Transcript Chapter 2 interviewing to obtain a health history student

Chapter 2
Interviewing Patients to
Obtain a Health History
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Interviewing Patients to Obtain a
Health History
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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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Foundation for Interviewing (contd.)
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Affected by numerous factors:
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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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Physical Setting
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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.
 Place a distance of 4-5 feet between
yourself and the patient.
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Note Taking
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Some use of history forms is unavoidable
Disadvantages
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Breaks eye contact too often
 Shifts your attention away from pt.
 Interrupts narrative flow
 Impedes your observation of nonverbal behavior
 Is threatening to the patient during sensitive issues.
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Three Phases of the Interview
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Introduction:
 Prepare patient for what to expect.
Discussion: (working)
 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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Professional Nursing Behavior
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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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Patient-Related Variables
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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 Asking Questions
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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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The Art of Asking
Questions (contd.)
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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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Types of Questions
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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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Techniques That Enhance
Data Collection
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Active listening concentrates on patient responses.
 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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Techniques That Enhance
Data Collection (contd.)
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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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Techniques That Enhance
Data Collection (contd.)
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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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Techniques That Diminish
Data Collection (contd.)
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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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Managing Awkward Moments
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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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Managing Awkward
Displays of Emotion
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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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Challenges to the Interview
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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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Challenges to the
Interview (contd.)
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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 Considerations
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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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The Health History
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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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Components of the Comprehensive
Health History
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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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History of Present Illness
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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.
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 and Past Health Status
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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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Family History
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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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Family History (contd.)
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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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Psychosocial Status
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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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Review of Systems
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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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Individual System Review
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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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Age-Related Variations:
Infants, Children, and Adolescents
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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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Age-Related Variations:
Older Adults
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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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Charting
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Individual’s record: A permanent legal document
that provides a comprehensive account of
information about the individual’s health care
status.
Date/Time each entry
Written legibly with black ink
No blank lines between entries
Clear concise and specific
As descriptive as possible
Correcting errors
Signature
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SOAP Method
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Subjective: Describes the patient’s current condition in narrative
form. This section usually includes the patient’s chief complaint, or reason
why they came to the physician.
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Objective: Documents objective, repeatable, and traceable facts about
the patient’s status.
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Assessment: The Physician’s medical diagnoses for the medical
visit.
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Plan: This describes what the health care provider will do to treat the
patient – ordering labs, referrals, procedures performed, medications
prescribed, etc.
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Charting Con’t
Review of System:
Skin: Denies lesions, masses, discolorations, or
rashes to skin.
Hair: Denies texture changes or loss, uses hair
color monthly to cover gray; no scalp irritation
reported from the hair coloring.
Nails: Denies changes in texture, color, shape
Health Promotion: Uses sunscreen “occasionally”
when outside.
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Pause for a Cause
Because a nurse seeks to create a patient-centered
interview process, the nurse will:
A.
B.
C.
D.
Ask the patient, “Do you suffer from any arthralgias?”
Give the patient as little information as possible to avoid
fear.
Ask the patient, “Can you please tell me more about your
spells?”
Inform the patient, “You don’t have to share anything with
me that makes you uncomfortable.”
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Pause for a Cause
Preparation for an interview with a patient requires
thoughtful consideration of the physical environment. As
the physical space is arranged:
A.
B.
C.
D.
Desks should not be used because they bestow too
much “power” on the interviewer.
Desks are usable as long as they are not a barrier
between interviewer and interviewee.
Interviewer eye level should be six inches lower than
interviewee eye level.
Interviewer eye level should be six inches higher than
interviewee eye level.
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Summary
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In today’s class
Factors that influence the interview
Stages of the interview process
Interview techniques
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Therapeutic & Non-therapeutic
Elements of a comprehensive health history
General documentation
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Summary Continued
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Make sure to read chapter 2 before lab
Thursday
Chapter 23 page 539-540 Review of systems
before lab Thursday
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Print off Obtaining a health history form.
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Questions?
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