Health History

Stages Key Elements ● ● ● ● ● ● Past medical history to include previous illnesses and state of health Last oral intake of liquids and foods Events leading to illness or injury Allergies and types of reactions Symptoms or chief complaint Each prescribed medication, OTC medications, and herbal supplements Three-Stage Interview Opening Stage ● Introduce yourself and the reason for your health history interview ● Establishes client rapport Information Gathering Stage/Body ● Use therapeutic communication techniques to collect and document data Closing Stage ● Ends the interview ● Thank the client for their participation, answer any questions, and summarize the collected information Planning ● Assemble the tools needed to take notes ● Know how long you have access to the client ● Pace and edit questions to fit them into your timeframe Medical Record ● Arrange to access it as a paper/electronic record ● Review for an understanding of previous clinical issues ● Assists with formulating relevant questions Time and Place ● Schedule at a convenient setting ○ Ex. beginning of the intake or admission process ○ Once the client is in a private environment ● Curtains or doors should be shut ● Ensure proper lighting and ventilation Seating ● Be 2-3 feet from the client ● St face-to-face to see their nonverbal cues ● Avoid being at a significantly higher seating/standing position Pain ● Interferes with the client’s ability to concentrate and remember information ● Ask the client if they are experiencing pain ● If so, intervene to reduce their discomfort, and document pain-relieving activities Interviewing Techniques Directive ● ● ● ● ● The nurse controls the elements of the interview, often with a list of essential questions The client responds to the questions but has limited opportunity to discuss concerns Allows precise details to be obtained Usually involves closed-ended questions Ex. used prior to emergency surgery Nondirective ● Allow the client to control the pace and information-seeking route ● Helps to develop a rapport; usually involves open-ended questions ● Ex. used in providing education Types of Questions to Use Closed-Ended ● Direct, non-complex questions ● Time-saving, less threatening, and easily documented ● Lack in-depth information and the ability to discern emotional state/feelings about a topic Open-Ended ● Allows the client to elaborate on their answer with a more thorough and detailed response ● The client can relay information that is important to them while the nurse actively listens ● Requires more time, may include unnecessary responses, and is harder to document ○ Redirection might be necessary Interviewing Tips ● Avoid using medical terminology ● Avoid phrasing in ways that can be interpreted as judgment ● Avoid asking “why” questions ● Avoid changing the topic abruptly or interrupting the client ● Avoid leading questions ● Avoid projecting your values Phrases to Avoid ● ● ● ● ● ● You should… Why haven’t… Surely you don’t… Let’s discuss this later… Don’t worry… If I were you… Interpret and Validate Data ● Identify information topics that need further investigation ● Validate all factual conflicts or discrepancies ● Double-check significant findings at the end ● Document assessment findings using facts Current Health ● Record the date and time as well as the client’s preferred language ● If you do not speak the language, arrange for an interpreter or use a “language line” ● Family and friends are not standard procedure for interpretation Using an Interpreter ● ● ● ● Speak in the first person and directly to the client Speak in short sentences and allow the interpreter time to convey the questions Avoid the use of medical terminology Document the source of information (client, relative, interpreter, or medical record) Biographic Data ● ● ● ● ● Check the client’s name, address, and phone number against the medical record Ask the client to state their age and date of birth Ask if the client has any illnesses/disabilities that affect daily living or social interactions Ask if there is an emergency contact person Determine sex and gender identity by asking: ○ What sex was originally on your birth certificate? ○ What gender do you identify as? ○ What pronouns do you use? Reasons for Seeking Care ● For a healthy client, as for a statement of their overall health ● For an ill/injured client, focus on their reason for seeking medical care ○ Known as the “chief complaint” or “presenting problem” ○ Should be documented in