeking medical care
- cognitive
- pertaining to the operation of the mind process by which we become aware of perceiving, thinking and remembering
- congruence
- the verbal expression of the message matches the sender's nonverbal body language
- diagnosis
- concise technical description of the cause, nature, or manifestations of a condition or problem
- Initial diagnosis
- physician's temporary impression, sometimes called a "working diagnosis"
- Differentiated diagnosis
- comparison of two or more diseases with similar signs and symptoms
- final diagnosis
- conclusion physician reaches after evaluating all findings, including lab and other test results
- familial
- occurring in or affecting members of a family more than would be expected by chance
- present illness
- the chief complaint, written in chronological sequence, with dates of onset
- psychosocial
- pertaining to a combination of psychological and social factors
- rapport
- relationship of harmony and accord between the patient and the healthcare professional
- Medical history components
-
Database - name, address, DOB, etc
Past med. history - pts previous health
Family history - pt's mother, father - their health, cause and age of death
Social history - lifestyle, hobbies
System's reviews - general health - active listening techniques
-
restatement - "you are saying..."
reflection - "you sound frustrated about..."
clarification - "explain to me about..." -
non-verbal communication observations
Breathing patterns - rapid respirations, sighing, shallow, thoracic breathing
-
non-verbal communication observations
Eye Patterns - no eye contact, side to side movement, looking down at hands
- open ended questions
- asking for general information (How are you feeling today?)
- closed questions
- asking for specific information (Do you have a headache?)
-
Communication techniques
Open ended questions - encourages pt to respond in a comfortable manner
-
communication techniques
direct questions - ask for specific information, usually reply is a yes or no
-
communication tecniques
listening - nonverbally communicates your interest in the patient
-
communication techniques
silence - communicates your acceptance of the patient, nonverbally
-
communication techniques
establishing guidelines - helps the patient to know what is expected
-
communication techniques
acknowledgement - shows the importance of the patient's role
-
communication techniques
restating - checks your interpretation of the patient's message for validation
-
communication techniques
reflecting - shows the importance of the pt's feelings
-
communication techniques
summarizing - helps the patient to separate relevant from irrelevant material
- Subjective findings
- Symptoms - perceptible only to the patient
- objective findings
- signs - perceptible to a person other than the patient