Obtaining a Health History

• Definition of health history:

  • Systematic collection of subjective data stated with the client and objective data observed by the nurse
• Complete health history:

  • Excellent way to begin the assessment process
  • Provides foundation for identifying nursing problems and focus for physical examination
  • Assists in identifying areas of strength and limitation in individual's lifestyle and current health status
  • Provides specific cues to health problems most apparent to the client
  • Modified or shortened when necessary
• Phases of taking health history:

  • Two phases: interview phase and recording phase
• Phases of interview:

  Introduction:

  • Introduce self to the patient
  • Describe purpose of the interview
  • Describe the interview process

  Discussion:

  • Facilitate and maintain a patient-centered discussion
  • Use various communication techniques to collect data

  Summary:

  • Summarize the data with the patient
  • Allow the patient to clarify the data
  • Communicate an understanding of the problems to the patient
• Keys to obtaining a health history successfully:

  • Develop an atmosphere of trust
  • Learn to ask the right questions
  • Gain skill in interpreting the responses
  • Know what to do next
  • Care begins simultaneously during the history
• Tips to enhance the success of an interview:

  • Make a good first impression
  • Be prepared
  • Be an attentive listener throughout the interview
  • Use questioning techniques to optimize conversation
  • Avoid using medical jargon
• Guidelines for taking nursing history:

  • Private, comfortable, and quiet environment
  • Allow the client to state problems and expectations for the interview
  • Orient the client to the structure, purposes, and expectations of the history
  • Communicate and negotiate priorities with the client
  • Listen more than talk
  • Observe nonverbal communications
  • Review information about past health history before starting the interview
  • Balance between allowing a client to talk in an unstructured manner and the need to structure requested information
• • Clarify the client's definitions (terms & descriptors)
  • Avoid yes or no questions when detailed information is desired
  • Write adequate notes for recording
  • Record nursing health history soon after the interview
• Active Listening:

  • Involves listening with a purpose to the spoken words as well as noticing nonverbal behaviors
  • Concentrating on what the patient is saying
• Facilitation:

  • Uses phrases to encourage patients to continue talking
  • Nonverbal response includes head nodding & shifting forward in your seat with increased attention
• Clarification:

  • Used to obtain more information about conflicting, vague, or ambiguous statements
• Restatement:

  • Involves repeating what the patient has said to confirm the interpretation of what was said
• Reflection:

  • Technique used to gain clarification by restating a phrase used by the patient in the form of a question
  • Encourages elaboration & indicates interest in more information
• Techniques that enhance data collection:

  • Example: Patient says, "I got out of bed and I just didn't feel right."
  • Nurse responds, "You didn't feel right?"
  • Patient: "Uh-huh, I was dizzy and had to sit back on the bed before I fell over"
• Confrontation:

  • Used when inconsistencies are noted between the patient reports & observations or other data about the patient
• Complete health history:

  • Taken on initial visits to health care facilities
• Taking a health history should begin with:

  • Explain to the client why the information is being requested
  • Biographical data
  • Reasons for seeking health care
  • Chief Complaint
  • History of present health illness/concern
  • Personal/Past health history
  • Family health history
  • Current Medications
  • Lifestyle and health practices profile
  • Developmental level
  • Psychosocial History
  • Review of Systems for Current Health problems
• Sections of health history:

  Biographical Data:

  • Full name
  • Address and telephone numbers
  • Birth date and birth place
  • Sex
  • Religion and race
  • Marital status
  • Social security number
  • Occupation
  • Source of referral
  • Usual source of healthcare
  • Source and reliability of information
  • Date of interview

  Chief Complaint:

  • "Reason For Hospitalization"
  • Examples of chief complaints
• History of present illness:

  • Gathering information relevant to the chief complaint and the client's problem
  • Introduction: "client's summary and usual health"
  • Investigation of symptoms: onset, date, gradual or sudden, duration, frequency, location, quality, and alleviating or aggravating factors
  • Negative information
  • Relevant family information
  • Disability affected the client's total life
  • A systematic method of collecting data about the history and status of symptoms
• Components of health history:

  • Collection of data about the past and present of each of the client systems
  • Assessment of general review of various body systems
  • Assessment of social and psychological systems
  • Description of appetite and typical daily dietary intake
  • Food preferences
• Nutritional health history:

  • Includes how the client and his family cope with disease or stress, and how they respond to illness and health
  • Assessment of psychological or social problems affecting the general health of the client
• Assessment of interpersonal factors