their own words ● Take note of signs of illness/injury and the duration of their ill health ● Repeat back a summary of their responses for validation History of Present Illness ● Document in chronological order the appearance of the manifestations connected with the reason for seeking care, going until the present time ● For each reported symptom, note the location, characteristics, severity of its appearance, timing, and setting in which it became noticeable ● Ask about aggravating or relieving factors (ex. medications or cold compresses) ● Ask about the client’s knowledge of any associated factors with the illness/injury ● Inquire if the client noticed any other symptoms that occur along with the complaint Gathering Details ● ● ● ● ● ● ● ● Onset: When symptoms began Location: Where symptoms occur Duration: How long the symptoms last Characteristics: The characteristics of the symptoms Aggravating/Alleviating factors: What affects the symptoms Related symptoms: Other symptoms that are present Treatment: What treatments have been tried Severity: How severe symptoms are Social Determinants of Health ● Include social and economic opportunities that affect health ● Five determinants include economic stability, access to and quality of education, social and community aspects, access to and quality of healthcare, and the neighborhood and build environment in which the client works and lives ● Recognize if any of these factors are active in their health status ○ If so, follow that topic of conversation ● You could possibly connect the client with available community resources and support General Data Collection Childhood Illnesses ● Ask the client about illnesses experienced as a child and if they have experienced any complications from the infections Injuries ● Determine if the client has experienced any significant injuries ○ Ex. auto accident, fractures, head injuries, penetrating wounds, or serious burns ● Note the dates and outcomes Chronic Illness ● Inquire if the client has any serious/chronic illness ○ Ex. asthma, diabetes, seizures, sickle cell anemia, hepatitis, or heart disease Hospitalizations ● Questions if the client has ever been hospitalized due to an illness ● Note the reason, date, and length of hospitalization Surgeries ● Determine if the client has ever had surgery ● Detail the type, when it occurred, and the outcome Immunizations ● Ask the client if they have received the recommended immunizations for their age ● Adults are advised to have the annual influenza, Tdap, MMR, HPV, varicella, and COVID-19 immunizations ● Depending on age and lifestyle, one might also have hepatitis A and B, pneumococcal, meningococcal, and Haemophilus influenzae type B immunizations ● International clients may have received the BCG vaccination for tuberculosis Health Maintenance Examinations and Screenings ● Question when the client last had a visit for a physical, dental, and vision assessment ● Determine if they have done routine health screenings ○ Ex. colonoscopy, cholesterol levels, tuberculin skin test, mammogram, and pap smears ○ Determine when and what the results were Allergies ● Inquire if the client has had any allergic reactions to food, medications, or environmental/contact triggers (ex. latex) ● Document the type of reaction the client has to the allergen ● For medications, document only those that cause a true allergic reaction as opposed to unpleasant side effects Current Medication (Medication Reconciliation) ● Ensure that the record of the client’s medications is accurate ● This includes prescription medications, all supplements, herbal compounds, and regular use of OTC medications ● Determine the name, dosage, and frequency of the medications ● Note the reason that the client takes the medication Nutrition ● Ask the client about their current eating habits and appetite ● Document if the client has noted recent changes in body weight Obstetrical ● For clients of childbearing age, ask about obstetrical history and record using GTPAL: ○ Gravida: Total number of pregnancies the client expected ○ Term: The number of pregnancies that were carried out within 2 weeks of the client’s due date ○ Preterm: The number of pregnancies that were delivered more than 2 weeks before the client’s due date ○ Abortion: Any spontaneous (miscarriage) or induced (therapeutic) abortions ○ Living Children: The current number of living children ● If the client is transgender, include any gender-affirming treatments Emotional and Psychological ● ● ● ● Ask