Nursing Health History

• Interview is a meeting between you and your patient to record a complete health assessment.
• Your skill in an interview will glean all the necessary information as well as build rapport for a successful working relationship.
• Special considerations during the interview include gerontologic variations in communication, cultural variations in communication, and emotional variations in communication.
• The adult's use of why questions usually implies blame and condemnation, putting the person on the defensive and forcing the client to rationalize their behavior.
• Interpretation of the data is not based on direct observation but on your conclusion, which ascribes feelings and helps the client understand feelings in relation to the verbal message.
• Giving advice is better to help the client problem solve through a situation and make a decision.
• False reassurance closes off communication and trivializes anxiety the client may be feeling.
• Summary of the client's statement is a type of validation in that the client can agree with the information or correct the information.
• Biased questions ask a question in a way that may force the client to correspond to your values and feel guilty when they must admit to another value.
• History of Present Illness is a short statement of general health for a well client and a chronological record of the reason for seeking care for the client experiencing alterations in health status, including a symptom analysis.
• R stands for region or radiation, which refers to where it is and where it spreads.
• Components of a Review of the Systems include general overall state of health, skin, ears, hair, head, eyes, nose and sinuses, mouth and throat, neck, breast and axilla.
• Past Medical History should include health assessment, health history, and review of the systems.
• Symptom analysis should include eight critical characteristics: COLDSPA Character, Onset, Location, Duration, Severity, Pattern, Associated Factors, and Patient’s Perception.
• S stands for severity, which is measured on a scale of 1-10.
• U stands for understanding, which refers to the patient’s perception of what the symptom means.
• The purposes of a Review of the Systems are to evaluate the past and present health state of each body system, to double check in case any significant data was omitted in the present illness section, and to evaluate health promotion practices.
• Q stands for quality or quantity, which refers to how it looks, feels, sounds, and its intensity.
• T stands for timing, which refers to when it occurred, how long it lasted, and how often it occurs.
• P stands for provocative or palliative, which refers to what brings it on and what makes it worst or better.
• PQRST method can be used to organize information.
• An interview contract should include time and place of the interview and succeeding physical exam, introduction of yourself and a brief explanation of your role, the purpose of the interview, the length of time it will take to conduct the interview and physical examination, expectation of participation of each person, presence of any other people (client’s family, other health care professionals, students), confidentiality and to what extent it may be limited, and any costs that the client must pay.
• Interview approach inclusions: Give 3 (clue: PPe Dress BMI)

  privacy

  interruptions

  physical environment

  dress

  note taking

  biases and misconceptions.
• Open ended questions in therapeutic interviewing ask for narrative information, leaving the client free to answer in any way and encouraging a spontaneous account in any chosen order.
• Closed ended questions in therapeutic interviewing are direct and request specific information, eliciting a short, one or two word answer ask only one direct question at a time.
• Reflection in therapeutic interviewing echoes the client’s words, repeating part of what the client has said and helps the client continue.
• Closing or termination of the interview process should include positive health aspects, any health problems that have been identified, any plans of action, or an explanation of the following physical examination.
• Subjective data is the verbal responses that the client has made during the interview.
• Empathy in therapeutic interviewing recognizes a feeling and puts it into words, naming a feeling and allowing the expression of the feeling.
• The stages of the interview process include introduction, working (subjective and objective information), and closing or termination.
• Clarification in therapeutic interviewing is utilized when the client’s statements are ambiguous or confusing.
• Facilitation in therapeutic interviewing encourages the client to say more, showing that you are listening and are interested.
• Privacy in an interview aims for geographical privacy (unoccupied room or a place where the client feels secure that no one can overhear the conversation), refuses interruptions, and informs staff of your interview and asks that they not disturb you during this time.
• Objective data is the observations of the interviewer during the examination or data collection.
• The working phase of the interview process is the data gathering phase where verbal skills include your questions to the client and your responses to what the client has said.
• Silence in therapeutic interviewing communicates that the client has time to think, organize information without interruption from you and gives you a chance to observe the person and note nonverbal cues.
• The introduction stage of the interview process addresses the patient by his or her surname, introduces yourself and states your role in the health care system, gives reason for the interview, and begins with open ended questions.
• Physical environment in an interview should be a room temperature at a comfortable level, sufficient lighting, reduce noise (TV, radios etc), remove distracting objects from view, place the distance between you and the client at 4 to 5 feet which doesn’t invade his or her private space, arrange equal status seating (eye level), and arrange a face to face position when interviewing a bedridden hospitalized patient.
• Dress in an interview should be the client should remain in street clothes unless hospitalized and your dress should meet professional standards (uniform, or lab coat over street clothes name tag).
• Note taking in an interview may be unavoidable but should be done with disadvantages in mind: it can break eye contact, shift your attention away from the client to often, interrupt the client’s narrative flow, impede observations of the client’s non-verbal behavior, and may be threatening to the client.