Transcript The Health History

Interviewing Patients to
Obtain a Health History
DSN
Kevin Dobi, MS, APRN
Copyright © 2013 by Mosby, an imprint
of Elsevier Inc.
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Two primary components of health assessment:
 Health history.
 Physical examination.
Health history = Subjective data
 Database used to create plan, prevent disease,
resolve problems, and minimize limitations.
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Nurse facilitates discussion to determine patient’s
beliefs:
 How does the patient define health?
 Beliefs about attaining and maintaining health.
 View of responsibility for health, health behaviors
currently practiced, and unhealthy behaviors
patients are willing to change.
 Health expectations based on life experiences: self,
family, friends, and culture.
Nurse’s broader view compares patient’s health with
optimal health standard.
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Introduction:
 Prepare patient for what to expect.
Discussion:
 Facilitate, collect, and record health history and data.
 Keep it patient centered—that is, patients share their concerns,
beliefs, and values in their own words.
 Nurse facilitates, collects, and records data.
 Nurse prompts questions and takes brief notes.
Summary:
 Data collected is the foundation for personalized and effective
health care.
 Allows for clarification of data and provides validation of
accurate understanding.
 Provides closure.
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Single-most important factor for successful
interviewing is the communication skill of the nurse.
Professional communication gains the patient’s trust.
Affected by numerous factors: physical setting, nurse
behaviors, type of questions asked, how questions are
asked, as well as:
 The personality and behavior of patient.
 How patient is feeling at the time of interview.
 Nature of information being discussed or problem
being confronted.
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Affected by numerous factors:
Physical setting
 Nurse behaviors
 Type of questions asked
 How questions are asked
 Personality and behavior of patients
 How patient is feeling at the time of interview
 Nature of information being discussed or problem
being confronted
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Private, quiet, comfortable room without distractions.
Privacy is essential for sensitive issues:
 Openness and honesty.
 Health care facilities are not always conducive to
privacy; draw curtains, when available.
 Physical comfort for patient and nurse.
 Try to minimize distractions.
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First impression starts with nurse’s appearance
and warm professional demeanor
Interpersonal skills important to successful
interview:
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Use active listening to show interest and
understanding of patient’s point of view.
Communicate acceptance and treat patient
respectfully.
Watch word usage and patient interpretations.
Avoid extreme nonverbal reactions.
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Consider patient age and physical, mental, and
emotional status.
Ideally, the patient will be alert and in no physical or
emotional discomfort.
If in distress, limit the number and nature of necessary
questions. Save additional questions for later.
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The art of obtaining information and listening carefully
is an essential competency of nurses:
 Questions should be clearly spoken and understood.
 Define words, avoid using technical definitions, and
use slang only if necessary for certain conditions.
 Adapt questions consistent with patient level of
understanding and knowledge.
 Encourage patients to be specific and to clarify
meanings.
 Ask one question at a time, and wait for reply.
 Be attentive to patient’s feelings that may indicate
need for additional data.
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Some areas of questioning are sensitive, and sensitivity
varies.
 Explain that you may have sensitive or personal
questions.
 Use technique referred to as permission giving –
Ensure your patient knows that it is safe to discuss a
certain uncomfortable topic.
Seek clarification:
 “Tell me more about what you are thinking.”
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Begin with open-ended questions to encourage a freeflowing, open response:
 Focus on questions about patient’s health.
 May need to refocus questions if patient unable to
focus on topic or takes excessive time.
Close-ended questions yield more precise data
 Give patient options for response.
Directive questions lead patient to focus on one set of
thoughts.
 Most often used in reviewing systems and
evaluating functional status.
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Active listening concentrates on patient responses and
subtleties.
 Avoid formulating the next question during
responses.
 Avoid making assumptions about patient responses.
Facilitation uses verbal and nonverbal phrases to
encourage patients to continue talking further.
Clarification is used to gather more information.
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Restatement is repeating what patient says in different
words to confirm interpretation.
Reflection is repeating what patient said and encourages
elaboration or more information.
Confrontation is used when inconsistencies are noted
between patient report and nurse’s observations.
 Use tone of voice to convey confusion or possible
misunderstanding.
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Interpretation is used to share conclusions drawn from
data.
 Patient may then confirm, deny, or revise.
Summary condenses and orders data to clarify sequence
of events for patient.
 Emphasizes data related to health promotion,
disease protection, and resolving health problems.
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Using medical terminology confusing to patient:
 Patient may not understand question or may be
embarrassed to request clarification and therefore
may give inaccurate responses.
Expressing value judgments.
Interrupting while patient is talking.
Having an authoritarian or paternalistic demeanor.
Asking “Why” questions that may threaten patient and
make him or her defensive.
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Answering personal questions:
 Brief direct answer.
 Share experiences that support patient.
 Enhance relationship and increase credibility.
Silence:
 Necessary for patients to reflect and gather courage
to address painful topics or issues.
 Feedback that patient is not ready to discuss topic or
that the approach needs to be evaluated.
 Become comfortable with silence.
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Displays of emotion:
 Crying is natural and should be expected.
 Postpone further questioning until the patient is
ready.
 A compassionate response enhances relationship.
 Anger is uncomfortable for patient and nurse:
 Deal with it directly.
 Identify source of anger.
 Discuss approaches and acknowledge feelings.
 If patient is unable to continue, honor request to
work with another nurse.