about how much stress is currently being experienced and the source Explore personal coping strategies and their efficacy Ask about a history of previous counseling or mental health care (ex. medications) Ask about the experience of recent losses to assess if grief is playing a part in their current emotional state ● Inquire about the client’s support system, including family and friends Family Health History ● Concentration on the health of three generations of blood relatives ○ Grandparents, parents, and any siblings ● For any deceased family members, ask the age and cause of their death ● Sets of diseases to inquire about: ○ Genetically linked diseases: Blood disorders, obesity, kidney disease, or cancer of the breast, colon, prostate, or ovaries ○ Neurological or psychological disorders: Mental illness, stroke, seizures, substance use disorders, dementia, or Alzheimer’s disease ○ Cardiac diseases: Heart attacks, high blood pressure, or elevated cholesterol levels ○ Endocrine issues: Diabetes or thyroid disease ○ Arthritis ○ Asthma or tuberculosis ○ Allergic reactions to medications, foods, or environmental triggers Review of Systems ● Conduct a review of body systems from head to toe ● Evaluate the client’s overall health and identify any unexpected manifestations ● If manifestations in a certain body system are found, a thorough assessment is warranted ● If the client reports painful symptoms, addressing those symptoms becomes the priority Overall Health ● Ask easy-to-answer questions, such as those involving weight changes, fatigue, stress, and discomfort ● A head-to-toe approach provides an outline for overall health Skin ● Does the client have a history of skin disease? ● Are they aware of any changes in their skin or nails? ● Are they aware of changes in their hair growth pattern or texture? Head and Neck Head ● Start with the head as a whole ● Has the client had any headache experiences? ○ If so, where and of what quality? ○ Is it a sensation of tightness or pounding? ● Does the client report any dizziness or lightheadedness? ● Is there a history of head trauma or injury? ○ If so, was there a loss of consciousness? Following the head is gathering data about four of the five senses, excluding touch at this time. Eyes ● ● ● ● Are they wearing glasses or contact lenses? When was their last eye examination? Do they have a history of any chronic conditions of the eye? Have they noticed any recent visual changes? ○ If so, would it be described as blurred vision, double vision, or eye pain? ● Are they experiencing any discharge or excessive tearing? Ears ● Are they wearing a hearing aid? ● Have they experienced any recent changes in their hearing, such as a decreased ability to hear people’s conversations or a ringing sound? ● Do they have a pattern of frequent earaches? ● Have they had fluid drained from their ears? Nose and Sinuses ● ● ● ● ● Are they having any discharge from their nose? Have they had nosebleeds? Do they have allergies to environmental substances, such as pollen or mold? Have they noticed a change in their sense of smell? Do they snore? Mouth and Throat ● Do they wear dentures or bridges? ● Are they having any pain or sensitivity to heat or cold in their teeth or gums? ● ● ● ● ● ● Have they noticed any bleeding or swelling of the gums? Do they have any sores or lesions in their mouth or on their tongue? Is their voice hoarse or strained? Do they have a sore throat? Are they having any difficulty swallowing? Have they noticed a change in their sense of taste? Neck ● Are they experiencing any tenderness in their neck muscles? ● Are they aware of any enlarged lymph nodes, lumps, or swelling in their neck? ● Do they have any pain or limitations to their movement of the neck? Breast and Lymphatics ● ● ● ● ● Do they have a history of any breast conditions? Have they had any surgery on the breast? Do they have any lumps, pain, or notice a difference in the breast tissue? Have they had any drainage from their nipples? For the axilla, have they noticed any tenderness, pain, lumps, or swelling? Respiratory System ● Do they have a history of lung disease or a chronic lung condition? ● Do they ever have any difficulty breathing or shortness of breath? ○ If so, what precipitates the difficulty? ● Have they had a recent cough? ○ If so, was it dry or productive? ○ If it produced any material, have the client describe its characteristics, like color and thickness ● When did they last have a screening test for tuberculosis? Cardiac