INTER

• Interviewing

  1. Obtaining a valid nursing health history requires professional, interpersonal, and interviewing skills

  2. Two focuses: Establishing rapport and trusting relationship with the client to elicit accurate and meaningful information

  3. Gathering information on the client's development, psychological, physiologic, sociocultural, and spiritual status to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nurse-client collaboration
• Definition of Health History: Systematic collection of subjective data stated with the client, and objective data observed by the nurse
• Verbal Communication


  • Open-ended questions
  • Closed-ended questions
  • Laundry list
  • Rephrasing
  • Well-placed phrases
  • Inferring
  • Providing information
• Method of Collecting Data: Interviewing

  1. Two approaches: Directive - The interviewer directs the interview and asks specific questions

  2. Non-directive - Conversational type and allows topics to be examined as they arise
• Types of Communication

  • Nonverbal communication
  • Verbal communication
• Subjective data consist of

  • Sensation or symptoms
  • Feelings
  • Perceptions
  • Desires
  • Preferences
  • Beliefs
  • Ideas
  • Values
  • Personal information
• Nonverbal Communication

  • Appearance
  • Demeanor
  • Facial Expression
  • Attitude
  • Silence
  • Listening
• Phases of Interview

  1. Introductory phase

  2. Working phase

  3. Summary phase or closing phase
• Special Considerations

  • Gerontologic
  • Cultural
  • Emotional
• Open-ended questions


  • Disadvantages: Take more time, Only brief answers may be given, Valuable information may be withheld, etc.
• Closed-ended questions


  • Disadvantages: Provide too little information and require follow-up questions, May not reveal how the interviewee feels, Do not allow the interviewee to volunteer possibly valuable information, etc.
• Types of interview questions

  Open-ended questions, Closed-ended questions
• Verbal Communication to Avoid

  • Biased or Leading Questions, Rushing through the interview, Reading the questions
• Interacting with Clients With Various Emotional States


  When interacting with an Anxious Client, Angry Client, Depressed Client, Seductive Clients, Discussing sensitive issues
• Planning the Interview and Setting

  Time, Place, Seating Arrangement, Distance, Language
• Open-ended questions


  • Advantages: Let the interviewee do the talking, Easy to answer and non-threatening, Reveal what the interviewee thinks is important, etc.
• Closed-ended questions


  • Advantages: Questions and answers can be controlled effectively, Require less effort from the interviewee, Less threatening since they do not require explanations or justifications, etc.
• Method of collecting data - Interviewing

  Two approaches: Directive (interviewer directs the interview and asks specific questions), Non-directive (conversational type allowing topics to be examined as they arise)
• Nonverbal Communication to Avoid

  • Excessive or insufficient eye contact, Destruction and distance, Standing
• 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
• Guidelines for Taking Nursing History cont..

  • Review information about past health history before starting 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)
• Component of Health History

  • Biographic data
  • Chief complaint or reason for visit
  • History of present illness
  • Past history
  • Family history of illness
  • Review of systems
  • Lifestyle
  • Social data
  • Psychological data
  • Pattern of health care
• Biographical Data includes Full name, Address and telephone numbers, Birth date and birth place, Sex, Religion and race, Marital status, Social security number, Occupation (usual and present), Source of referral, Usual source of healthcare, Source and reliability of information, Date of interview
• Phases of taking health history

  1. The interview phase

  2. The recording phase
• Guidelines for Taking Nursing History cont..

  • Communicate and negotiate priorities with the client
  • Listen more than talk
  • Observe nonverbal communications e.g. body language, voice tone, and appearance
• Guidelines for Taking Nursing History cont..

  • Avoid yes or no questions (when detailed information is desired)
  • Write adequate notes for recording
  • Record nursing health history soon after interview
• Types of Nursing Health History

  • Complete health history
  • Interval health history
  • Problem-focused health history
• Component of Present Illness

  1. Introduction: client's summary and usual health

  2. Investigation of symptoms: onset, date, gradual or sudden, duration, frequency, location, quality, and alleviating or aggravating factors

  3. Negative information

  4. Relevant family information

  5. Disability affected the client's total life
• Past Health History


  1. Purpose: to identify all major past health problems of the client

  2. Includes childhood illness, history of accidents and disabling injuries, history of hospitalization, history of operations, history of immunizations and allergies, physical examinations, and diagnostic tests
• Environmental History


  Purpose: to gather information about the surroundings of the client, including physical, psychological, social environment, and presence of hazards, pollutants, and safety measures
• History of Present Illness


  Gathering information relevant to the chief complaint and the client's problem, including essential and relevant data, and self-medical treatment
• Family History

  1. Purpose: to learn about the general health of the client's blood relatives, spouse, and children, and to identify any illness of environmental, genetic, or familiar nature that might have implications for the client's health problems

  2. Includes family history of communicable diseases, heredity factors associated with causes of some diseases, strong family history of certain problems, health of family members, and cause of death of family members
• Component of Present Illness

  1. Four parts: Usual health status

  2. Chronological story

  3. Relevant family history

  4. Disability assessment
• Current Health Information/Lifestyle

  1. Purpose: to record major, current, health-related information

  2. Includes allergies, habits (alcohol, tobacco, drug, caffeine), medications taken regularly, exercise patterns, sleep patterns, and daily routine
• Nutritional Health History

  1. Eating habits and pattern

  2. Quality and quantity of food

  3. Sources of food
• Health Information/Lifestyle

  • Allergies: environmental, ingestion, drug, other
  • Habits: alcohol, tobacco, drug, caffeine
  • Medications taken regularly prescribed by doctors or self-prescription
  • Exercise patterns
  • Sleep patterns (daily routine)
  • Pattern life (sedentary or active)
• Psychosocial History includes how the client and their family cope with disease or stress, and how they respond to illness and health
• Review of Systems (ROS) involves collecting data about the past and present of each of the client's systems to identify hidden problems and indicate client strengths and liabilities
• Assessment of Interpersonal Factors

  • Educational history
  • Occupational history
  • Economic status
  • Home and neighborhood condition
• Physical Systems Assessment

  1. General review of skin, hair, head, face, eyes, ears, nose, sinuses, mouth, throat, neck nodes, and breasts

  2. Assessment of respiratory and cardiovascular system

  3. Assessment of gastrointestinal system

  4. Assessment of urinary system

  5. Assessment of genital system

  6. Assessment of extremities and musculoskeletal system

  7. Assessment of endocrine system

  8. Assessment of hematopoietic system

  9. Assessment of social system

  10. Assessment of psychological system