医学问诊概述.pptVIP

第二章 问 诊（Inquire）第一节 概述 上海交通大学护理学院 吴觉敏 教学目标 能简述问诊的主要目的 能举例说明问诊的各种技巧 能准确阐述问诊的主要内容 能在临床实践中运用正确的问诊方法，获取详实的护理资料，对患者进行准确评估和诊断 能运用特殊技巧处理实际工作中的问诊难题 健康资料 健康资料的类型 按照资料收集的方法 主观资料 Subjective data（问诊所获得） 症状（symptom）：评估对象患病后对机体生理功能异常的自身体验和感受。 客观资料 Objective data（查体等所获得） 体征（sign）：评估对象患病后机体的体表或内部结构发生了可察觉的改变。 按照资料提供时间 目前资料 基本资料、现病史 既往资料 既往史、治疗史、过敏史等 健康资料的来源 主要来源：评估对象本人 次要来源：家庭成员及关系密切者 事件目击者 其他医疗保健人员 病历及即往健康记录 健康资料的内容 健康评估基本方法 问诊 体格检查 实验室检查 心电图检查 影像学检查 问诊 Inquire The assessment interview History taking The assessment interview is a structured, goal-directed conversation between the nurse and an individual for the purpose of yielding information about the person, their health perceptions, functional status, and other factors relevant to health, healing, and illness. 问诊 问诊内容 问诊的目的（Purpose） Make diagnosis on the basis of observation you make during the interview, including the overall appearance of the individual and the actual data elicited as responses to your question. The opportunity to establish a positive, therapeutic relationship 问诊的重要性 了解病情的主要方法 获得诊断依据的重要手段 可为进一步检查提供线索 建立良好护患关系的桥梁 The interview process Usually formal and structured Informal: discuss specific concerns while providing nursing care Lasting as long as you and the person interact Three phases The introductory phase The working phase The termination phase The introductory phase Establishing rapport Demonstrating respect for the client Addressing the person by name Introducing yourself Beginning the interview with a brief, casual conversation Ensuring comfort In a private setting Assure the confidentiality of the information Stating purpose The working phase Collect data that pertinent to the person’s overall health status Record both verbal responses and nonverbal behavior Collect biographic data Collect data pertinent to the person’s health status Identify and respond to the client’s needs The working phase Proceed smoothly from one topic to the next by using transitional