Transcript 1 - KLAS
The Interview & Complete Health History YEO JIN IM, RN, PhD, BC-PNP. Health Assessment Kyung Hee Univ. 2016/Fall 1 IMYJ 2016/Fall Health Assessment What is Health? Biomedical model: western tradition views health as the absence of disease Expanding the concept of health 2 Holistic approach Health promotion & disease prevention IMYJ 2016/Fall Health Assessment Nursing Process : A way of thinking (ANA, 1998) 3 Assessment: data collection Diagnosis: actual or potential health problems Planning: outcome identification-pt centered expected outcome Implementation: it is the term for the actions that you take in the care of your pts. Evaluation: Did it work? IMYJ 2016/Fall Health Assessment Assessment: Data Collection Types of data: Subjective vs. Objective Methods of Data Collection 4 Interview & Health History: subjective (what the pts TELLS you about him/herself during history taking) Physical Examination: objective Diagnostic & Laboratory Data: objective (e.g., chest x-rays, blood tests) Reviewing medical record: objective IMYJ 2016/Fall Health Assessment The Interview: Health History Goal of the interview: To record a complete health history To identify the person’s health strengths and problems A bridge to the next step in data collection, the physical examination The first & most important part of data collection It collects subjective data! 5 IMYJ 2016/Fall Health Assessment The Process of Communication (Vehicle of interviewing !) Sending: verbal/nonverbal communication Receiving: be interpreted in a specific context to have meaning 6 IMYJ 2016/Fall Health Assessment Greater risk for misunderstanding exists in the health care setting Physical Environment Room temperature Sufficient lighting Reduce noise Remove distracting objects or equipment Place the distance (x2 arm length) Arrange equal-status seating AVOID STANDING! Arrange face-to-face position 7 IMYJ 2016/Fall Health Assessment Techniques of Communication Introducing the interview 8 Introduce yourself (state your role) Give the reason for the complete history Ask an open-ended question IMYJ 2016/Fall Health Assessment The working phase Open-Ended Questions Asks for narrative information Encourages the person to respond in paragraphs Use it to begin the interview Listen carefully “Tell me about it”, “Anything else?” Examples “Tell me how I can help you” “What brings you to the hospital?” “You mentioned shortness of breath. Tell me more about that.” 9 IMYJ 2016/Fall Health Assessment Closed or Direct Questions Ask for specific information Elicit a short, “yes” or “no”, one- or two-word answer, forced choice Limit answer Use after the person’s opening narrative to fill in any details NOT to overuse Ask only one direct question at a time “ Have you ever had pain, double vision, watering, or redness in the eyes?” 10 Choose language the person understands IMYJ 2016/Fall Health Assessment Closing the interview 11 Is there anything else you would like to mention?: Give the pt. a final opportunity for self-expression Give a summary IMYJ 2016/Fall Health Assessment Ten Traps of interviewing : Moments of tension Providing false assurance/reassurance: “Now, don’t worry, I am sure …. ” Giving unwanted advice: “If I were you, I’d…” Using authority: nurse knows best Using avoidance language: 완곡하게 말하는 것 Engaging in distancing: use of impersonal speech ‘there is a lump in the Lt. breast’ 12 IMYJ 2016/Fall Health Assessment Using Professional jargon: adjust vocabulary to the pt. Using leading or biased questions: you don’t smoke, don’t you? Talking too much: listen more than you talk! Interrupting Using “why” questions: why=implies blame 13 IMYJ 2016/Fall Health Assessment Developmental Care & special consideration Interviewing children with the Parents 14 Should build rapport with the child and the parent Focus more on the parent if pt is a younger child (1-6yr) Provide toy, refer to the child by name, do not ignore the child completely Nonverbal communication: important to children >adult Understand developmental characteristics Infant, preschooler, school-age child, adolescent IMYJ 2016/Fall Health Assessment Interviewing the older adult 15 Knowledgeable about physiologic, sociologic, and psychological changes a/w aging. Speak slowly and clearly! Ask short question! Consider physical limitation: difficulty in hearing, impaired visual