and Peripheral Vascular System ● Do they have a history of any heart condition, such as rheumatic fever, a murmur, hypertension, heart disease, or anemia? ● Have they had any reports of chest pain, tightness, or discomfort? ● Has the client experienced any irregular heart rhythms, such as palpitations? ● Have they ever felt short of breath during the day or while sleeping? ● Do they wake up at night feeling short of breath? ● Have they ever had surgery on their heart or any of the blood vessels? ● Have they noticed swelling in their hands or lower extremities? ● ● ● ● For both hands and feet, do they feel sensations of coldness, numbness, or tingling? Have they noticed any change in the color of their extremities? Have they ever noticed swelling of the hands, feet, or ankles? Do they have any calf or leg pain that is relieved with rest? Gastrointestinal System ● Do they have a history of any abdominal cases involving the liver, gallbladder, appendix, or intestines, such as colitis, ulcer, or irritable bowel disease? ● Have they had any changes in their appetite or food intolerances? ● Have they had any nausea, vomiting, heartburn, constipation, or diarrhea? ● Do they have pain associated with food? ○ Does this occur when their stomach is empty or after eating? ● Ask the client to describe their stools. ○ What is their usual pattern? ○ Do they have any pain or difficulty with defecation? ○ What color are their stools? ○ Have they noticed any blood in their stools? ○ Do they have hemorrhoids? ○ Do they use laxatives or antacids? ■ If so, how often? ● Have they had a screening for colon cancer? Genitourinary System Urinary ● Do they have a history of any urinary problems, such as kidney stones or failure? ● Do they have pain upon urination, hesitancy, or straining to maintain a regular stream? ● Are they experiencing changes in urinary frequency, including the need to get up and urinate at night (or when asleep)? ● Do they have any flank or suprapubic pain, dribbling, or incontinence? ● What color is their urine? Reproductive ● ● ● ● ● Ask about gender identity and sexual orientation Questions about sexual health include the use of contraceptives and a past history of STIs Inquire about pain or difficulty with sex Record the description of sexual activity, including the types and number of partners For a male client: ○ Ask about pain, sores on/around the genitalia, and discharge from the penis? ○ Do they have lumps in their groin or testicles? ○ Do they perform a monthly testicular examination? ● For a female client: ○ Ask about the presence of any lesions, discharge, or pelvic pain ○ Ask about the onset and ending of menstruation ○ Do they have menstrual pain or premenstrual symptoms (PMS)? ○ Ask them to describe their menstrual cycle ○ If menses has ended, do they have any postmenopausal bleeding? ○ When was the first day of their last menstrual period? ■ How long did it last? Whole-Body Systems Musculoskeletal System ● ● ● ● Do they have a history of musculoskeletal disorders, such as scoliosis, arthritis, or gout? Do they experience any pain, stiffness, or difficulty with movement? Do they experience any swelling, redness, warmth, or deformity of the joints? Does the client have any difficulty performing ADLs? Neurologic System ● Does the client have any difficulty with coordination, ataxia (balance), paralysis, numbness, weakness, tremors, or spasms? ● Do these interfere with the completion of ADLs? ● Does the client have a history of fainting? ● Do they have marked memory loss, forgetfulness, personality changes, or emotional lability (rapid up-and-down mood swings)? ● Do they have any spasms, pain, numbness, tingling, or paralysis of the extremities? ● Do they have a history of seizures? ○ If so, ask them to describe the seizures, including the presence of an aura (a sense that a seizure is about to occur) Hematologic System ● Does the client have any bleeding issues or tendencies? ● Does the client have any unusual bruising? ● Does the client have a history of receiving transfusions or having a transfusion reaction? Endocrine System ● Does the client have excessive thirst, hunger, or urination? ● Do they have any heat or cold intolerances? ● Have they been diagnosed with diabetes or a thyroid disorder? Functional Assessment ● Determine the client’s ability to care for themselves when they are not experiencing an acute illness ● Investigates lifestyle, living environment, and ability to perform the activities associated with daily living