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Managing overly talkative patients:
 Overly detailed problems may become a distraction.
 Refocus interview on events relative to the present.
 Redirect conversation with closed-ended questions
that may help reduce distractions.
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Others in the room:
 Do not assume relationships; it is best to clarify.
 Parent or guardian may answer for child.
 Interview adolescents directly.
 For adults unable to answer, another person may
assist.
Language barriers:
 Interpreter should be objective observer, of same
gender, but not a family member.
 Takes more time to obtain the most important data.
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Cultural differences:
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Nurse accountable for cultural competence
 Demonstrate communication skill between or among
cultures and outside own culture.
 Identify cultural factors that may influence patients’
beliefs about health and illness.
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Interact with patients as unique persons with
experiences, beliefs, and values learned or passed
down.
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Types of health histories:
 Comprehensive health history establishes complete
database.
 Problem-based or focused health assessment
includes data limited to the scope of problem.
 Episodic or follow-up assessment focuses on specific
problems for which patient is already receiving
treatment.
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Biographic data – initial visit
Reason for seeking care
Present health status
Past medical history
Family history
Personal and psychosocial history
Review of all body systems
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Chief complaint or presenting problem:
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Brief statement regarding purpose for visit.
Recorded in direct quotes from patient.
Multiple reasons: List and prioritize.
Patient may not give reasons until comfortable.
Patient condition determines next step.
 Urgencies require expediency.
 Bibliographic data delayed.
 Data analysis to determine cause and to develop plan.
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Include all of the following:
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Symptomology: Onset, location and duration, related and
alleviating factors, attempts at self-treatment.
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Present history focuses on the patient’s acute and chronic
conditions:
 Current health conditions
 Medication reconciliation
 Allergies
Past health assessment focuses on important health history:
 Childhood illnesses
 Surgeries
 Hospitalizations
 Accidents or injuries
 Immunizations
 Obstetric history
 Last examinations
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Blood relatives: Biologic parents, aunts, uncles,
siblings, children, and spouse.
 Identify genetic, familial, environmental
factors that might affect current or future
health status.
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Ask about specific diseases:
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Alzheimer’s disease
Cancer (all types)
Diabetes mellitus (specify type 1 or type 2).
Coronary artery disease, including myocardial infarction
Hypertension
Stroke
Seizure disorders
Mental illness, including depression, bipolar disorder,
schizophrenia
Alcoholism and/or drug abuse
Endocrine diseases
Kidney disease
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Personal status: General statement of feelings about
self
Family and social relationships
Diet and nutrition
Functional ability
Mental health
Personal habits: Tobacco, alcohol, illicit drugs.
Health promotion activities
Environment
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Past and present health of each body system.
Conduct symptom analysis when patient indicates
presence of symptoms.
Define medical terms, when necessary.
Additional health promotion data may be collected
during review of systems.
In a comprehensive health assessment, you will ask
most of the questions.
In a focused health assessment, you ask questions
about systems related to reasons for seeking care.
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General symptoms
Integumentary
system
Head and neck
Breasts
Respiratory
system/chest
Cardiovascular
system
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Gastrointestinal
system
Urinary system
Reproductive system
Musculoskeletal
system
Neurologic system
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Not all histories are organized by body systems.
Nurses may use an alternative format based on a
health status approach:
 e.g. – Gordon’s Functional Health Patterns
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Health PerceptionHealth Management
Nutrition-Metabolic
Elimination
Activity-Exercise
Cognitive-Perceptual
Sleep-Rest
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Self-PerceptionSelf-Concept
RoleRelationship
SexualityReproductive
Coping-Stress
Tolerance
Values-Belief
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Pediatric health history similar to that of adult.
 Additions of pregnancy, prenatal care, growth and
development, behavioral status, as applicable.
 Most data are obtained from adult accompanying
child, but should include child as much as
appropriate for age.
 Nurse determines if an adult or pediatric database
format is appropriate for adolescent.
 Nurse determines whether to interview adolescent
alone or with parent present.
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Comprehensive health history is obtained at first
prenatal visit.
Establishes baseline data.
Special emphasis on data that may impact pregnancy
outcomes.
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Incorporation of various age-related questions and
functional status questions.
May not be necessary to collect data on childhood
immunizations or develop a genogram.
Many older adults have multiple symptoms,
conditions, medications, and a long past health history.
 Time needed to complete interview may be much
longer.
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Health histories can provide nurses with data needed for
appropriate care. Nurses obtaining a health history should:
Help the patient identify personal beliefs about health.
Assess vital signs.
Inquire about activities that can affect financial stability.
D. Explain patient rights and responsibilities.
A.
B.
C.
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Because a nurse seeks to create a patient-centered interview
process, the nurse will:
Ask the patient, “Do you suffer from any arthralgias?”
Give the patient as little information as possible to avoid
fear.
C. Ask the patient, “Can you please tell me more about
your spells?”
D. Inform the patient, “You don’t have to share anything
with me that makes you uncomfortable.”
A.
B.
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Preparation for an interview with a patient requires
thoughtful consideration of the physical environment. As
the physical space is arranged:
Desks should not be used because they bestow too much
“power” on the interviewer.
B. Desks are usable as long as they are not a barrier
between interviewer and interviewee.
C. Interviewer eye level should be six inches lower than
interviewee eye level.
D. Interviewer eye level should be six inches higher than
interviewee eye level.
A.
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