Non-therapeutic Responses

1. Non-therapeutic Responses

2. Often in social situations, people use nontherapeutic casual responses that are inappropriate in the nurse–patient relationship:

3. False reassurance helps to minimize uncomfortable feelingsbut may mislead a patient into minimizing a health concern or neglecting to perform a needed health-promoting activity. • Sympathy is feeling what a patient feels from the viewpoint ofthe nurse, not of the patient. • Unwanted advice, although common in social situations, is non-therapeutic, because it usually is from the nurse’s perspective, not the patient’s. • Biased (leading) questions impose judgment and lead patients torespond in the way they think the nurse wants

4. Changing the subject may happen when a situation is uncomfortable for a nurse because of personal experiences or coping mechanisms. • Environmental distractions contribute to nontherapeutic communication. • Too many technical terms or too much information can over-whelm patients. As she or he develops medical vocabulary and knowledge, the beginning nurse must practice translating from medical terminology to lay language. • Talking too much and interrupting are nontherapeutic. Theprofessional nurse listens more than talks.

5. Health history (subjective data collection) • Interviewing is the method by which health care providers take health histories and gather subjective data. Information discussed allows the nurse to assess the patient’s health status and to provide therapeutic communication when indicated. The following sections review the elements of a complete comprehensive health history. • Sources

6. The individual patient is considered the primary data source. Charts and family members are considered secondary data sources. • A reliable historian provides comprehensive information consistent withexisting records. If information differs from past descriptions or details change each time, the patient may be unreliable or considered an inaccurate historian.

7. Components • Demographical Data • Demographical data include name, address, billing information, employment, and insurance details. • They also encompass environmental data about exposure to contagious diseases, travel to high-risk areas, and concerns about exposure to pollution, hazards, and allergens. • For hospitalized patients, the nurse assesses housing information to identify the level of independence and support needed following discharge, number of stairs at home, and any concerning structural barriers. • Further occupational information helps to establish the ability of patients to return to work, work safely, avoid occupational hazards, and have access to personal protective equipment, handicapped access, and adaptive devices

8. Reason for Seeking Care • This brief statement, usually in the patient’s own words, establishes why he or she is making the visit. The nurse asks, “Tell me why you came to the clinic today” or “What happened that brought you to the hospital?” and records responses in the subjective part of documentation or puts the statement in quotes.

9. History of Present Illness • The nurse begins with open-ended questions and asks patients to explain symptoms. A complete description of the present illness is essential. • Questions about symptoms (subjective sensations or feelings of patients) in six to eight categories assist patients to be more specific and complete: location, duration, intensity, description, aggravating factors, alleviating factors, pain goal, and functional impairment.

10. Common mnemonics used to remember the key elements of the presenting symptom(s) are OLDCARTS (Onset, Location, Dura-tion, Character, Associated/Aggravating factors, Relieving factors, Timing, Severity) and PQRSTU (Provocative/Palliative, Quality, Region, Severity, Timing, Understanding patient perception).

11. Past Health History • The past health history 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.

12. Current Medications and Indications • The nurse asks about current medications including names, doses, and routes; purpose of each; and any over-the-counter medications, supplements, or herbal remedies uses. • If confusion about any medication exists, the nurse may ask patients or their family members to bring in pill bottles. For hospitalized patients, the nurse must reconcile all medication lists with medications taken regularly at home so that patients continue using the correct drugs.

13. The nurse verifies allergies with patients and compares findings against legal records. The nurse notes the type of allergic response (eg, rash, throat swelling, and anaphylaxis) and differentiates allergies from side effects or adverse reactions to medications.

14. Family History • Questions about the health of parents, grandparents, siblings, and children help identify those diseases for which patients may be at risk and enable nurses to provide health teaching. • Important familial conditions include high blood pressure, coronary artery disease, high cholesterol, stroke, cancer, diabetes mellitus, obesity, alcohol or drug addiction, mental illness, and genetic conditions.

15. ** Types of nursing health history: • A complete health history: This is taken on initial visits to health care facilities. • An interval health history: used to collect information in visits following the one in which an initial data base is collected. • A problem – focused health history: used to collect data about a specific problem system or region. • * Clients must be able to provide information they consider relevant, however the nurse must probe, clarify and quantify in structured ways.

16. * The nurse should take notes during data collection; however, it is usually not possible to write the entire health history during the interview. • * The nurse should record as much of the health history during interview as possible and the remainder soon after the interview.

17. Components of health history • Biographical data : This includes : • Full name • Address and telephone numbers (client’s permanent, contact of client) • Birth date and birth place. • Sex and race. • Religion. • Marital status. • Social security number. • Occupation (usual and present) • Source of referral. • Usual source of health care. • Source and reliability of information. • Date of interview.

18. Chief complaint: • "reason for hospitalization. • The chief complaint statement is a short statement. In the client’s own words, indicates the client’s purpose for requesting health care at this time. • ** The following are examples of adequately stated chief complaints: • Chest pain for 3 days. • Swollen ankles for 2 weeks. • Fever and headache for 24 hours. • Pap smear needed. • Physical examination needed for camp.

19. History of present illness: • Gathering information relevant to the chief complaint, and the onset of client’s problem, including essential and relevant data, and self medical treatment. • ** Components of present illness: • Introduction: “client’s summary and usual health”. • Investigation of symptoms: “onset, date, gradual or sudden, duration, precipitating factors, frequency, location, quality, and alleviating or aggravating factors”. • Negative information. • Relevant family information. • Disability system "affected the client’s total life".

20. Past health history: • The purpose of the past history is to identify all major past health problems of the client. This includes. • Child hood illness e.g. history of rheumatic fever. • History of accidents and disabling injuries regardless he was hospitalized or not. • History of hospitalization includes time of admission and date of it with admitting complaint and discharge diagnosis and the follow up care. • History of operations “how and why this done” • History of immunizations and allergies. • Physical examinations and diagnostic tests.

21. Family history : • The purpose of the family history is to learn about the general health of the client's blood relatives, spouse, and children ant to identify any illness of environmental, genetic, or familiar nature that might have implications for the client’s current or future health problems and needs or to their solution: • Family history of communicable diseases. • Heredity factors associated with the causes of many diseases. • Strong family history of certain problems. • Health of family members “maternal, parents, siblings, aunts, uncles, spouse and children”. • Cause of death of the family members “immediate and extended family”.

22. Environmental history: • The purpose of environmental history is "to gather information about surroundings of the client", including physical, psychological, social environment, and presence of hazards, pollutants and safety measures.” • Current health information: • The purpose of the current health information is to record major, current, health related information.

23. * recommended out line for the information: • Allergies: environmental, ingestion, drug, other. • Habits “alcohol, tobacco, drug, caffeine” • Medications taken regularly "by doctor or self prescription • Exercise patterns. • Sleep patterns. • * The pattern of sedentary and active activities in the client's usual routine is explored. A weekly pattern of activity is recorded. The client’s sleep pattern is explored and usual daily routine is recorded

24. Psychosocial history: • Which includes: how client and his family cope with disease or stress, and how they responses to illness and health. • The nurse can assess if there is psychological or social problem and if it affects general health of the client. • Review of systems : (ROS) • This includes a collection of data about the past and present health of each of the client’s systems. This review of the client’s physical, sociologic, and psychological health status may identify hidden problems and provides an opportunity to indicate client strengths and liabilities.