| Knowledge |
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States Relative Contraindications of procedure.
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| Preparation |
| Clinical Standards for Procedures and Interventions. |
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| Reviews the available medical record, active orders or protocols, diagnoses, recent tests, medications, allergies, and infection-control requirements before the interview. |
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| Provides privacy, limits distractions, determines communication needs, and arranges a qualified medical interpreter or other accessibility support when indicated. |
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| Uses two patient identifiers, introduces self and role, explains the purpose of the interview, and confirms the patient is willing and able to participate. |
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| Assessment |
| Immediately observes general appearance, level of consciousness, speech, respiratory rate and pattern, work of breathing, skin color, and ability to speak; stabilizes and escalates urgent findings before continuing. |
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| Elicits the chief concern and history of present illness using open-ended questions followed by focused clarification of onset, timing, progression, severity, quality, location or radiation, aggravating and relieving factors, and associated symptoms. |
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| Characterizes dyspnea at rest and with exertion, orthopnea or paroxysmal nocturnal dyspnea, triggers, trajectory, and effect on sleep and activities of daily living. |
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| Assesses cough, sputum amount and character, hemoptysis, wheeze, stridor, chest pain, fever, fatigue, weight change, and other respiratory or systemic symptoms. |
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| Obtains tobacco, vaping, cannabis, secondhand-smoke, and other inhalational exposure history, including duration, amount, quit attempts, and current exposure. |
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| Obtains occupational, environmental, travel, infectious-exposure, and home exposure history relevant to respiratory disease. |
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| Reviews past cardiopulmonary and other medical history, previous emergency visits or hospitalizations, prior intubations, surgeries, allergies, current medications, adherence, inhaler technique, and immunization status when relevant. |
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| Assesses baseline functional status, mobility, home oxygen or ventilatory support, sleep symptoms, nutrition, psychosocial factors, health literacy, and available caregiver or home support. |
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| Implementation |
| Uses active listening, neutral and nonjudgmental language, appropriate pauses, clarification, and summary statements; avoids leading or compound questions. |
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| Monitoring & Modifications |
| Stops the routine interview and activates the appropriate response for severe dyspnea, cyanosis, altered mental status, syncope, significant hemoptysis, unstable vital signs, or concerning chest pain. |
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| Post-Intervention |
| Summarizes the history back to the patient, resolves discrepancies, uses teach-back when education is provided, and confirms immediate comfort or care needs. |
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| Documents pertinent positive and negative findings, the source and reliability of the history, communication accommodations, patient statements when clinically important, and any escalation or recommendations. |
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| Post-Intervention Management Steps. |
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