Internal Factors Self-Concept ● Includes self-esteem, body image, role performance, and personal identity ● Self-esteem: How the client views themself and their self-worth ○ Are you happy with what you have accomplished with your life? ○ Do you have any difficulties with learning? ● Body image: Client’s attitude toward their appearance, health, strength, and sexuality ○ How would you rate your overall health? ○ Are you comfortable with your overall appearance? ○ Are you comfortable with your sexuality? ● Role performance: Client’s ability to meet their responsibilities at work and home as well as in personal and family relationships ○ Are you happy with what you have accomplished with your life? ○ Are you happy with your job and relationships? ● Personal identity: Client’s ability to be authentic with themself and others ○ Involves individuality and consistency in personal interactions ○ What is your highest level of education? ○ Are you comfortable with your sexuality? ○ Do you feel comfortable being yourself in different social situations? Health Literacy ● The ability of the individual to navigate, understand, and use health information with the intent of maintaining health ● Determines the ability to read prescriptions and understand health-related instructions ● Determines the best means of providing client education Stress ● Evaluate stressors and coping mechanisms ● Are the coping mechanisms healthy or unhealthy? ● Ask open-ended questions: ○ What types of stress have you experienced in the past year? ○ Have you had any changes in lifestyle or relationships in the past year? ○ What methods do you use to decrease your stress levels? ○ Do you feel these methods have been helpful in reducing your feelings of stress? Activity and Exercise ● Starts by asking the client to describe their typical day ● Are you able to complete daily tasks, such as dressing, bathing, toileting, and walking independently, or do you need assistance? ● Are you able to prepare food and complete errands? ● Do you use any mobility aids, such as a cane, walker, or prosthesis? ● Do you feel able to navigate safely in your home and environment? ● How often do you exercise? ● What kind of exercise do you participate in? ● How do you spend your leisure time? Sleep ● Tell me about your usual sleep pattern ● Do you usually take naps during the day? ● Do you use any aids to help you fall asleep? ○ If so, which ones, and how often do you use them? ○ How effective are they in helping you fall asleep? ● Do you feel rested after a night’s sleep? Spirituality ● ● ● ● Faith: Do you have any spiritual traditions you follow or would like us to be aware of? Influence: How does your religious faith/spirituality guide health choices and practices? Community: Do you participate in a religious or spiritual community? Address: Do you have any spiritual or religious preferences that we need to address? Substance Use Alcohol Use ● Tell me about your consumption of alcohol ● ● ● ● ● Do you ever drink alcohol in the morning? Have you ever felt guilty about your drinking? How often do you consume alcohol? How much alcohol do you typically consume? When was your last alcoholic drink? ○ How much did you drink at that time? Tobacco/Nicotine Use ● ● ● ● ● ● Do you or have you ever smoked or chewed tobacco? What type of tobacco do you use? Do you vape? How many packs of cigarettes do/did you smoke each day? How long ago did you quit smoking, vaping, or chewing tobacco? How long have you been smoking, vaping, or chewing tobacco? Recreational Drug Use ● In the past year, how many times have you used an illegal drug, street drug, or taken medications for recreational purposes? ● What type of substances have you consumed? ● What is the dosage or amount that you consume? ● How often do you consume these substances? ● Do you share needles with others or use them more than once? External Factors Occupational Health ● Does your occupation expose you to health hazards, such as noxious fumes, fertilizer, or other chemicals? ● Does your job place you at risk for injury due to moving machinery or heavy lifting? ● Do you wear PPE, such as earplugs, goggles, and gloves when needed? ● Do you feel that your job responsibilities are stressful? ● How would you describe your interactions with coworkers? Have you experienced any feelings of discrimination or microaggressions toward you? ● Does your employer have educational programs and monitoring in place to support employee health? Have you taken advantage of