SAS 2

• Interviewing and Communication Health History Interview is a conversation with a purpose within three folds using health history format.
• Self-reflection is a continual part of professional development in clinical work and brings a deepening personal awareness to our work with patients, which is one of the most rewarding aspects of patient care.
• Reviewing the patient record and setting interview goals are part of the Pre-interview phase.
• Establishing the agenda for the interview and putting the patient at ease are part of the Introduction phase.
• Negotiating a plan, including further evaluation, treatment, education, and self-management support and prevention, is part of the Working phase.
• The seven attributes of a symptom include Onset, Location, Duration, Characteristic Symptoms, Associated Manifestations, Relieving/Exacerbating Factors, and Treatment.
• Exploring the patient’s perspective includes the patient’s Feelings, Ideas, Effect of the problem on the patient’s life and Function, and Expectations.
• Termination of the interview involves summarizing important points and discussing the plan of care.
• The Review of Systems component of the adult health history documents personal/social history.
• The Adult Health History includes a component that amplifies the patient’s chief complaint and describes how each symptom developed.
• The Health Patterns section provides a guide for gathering personal/social history from the patient and daily living routines that may influence health and illness.
• Cultural constructs of mental and physical illness vary widely, causing marked differences in acceptance and attitudes.
• The working phase of the interview is where the nurse invites the patient’s story, identifies and responds to emotional cues, and expands and clarifies the patient’s story.
• Understanding and using Review of Systems questions can be challenging for beginning students.
• Ask open-ended questions initially when discussing mental health issues.
• The history of present illness outlines or diagrams age and health, or age and cause of death, of siblings, parents, grandparents.
• The primary source of health history would be from the patient.
• An objective information is an example of dizziness, headache, skin warm to touch, or itchiness.
• The primary goal in the introduction phase of the interview is for the nurse to obtain subjective data.
• Review of Systems questions pertain to symptoms, but on occasion some nurses also include diseases like pneumonia or tuberculosis.
• Subjective data are information from the client's point of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews.
• Objective data are observable and measurable data (“signs”) obtained through observation, physical examination, and laboratory and diagnostic testing.
• History of Present Illness (HPI) is a section of the history that is a complete, clear, and chronologic account of the problems prompting the patient to seek care.
• The HPI should reveal the patient’s responses to the symptoms and the effect the illness has had on daily living.
• Onset in the HPI refers to when the symptom started.
• Duration in the HPI refers to how long the symptom lasts.
• Treatment in the HPI refers to what has been done to treat the symptom and its effectiveness.
• Associated Manifestations in the HPI refers to anything else that accompanies the symptom.
• Under Family History, outline or diagram on a genogram the age and health, or age and cause of death, of each immediate relative, including parents, grandparents, siblings, children, and grandchildren.
• Characteristic Symptoms in the HPI describes what the symptom is like and how severe it is, for pain ask a rating on a scale of 1 to 10.
• Relieving/Exacerbating Factors in the HPI refers to anything that makes the symptom better or worse.
• Review of Systems in the Past History should include allergies, medications, childhood illnesses, adult illnesses, health maintenance, and risk factors.
• Medications in the Past History should include name, dose/route, and frequency of use, and also list home remedies, nonprescription drugs, vitamins, mineral or herbal supplements, oral contraceptives, and medicines borrowed from family members or friends.
• Risk Factors in the Past History should include tobacco, environmental hazards, substance abuse, alcohol, and family history.
• The narrative should include the onset of the problem, the setting in which it has developed, its manifestations, and any treatments.
• Allergies in the Past History should be recorded, including specific reactions to each medication, such as rash or nausea, and allergies to foods, insects, or environmental factors along with the patient’s reaction.
• Adult Illnesses in each of the following areas: Medical, Surgical, Accidents, and Psychiatric should be included.
• Location in the HPI refers to where the symptom is located and whether it radiates.
• Health Maintenance in the Past History should include immunizations and screening tests, and safety measures such as seat belts in cars, smoke/carbon monoxide detectors, sports helmets or padding, etc.
• The HPI should include seven attributes of each principal symptom: Onset, Location, Duration, Characteristic Symptoms, Associated Manifestations, Relieving/Exacerbating Factors, and Treatment.