Diagnostic reasoning is a scientific process in which the practitioner suspects the cause of a patient’s symptoms and signs based on previous knowledge (Dains, Baumann, & Scheibel, 2016). Accurate diagnostic reasoning allows the clinician to identify the correct disease and plan of treatment. Therefore, it is critically important for the clinician to complete thorough health history. In addition, the purpose of taking a complete health history is to collect subjective and combine with objective data from physical examination and diagnostic test (Jdonah, 2017). As clinicians, it is imperative to listen empathetically during interview and health history. When one connects with their patients therapeutically, it builds trust and compliance. To build a therapeutic alliance with patients, clinicians must utilize these eight interviewing techniques: empathy, active listening, partnering, empowering the patient, positive body language, validation, reassurance and open communication (Bickley, 2017). For patient “a feeling of connectedness… of being deeply heard and understood is the heart of healing (Bickley, 2017). …show more content…
The health history format is a structured framework for organizing patient information in written and verbal form (Bickley, 2017).
I would organize my health history in seven components: identifying data, reliability, chief complaint, present illness, past history, family history, personal and social history, and review of
systems. As a beginner, I would memorize and utilize notecards as a guide during health history interview. In addition, to develop a systematic sequence documentation in reviews of the system, I will use the head to toe sequence to avoid missing needed information. Also, I will utilize the mnemonic OLDCART (onset, location, duration, character, aggravating factors, relieving factors, and timing). The OLDCART is used when assessing for pain in patients. For example, if patient’s initial complaint was a headache, you must use the mnemonic OLDCART to ask the onset, location, duration, character, aggravating factors and timing of her headache.
This essay will demonstrate an understanding of the clinical reasoning cycle which describes the procedure by which nurses gather prompts, process the data, come to an understanding of a patient’s problem, design and implement interventions, assess results, and reflect on and learn from the process (Hoffman, 2007; Kraischsk & Anthony, 2001; Laurie et al., 2001). The clinical reasoning cycle consists of five main stages, it comprises of; considering the persons condition, collecting indications and data, processing the information, recognizing problems/issues and detailing the assessment (Levett-Jones 2013). Throughout this essay these five main parts of the clinical reasoning cycle will be discussed and put into context. The first step of
Stickley, T. & Freshwater, D. (2006). “The Art of Listening to the Therapeutic Relationship” Journal of Mental health Practice. 9 (5) pp12 - 18.
233). From this, clients should want to change as well as believe in their capacity for change. For Jim, he can benefit from motivational interviewing since it can be used to help him overcome ambivalence to change. A collaborative, and nonconfrontational relationship are part of motivational interviewing. This is important for the client Jim in order to respect and encourage his self-determination. Motivational interviewing gives clients like Jim the opportunity to discover their own reasons for making change. One of the principles for motivational interviewing is expressing empathy where it gives clients the chance to freely explore their values, perceptions, goals and the implications of their present situation without being judged. The counsellor who is working with Jim can use active listening skills for expressing empathy in order for Jim to feel like he is being heard. The second principle is developing
Stickley, T., & Freshwater, D. (2006). The art of listening in the therapeutic relationship. Mental Health Practice, 9 (5), 12-18.
I let my client tell me how he felt about illness based on his own values and beliefs. I also used therapeutic communication techniques such as general lead, listening, sitting at eye level with the client etc. to make this as comfortable as possible for him. I think I was appropriate and very successful at retrieving my client’s beliefs about illness and sickness without pressuring him too much. In the future when conducting an interview with another person about their culture, I would use the same techniques and approach as I found it to be very successful, and my client was very comfortable and established a trust worthy relationship with him regarding his illness based on his cultural beliefs and values. This interview contributed in preparing me for the future and also gave me insight on how to conduct a successful cultural assessment without making assumptions. I learned that every culture is unique and has somewhat of a similarity to other cultures, but one must never assume before doing a thorough assessment. This also prepared me in being more culturally competent while providing care to clients and their families from different cultures and
A helping interview is a conversation between a health care professional and a person in need and is a common tool of communication in any health care setting. Three components of the helping interview are 1) the orientation of the professional and the client to each other, 2) the identification of the client’s problem, and 3) the resolution of the client’s problem (Tamparo & Lindh).