these offerings? Living Environment ● Are there working smoke and carbon monoxide detectors in your home? ● Do you have dimly lit areas or throw rugs in your home that could lead to falls? ● What type of heating and cooling systems are used in your home? Are open-flue gas heaters used? ● Does your home have exposure to hazardous substances, such as lead paint or asbestos? ● Do you have access to fresh water and sewage services? ● Do you consider your home to be a safe place for you? ● Do you feel safe in your neighborhood? ● Have you been exposed to violence within your community? ● Do you have access to needed services, like fresh food, transportation, and healthcare? ● Does your neighborhood have a problem with air pollution or noise pollution? Relationships ● ● ● ● ● What is the relationship of those who live with you in your home? How would you describe your role in the household? Do the individuals within your household get along with one another? Is there a family member or friend that you could reach out to if you need help/support? Is there anything or anyone that prevents you from socializing or participating in groups as much as you would like? Maltreatment Ensure that the client is alone and in a safe space when answering these questions. Screening questions for intimate partner violence or adult abuse by a nonpartner ● In the last year, have you been hit, kicked, punched, slapped, choked, hurt, or threatened by someone? Who was that person? ● Are you fearful of your partner or someone else in your home? ● Are you afraid of anyone with whom you have had a previous relationship? Screening questions for human trafficking ● Do you ever feel pressured to do something that you did not want to do or felt uncomfortable doing? ● Do you feel that anyone is hurting your health, safety, or well-being? Screening questions for suspected elder or disabled adult maltreatment ● Has your caretaker hurt you or threatened to harm you ● Does your caretaker provide the help that you need with bathing, dressing, and meals? Competencies: ● Client-centered care ● Interdisciplinary collaboration ● Evidence-based practice ● Quality improvement ● Informatics ● Safety ● Client education ● Professionalism ● Leadership ● Decision making “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.” - American Nurses Association Specialized Knowledge: ● A nurse's knowledge base includes: ○ Biological, physical, and social sciences. ○ Pathophysiology ○ Understanding of nursing procedures and skills. ○ Nurses use this knowledge to critically think and make sound judgments to: ■ Promote health. ■ Prevent disease. ■ Empower others. Content of Nursing Knowledge: ● Physiology and pathophysiology ● Pharmacology ● Nutrition ● Nursing procedures ● Mathematics ● Information technology ● Legal issues ● Ethical issues ● Effective communication Physiology and Pathophysiology: ● Make appropriate nursing judgments ● Project client needs ● Anticipate changes Pharmacology-Related Nursing Responsibility: ● Administering drugs ● Evaluating therapeutic responses to drugs ● Promoting client adherence ● Providing education ● Intervene for adverse effects Nutrition Knowledge: ● Counsel ● Provide nutritional education ● Nutritional screenings ● Nutritional assessment Nursing Procedures: ● Guided by evidence-based literature ● Designed to provide safe, high-quality care ● Frequently evaluated for best practices Mathematic Calculations: ● Drug administration ● Nutritional needs ● Intake and output ● Incidence and prevalence rates ● Morbidity and mortality rates ● Percentage of weight loss ● Body mass index Information Technology: ● Internet ● Electronic medical records ● Telehealth ● Results: ○ Clients are better informed about health issues ○ Transmit client information electronically ○ Connect rural clients to providers and specialists Legal Issues ● Protect the public ○ Provide safe, high-quality care ○ Maintaining currency of practice ● Adhere to nursing practice acts ● Understand the legal requirements of: ○ Informed consent ○ Advance healthcare directives ○ Health Insurance Portability and Accountability Act Ethical Issues: ● May or may not be supported by legal requirements ● Guidance from: ○ Professional organizations ○ Facility regulations Effective Communication ● Fosters trust and therapeutic relationships ● Includes verbal, written word, expressions, gestures, and attitude Learning Styles: ● Do you prefer reading or listening? ● Do visual images work best to help you understand