perception, confused memory (esp. recent events) IMYJ 2016/Fall Health Assessment Culturally Competent Care http://www.liveinkorea.kr/homepage/kr/multidata/statistics Family.asp?language=KR&mc=M0031 16 IMYJ 2016/Fall Health Assessment Cross-cultural care: Culturally sensitive Health History interview Cross-cultural or intercultural communication=the HCP (health care provider) and a pt, different cultural backgrounds Increased the probability of miscommunication Cultural sensitivity: etiquette, cultural code Working with an interpreter (NOT a family member or a friend) – our responsibility to ensure a pt’s right 17 Phone interpreter In-person interpreter IMYJ 2016/Fall Health Assessment The Complete Health History 18 IMYJ 2016/Fall Health Assessment Complete Health History*** 1. Biographical(Demographic) data 2. Source of history=informant 3. Reason for Seeking Care (Chief Complaints, C.C.) 4. History of Present Illness(HPI) = Present Health History 5. Past Health = Past Medical/Surgical History (PM/SH) 6. Family History 7. Review of Systems (ROS) 8. Functional Assessment (Activities of Daily Living ) 9. Perception of Health 19 IMYJ 2016/Fall Health Assessment 1.Biographic (Demographic) Data name, address, phone #, age, birth date birthplace, gender, marital status, race, ethnic origin, occupation primary language, communication needs, authorized representative (if any) 2.Source of History(Hx): Informant 20 Who provide information? client herself or himself, relative, friend, parents, spouse, etc Judge how reliable the informant seems and how willing to communicate? Any special circumstances e.g. use of interpreter IMYJ 2016/Fall Health Assessment 3. Reason for seeking care, C.C.(Chief Complaint) Find out the pt’s main concern Brief spontaneous statement in pt’s own words that describes the reason for the visit. “ ” enclosed in quotation marks NOT a diagnostic statement “shortness of breath” vs. “emphysema” One (or two) symptoms or signs & duration If lists many reasons try to focus on “the most pressing concern” Examples 21 “chest pain” for 2 hours, “Earache and fussy all night” “Here for the yearly exam, IMYJ 2016/Fall Health Assessment Sign vs. Symptom Sign: objective abnormality You, as the examiner could detect on physical examination or in laboratory reports Symptom: subjective sensation 22 The person feels from the disorder. IMYJ 2016/Fall Health Assessment 4. Present Health or History of Present Illness: HPI For the well person: short statement about the general state of health:“I am healthy and active” For the ill person: chronologic record of the reason for seeking care, from the time the symptom first started until now Collect all the date first (do NOT JUMP to conclusions) 8 critical characteristics 23 IMYJ 2016/Fall Health Assessment HPI – 8 critical characteristics Location Be specific Note the precise site “Head pain” vs. “pain behind the eyes”, “jaw pain”, “occipital pain” “Is the pain localized to this site or radiating?” “Is the pain superficial or deep? Character or quality 24 Burning, Sharp, Dull, Aching Gnawing, Throbbing, Shooting,Viselike IMYJ 2016/Fall Health Assessment HPI – 8 critical characteristics Quantity or Severity Attempt to quantify the sign or symptom Examples 25 profuse menstrual flow soaking 5 pads per hour Quantify the symptom of pain using the scale “ On a 10-point scale, with 10 being the most pain you can possibly imagine and 1 being mild pain you barely notice, tell me how your pain feels right now” Ask how it affects daily activities: “I was able to go to work, but then I came home and went to bed” IMYJ 2016/Fall Health Assessment HPI – 8 critical characteristics Timing (Onset, Duration, Frequency) When did the symptom first appear? (Onset) 26 Give the specific date and time State specifically how long ago the symptom started prior to arrival (PTA). Example: Pain started yesterday ( ) pain started 2 days ago ( ) How long did the symptom last (duration)? Was it steady (constant), or did it comes and go during that time (intermittent)? Did it resolve completely and reappear days or weeks later (cycle of remission and exacerbation)? IMYJ 2016/Fall Health Assessment HPI – 8 critical characteristics Setting Where was the person or what was the person doing when the symptom started? What brings it on? Example: “did you notice the chest pain after jogging? Aggravating