Therapeutic relationships are an essential part of nursing; they are the foundation of nursing (CNO, 2009). The National Competency Standard for Registered Nurses states that nurses are responsible for “establishing, sustaining and concluding professional relationships with individuals/groups.” Throughout this essay, the importance of forming therapeutic relationships will be explained. The process of building a therapeutic relationship begins prior to time of contact with a patient, the interpersonal skills of the nurse; then the process includes skills required by the nurse to communicate effectively, including respect, trust, non-judgment and empathy. The way to portray these skills can be via verbal or non-verbal cues that are important to understand how they influence a person.
Providing clinical treatment, education, and empathy while involving the patient in their care achieves a win-win situation for all. I have adapted my practice to address the primary needs of each patient; education and treatment are modified to attain the best outcome for every client. Segueing from the bedside to clinical research has permitted me to concentrate on the distinct needs of each patient; while allowing me to contribute to the advancement of science and treatment modalities. As I work towards obtaining my advanced practice degree, I have focused on the evolving changes in health care (Mudd, 2014, p. 2).
This week’s readings of, “Asking Questions and Listening in Healthcare” written by Gwen Van Servellen discusses the therapeutic use of asking questions and silence. Silence and asking questions are a therapeutic skill. It takes talent to tailor the right question, and interject the right amount of silence for each individual patient in any given situation.
Clinical reasoning is an integral component of the occupational therapy profession. It is “the thought process that guides practice” (Rogers, 1983). The ability to effectively problem solve in a clinical work environment is a skill that must be practiced in order to master. In an ever-changing, diverse profession such as occupational therapy, it is imperative to remain knowledgeable and current of any changes or medical advances that may improve clinical competence. Clinical reasoning skills cannot be mastered solely with a textbook filled with examples of diagnoses and treatment interventions. Clinical competence is built on experience and opportunities to apply knowledge and learn from mistakes in a hands-on environment. Despite being exposed
First and foremost, it is essential that health care providers remain empathetic, knowledgeable and non-judgemental towards people facing a chronic illness. This will allow the patient to feel comfortable with their health care provider and help instill a sense of trust within the relationship. Several researchers postulated that hope evolves from a therapeutic relationship between patient and care provider, within which the patient feels heard, valued and respected (Hawthorn, 2015). This idea reflects the major importance of active listening by health care providers. Throughout the therapeutic relationship, it is beyond important for health care providers to refrain from pretending to understand what their patient may be experiencing or going through in terms of their chronic illness. “Findings from an early study by (Thorne, 1990) documented that chronically ill patients and their families often found that most health care providers could not be trusted to understand the requirements of managing a chronic health condition” (Bucher, Camera, Dirksen, Heitkemper, Lewis, 2014, p.75). This finding raises an important reminder that the patients are the most valuable and knowledgeable source of information concerning their illness, and that the greatest understanding of the illness will be
Therapeutic communication is an important skill for a nurse to utilize when it comes to relationships between the patient and nurse. In Regina’s case, integration of empathetic and compassionate communication skills in combinat...
Stickley,T. & Freshwater, D. (2006). “The Art of Listening to the Therapeutic Relationship” Journal of Mental health Practice. 9 (5) pp12 - 18.
As a result, I always felt that I am actively participating in patients’ care. She allowed me to perform patient examinations most of the time and encouraged me to build up a good rapport with the patients. I think my past experience and medical knowledge was helped me lot during the history taking because I was able to go through history taking in a systematic manner and at the same time I could think of possible differential diagnosis. Furthermore, working in a medical clinic as a physician assistant also helped me a lot because one of the responsibilities delegated to me is taking patients history, however, this time it was different that I had to work out and actively think about a possible cause for patient concerns. The weakness I observe during history taking was sometimes I am little quick that might hurt the doctor-patient relationship, So, I am planning to improve my listening skill with less interruption to patients, I believe that might help the patient to express their concerns freely. Also, I am determined to listen to patients concerns in a non- judgemental manner to get the unbiased clinical
"A Guide to Taking a Patient's History” is an article published in an August 24th, 2007 issue of Nursing Standard. Written by H. Lloyd and S. Craig, the process of taking a history from a patient is outlined. Many aspects pertinent to obtaining a sufficient health history are discussed. In addition to providing a framework for completing a thorough health history, guidelines and interview techniques are explored.