new information? ● With charts and images, do you focus on the text? ● Do you like to learn by doing? ● We each perceive and process information in different ways ● Learning styles are different approaches to learning Visual Learners: ● Learn best from strategies that involve sight ○ Written word ○ Pictures ○ Graphs ○ Diagrams ○ Mental visualizations ● Characteristics ○ Sit at the front, avoiding visual obstructions ○ Take detailed notes Learning Strategies for Visual Learners: ● ● ● ● ● Use charts or outlines View videos Read books or pamphlets - highlight important words and information Place information on a timeline or diagram Organize notes in an outline - create a PowerPoint or handout Auditory Learners: ● Learn best by hearing ○ Verbal repetition ○ Tapes ○ Lectures ● Characteristics ○ Likes to talk things through ○ Likes listening to others ○ Dislikes working quietly for extended periods of time ○ Easily distracted by noise and silence Learning Strategies for Auditory Learners: ● Read text aloud ● Use a tape recorder in class ● Record summary of notes - emphasize major points ● Create songs or pneumonics ● Study in groups ● Explain the information being read aloud Tactile Learners: ● Learn best by touching and doing ○ Projects ○ Concept maps ○ Simulations ○ Role-playing ● Characteristics ○ Actively explore the physical world ○ Easily distracted from learning ○ Enjoy using the computer Learning Strategies for Tactile Learners: ● Apply classroom knowledge in the clinical setting ● Simulation ● Create models or displays ● Practice kits with equipment ● Be active during scheduled breaks Strategies for Success: ● Be prepared for class, work, and study time ● Preparation decreases stress, allowing for a better learning experience ● Key skills: ○ Being organized ○ Reading effectively ○ Managing time Staying Organized: ● Prevents procrastination ● Prevents undue stress ● Make time ● Make a plan ● Effective preparation can cut study time in half Plan for Success: ● Use your calendar: ○ Regularly scheduled study times ○ Exam and assignment dates and times ○ Be realistic about how long activities take ● Also, consider ○ Family responsibilities ○ Recreational activities ○ Work hours Stick to a Routine: ● Identify a regular time to study ● Learning requires: ○ Reinforcement ○ Feedback ○ Opportunities to process information ● Be prepared to study ○ Designate a study area ○ Keep study material together Meaningful Reading: ● Taking the time to complete reading assignments will reduce the time required to review for exams ● Common mistakes: ○ Reading too hurriedly ○ Beginning reading immediately ○ Reading passively ○ Underlining too much or too little ○ Failing to question themselves about the importance of the material Step 1: Skim: ● Skim the reading assignment quickly (5 min) ● Orient yourself to the chapter ○ Look closely at the headings and subheadings ○ Inspect all graphs, charts, tables, and diagrams ○ Closely examine all illustrations and captions Step 2: Read Actively ● Look for basic concepts and the most important information ● Underline and highlight keywords and phrases, important definitions, and formulas ● Note or mark important passages, passages you find confusing, or questions to ask about Step 3: Ask Questions ● Ask, “What are the main points the author is trying to communicate?” ● Convert headings and subheadings into who, what, where, when, why, and how questions ● Post the remaining questions to the course’s online discussion threads for peer input ● Use the five phrases of the nursing process ○ What are the major manifestations of the disease process? ○ What are the major goals for someone with this disorder? Step 4: Stop and Think ● Allow time to reflect on what you’ve learned and commit it to memory ● Recall what you’ve read before moving on: ○ Recite the main points from memory ○ Restate major concepts in your own words Step 5: Review Periodically ● Refreshing your memory increases retention ● When to review assignments: ○ As soon as possible after learning them ○ Before and after class ○ Before an exam Maintain Consistency ● Attend class daily and on time ● Complete assignments promptly ● Regular work, steady application, and self-pacing = success ● Avoid procrastination by breaking larger tasks into smaller ones Budget Your Time ● Create a calendar each semester ● Schedule: ○ Regular times to study ○ Dates of exams ○ Assignment due dates ○ Dates and times for clinical ● Consider your major projects and tests ● Be realistic