Transcript PN1lab notes\Week 2 - Health history interview

Practical Nursing
Diploma Program Semester 1
The Health History Interview
Orienting the
patient……...
• to the surroundings
• to the rules
• to the team members they may come
in contact with
• to the resources available - kitchen,
showers etc.
• to the plan of care
Why do we do this?????
• if we’re going to help the patient, we
need to know as much about him/her
as possible
• the health history interview
accomplishes that objective
• once completed, the document is
placed on the chart so that other
team members can review it
• can reduce repetition of questions to
• discharge planning begins on
admission - we need to know if this
patient is going to be able to go back
to the same environment post
hospitalization or if he will need
support systems
• if help will be needed, the process
can start early to avoid unnecessary
delays on discharge
Information to be
gathered…….
• Vital signs, height, weight
• medical history - illnesses,
hospitalizations
• allergies
• current medications
• current symptoms
• next of kin
• head to toe assessment
• does he have a power of attorney for
personal care, Living will??
• religious preferences re food, blood
etc.
• all forms differ but most include the
same types of information
• information can be gathered from:
the patient, the family, old charts,
other team members, family doctor
Personal belongings……..
• valuables should be locked up with
security
• follow hospital protocol
• encourage patient to send home
valuables with family members if
present: storage is an issue
• document things like dentures,
hearing aids, personal walkers etc.