or Relieving Factors What makes the pain worse? What relieves it? 27 Is it aggravated by weather, activity, food, medication, standing bent over, fatigue, time of day, season, and so on? E.g. rest, medication, ice pack? What have you tried?, what seems to help? IMYJ 2016/Fall Health Assessment HPI – 8 critical characteristics Associated Factors Is this primary symptom associated with any others? Urinary frequency and burning associated with fever and chills? Review of system, Review medication regimen (side effect or toxic effect?) can be needed at this point Patient’s Perception Find out the meaning of the symptom by asking how it affects daily activities 28 “How has this affected you?” “What do you think it means?” IMYJ 2016/Fall Health Assessment PQRSTU Provocative or Palliative Quality or Quantity Region or Radiation Severity Scale Timing: Onset, Duration, Frequency Understand Patient’s Perception 29 IMYJ 2016/Fall Health Assessment 5. Past Health History Past health are important: may have residual effects on the current health status Use date (mo/yr) ex. 3년전(X), 2007년 8월 (O) Childhood illnesses: measles, mumps, rubella, chickenpox, pertussis Accidents or injuries Serious or Chronic illnesses: including psychiatric illness, asthma, depression, diabetes, hypertension, heart disease, hepatitis etc Hospitalizations: cause, how the condition treated, how long, name of hospital, physician Operations: type, how the person recovered 30 IMYJ 2016/Fall Health Assessment Obstetric History: Immunizations Allergies: allergen & reaction Last exam date Gravida (# of pregnancies), term (# of full term deliveries), preterm(# of preterm pregnancies), abortions (# of incomplete pregnancies), living (# of children living) Physical, dental, vision, hearing, ECG, chest x-ray, mammogram, pap test, etc Current Medications 31 Prescribed AND over-the-counter medication Include Vitamins, birth control pills, aspirin, IMYJ 2016/Fall Health Assessment 6.Family Health(FH) History Use pedigree or genogram : graphic family tree Gender, relationship, age of immediate blood relatives At least 3 generations (parents, grandparents, siblings) Record the medical condition of each relative & other significant health data (age, cause of death, twin, tobacco use, heavy alcohol use) Ask specifically for Coronary heart disease High blood pressure Stroke Diabetes Obesity 32 Blood disorders Breast/ovarian cancer Colon cancer arthritis Allergies Alcohol or drug addiction Mental illness Suicide Seizure disorder Kidney disease Tuberculosis (TB) IMYJ 2016/Fall Health Assessment 33 IMYJ 2016/Fall Health Assessment 34 IMYJ 2016/Fall Health Assessment 7. Review of Systems 35 (1) to evaluate the past and present health state of each body system (2) to double-check in case any significant data were omitted in the HPI section (3) to evaluate health promotion practices order: roughly “head to toe” Ask about specific SYMPTOMS under each system Be directive and specific! IMYJ 2016/Fall Health Assessment Write out pertinent (+)’s and (-)’s or “denies” Unacceptable: “no problems”, “denies s/s”, “WNL” within normal level, “no complaints”, etc. Only list what you ask 36 IMYJ 2016/Fall Health Assessment Review of System NOT physical finding or objective data SUBJECTIVE data ONLY: Limited to patient statements 37 IMYJ 2016/Fall Health Assessment ROS General overall health state Present weight (gain or loss, over what period of time, by diet or other factors) Fatigue, weakness, fever, chills, sweats or night sweats Skin History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion Hair Recent loss, change in texture, Nails (change in shape, color, or brittleness) Head Any unusually frequent or severe headache, any head injury, dizziness(syncope), or vertigo Eyes Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia(double vision), redness or swelling, watering or discharge, glaucoma or cataracts Ears Earaches, infections, discharge, tinnitus, vertigo Nose & sinuses Discharge and its characteristics, unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, change in sense of smell. 