and conservative with time estimates ● Take time for yourself Foundational thinking ● The ability to recall and comprehend information and concepts foundational to quality nursing practice ● Apply knowledge from ○ Biological, physical, and social sciences ○ Nursing procedures and skills ● Levels of knowledge ○ Basic: Foundational thinking ○ Highest: Critical thinking Recalling Information: ● Requires remembering information that has been previously learned ● Does not require an understanding of the information or how it can be used Comprehending Information: ● Understand the knowledge retrieved ● Verbalize or use it in some manner ● Understanding is another term used for comprehension Foundational Knowledge in Clinical Practice ● Expected signs and symptoms of an illness ● Expected reference range for lab results ● Risk factors for an alteration in health ● Expected and side effects of a medication or treatment ● Nursing interventions that are appropriate to help meet a specified client's need Using Foundational Thinking ● Recall information ● Demonstrate comprehension ● Apply it to a clinical situation Study Strategies for Foundational Thinking ● Organizing content into an outline or concept map ● Practicing retrieval of knowledge by posing questions and answering them ○ Shortly after reading or lecture ○ Later on again for reinforcement ● Highlight keywords and make notations in the margins Critical Thinking ● Used when analyzing client issues and problems ● Thinking skills include: ○ Interpretation ○ Analysis ○ Evaluation ○ Inference ○ Explanation ● These skills facilitate critical analysis of the issue and assist you in determining the most appropriate action to take Interpretation: ● Interpreting information ○ Recognize ○ Understand ○ Describe ● Information for interpretation ○ The meanings of written materials ○ Verbal and non–verbal communication ○ Assessments and empirical data ○ Graphics Analysis: ● Analyzing information ○ Examine ○ Organize ○ Validate ○ categorize/prioritize ● Information for analyzing ○ Signs and symptoms of illness/injury ○ Evidence, facts, and research findings ○ Concepts and ideas ○ Beliefs and points of view Evaluating ● Assess ○ Credibility of sources of information ○ Strength of evidence ○ Relevance, significance, value, or applicability of information Inference ● Draw conclusions based on evidence ● Differentiate between conclusions and hypotheses ● Identify knowledge gaps or needs Explanation ● Clarify the assumptions and reasoning processes you followed ● Justify one’s reasoning and conclusions ● Concepts used ○ Evidence ○ Concepts ○ Methodologies ○ Contextual considerations Clinical Judgment ● The decision made regarding a course of action based on a critical analysis of data when nursing knowledge is applied to a clinical situation ● Requires the nurse to use critical thinking skills when: ○ Analyzing client data and relative evidence ○ Ascertaining the meaning of the data and evidence ○ Determining client outcomes desired and/or achieved as indicated by evidencebased best practices Clinical decision-making process 1. Identify that a client issue or problem exists 2. Analyze and interpret relevant data 3. Make inferences based on this interpretation to determine possible causes 4. List all possible actions that could be taken 5. Evaluate each action and possible outcome 6. Select the best action ● The outcome of the clinical decision-making process is the clinical judgment Critical Thinking in the Classroom ● Content becomes harder as you advance ● Knowledge of complex or multiple disorders ○ Hemodynamic and intracranial pressure monitoring ○ Fluid and acid-base balance ○ Signs and symptoms of medication interactions and toxicity ○ Prioritizing client care ○ Resuscitation procedures Critical Thinking in Clinical Practice ● Recognize and take the correct action ○ Hemodynamically unstable ○ Experiencing increased intracranial pressure ○ In metabolic or respiratory acidosis/alkalosis ○ Experiencing a life-threatening drug interaction or drug toxicity ○ In need of several actions to be taken at once ○ In cardiac or respiratory failure/arrest Experience improves clinical judgment ● Clinical judgment improves as the steps of the clinical decision-making process are done simultaneously ○ Listening ○ Evaluating ○ Selecting the best nursing action ○ Collection of data ○ Interpretation of data Clinical reasoning ● The mental process used when analyzing all the elements of a clinical situation and making a de