38 IMYJ 2016/Fall Health Assessment ROS Mouth & Throat Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste Neck Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter Breast & Axilla Pain, lump, nipple discharge, rash, history of breast disease, any surgery on the breast / tenderness, lump or swelling, rash in axilla Respiratory History of lung disease, chest pain with breathing, wheezing or noisy breathing, shortness of breath, cough, sputum (color, amount), hemoptysis Cardiovascular Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemia 39 IMYJ 2016/Fall Health Assessment ROS Peripheral vascular Coldness, numbness, tingling, swelling of legs, discoloration in hands or feet, varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers Gastrointestinal Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal & stomach burning sensation), nausea & vomiting, history of abdominal disease, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, rectal bleeding, rectal conditions Urinary system Frequency, urgency, nocturia, dysuria, polyuria or oliguria, urine color, history of urinary disease, pain in flank, groin, suprapubic region, or low back Musculoskeletal History of arthritis or gout. Joint: pain, stiffness, swelling, deformity, system limitation of motion, noise with joint motion, muscle: pain, cramps, weakness, gait problems, back: pain, stiffness, limitation of motion, history of back pain 40 IMYJ 2016/Fall Health Assessment ROS Neurologic system History of seizure disorder, stroke, fainting. Motor function: weakness, tic or tremor, paralysis, coordination problems, Sensory function: numbness, tingling, Cognitive function: memory disorder, Mental status: nervousness, mood change, depression Hematologic Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions Endocrine History of DM, thyroid disease, intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy Sexual health Genital system 41 IMYJ 2016/Fall Health Assessment 8. Functional Assessment (Including Activities of Daily Living) Measure person’s self-care ability Activities of Daily Living (ADLs): bathing, dressing, toileting, eating, walking, instrumental activities of daily living (housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances) Nutrition Social relationships and resources Self-concept and coping Home environment 42 IMYJ 2016/Fall Health Assessment Functional assessment questions should be included Self-esteem, self-concept Activity/exercise Education Financial status Value-belief system (religious practice, personal strengths) “Tell me how you spend a typical day” Note ability to perform AD Ls: Independent or needs assistance Sleep/Rest Nutrition/Elimination 43 Recall the past 24 hours Usual pattern of elimination or urinating IMYJ 2016/Fall Health Assessment Interpersonal relationships/resources Spiritual resources Social roles, support system FICA question: Faith, Influence, Community, Address Coping & Stress management Personal habits: tobacco, alcohol, street drugs 44 To screen excessive or uncontrolled Alcohol drinking: Use CAGE test: Cut down, Annoyed, Guilty, Eye opener IMYJ 2016/Fall Health Assessment Environment/Hazards Intimate Partner Violence Housing, neighborhood, safety of area, access to transportation hazards in workplace, at home, use of seatbelts, geographic exposure, etc “Do you feel safe?” “Have you ever been emotionally or physically abused by your partner or someone important to you? Occupational Health 45 IMYJ 2016/Fall Health Assessment Developing competence: Age-appropriate “ ? ” required Children: plus “developmental history”, “nutritional history (age-appropriate)” Adolescent: the HEEADSSS method of interviewing 46 Home environment Education and employment Eating Peer-related Activities Drugs Sexuality Suicide/depression Safety from injury and violence Older adults: focus “ADL” affected by aging process or the effect of chronic illness or disability. IMYJ 2016/Fall Health Assessment 9. Perception of Health How do you define health? How do you view your situation now? What do you think will happen in the future? What are your health goals? What do you expect from us (nurse, physician, other health care providers)? 47 IMYJ 2016/Fall Health Assessment Summary Make sure you got a thorough history! Include the significant components Did you ask enough questions to get a good HPI? Did you ask enough questions in the appropriate ROS? Always review PMH, Meds, ALL Are there any hereditary possibilities? Stay focused and don’t forget a pertinent Family History Make sure you documented thoroughly!! 48 IMYJ 2016/Fall Health Assessment QUESTIONS? 49 IMYJ 2016/Fall Health Assessment