Health Assessment in Planning the Interview and Setting
Scenarios for interacting with different client emotional states
Anxious client
Angry client
Depressing client
Seductive clients
Discussing sensitive issues
Nonverbal communication to avoid
Excessive or insufficient eye contact
Destruction and distance
Standing
Phases of taking health history
1. Interview phase
2. Recording phase
Disadvantages of asking too few questions in an interview
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
May inhibit communication and convey lack of interest by the interviewer
Interviewer may dominate the interview with questions
Considerations for interacting with clients with various emotional states
Verbal communication to avoid
Biased or leading questions
Rushing through the interview
Reading the questions
To obtain data that help the nurse understand and appreciate the client's life experience
Guidelines for Taking Nursing History
1. Balance between allowing a client to talk in an unstructuredmanner and the need to structure requested information
2. Clarify the client's definitions (terms & descriptors)
Negotiate priorities with the client
1. Listen more than talk
2. Observe non-verbal communications (e.g. body language, voice tone, and appearance)
Types of Nursing Health History
Complete health history
Interval health history
Problem-focused health history
Components 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
Guidelines for Taking Nursing History
1. Avoid yes or no questions when detailed information is desired
2. Write adequate notes for recording
3. Record nursing health history soon after the interview
Review information about past health history before starting the interview
To initiate a nonjudgmental, trusting interpersonal relationship
To elicit information about all the variables that may affect the client's health status
Components of Health History - Biographical Data
Full name
Address and telephone numbers (client's permanent contact)
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
Chief Complaint: '“Reason For Hospitalization”'
Four parts of Present Illness
Usual health status
Chronological story
Relevant family history
Disability assessment
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
History of hospitalization
1. Time of admission, date, admitting complaint, discharge diagnosis, and follow-up care
2. History of operations "how and why this done"
3. History of immunizations and allergies
4. Physical examinations and diagnostic tests
Information collected during health assessment
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
Past Health History
1. To identify all major past health problems of the client
2. Includes childhood illness e.g. history of rheumatic fever
3. History of accidents and disabling injuries
Family History
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
Component of Present Illness
1. 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 assessment affected the client's total life
Family History 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
Environmental History purpose: "to gather information about surroundings of the client", including physical, psychological, social environment, and presence of hazards, pollutants and safety measures
Psychosocial History: Includes: How client and his family cope with disease or stress, and how they responses to illness and health. You can assess if there is psychological or social problem and if it affects general health of the client
Review of Systems (ROS) Collection of data about the past and the present of each of the client systems. (Review of the client’s physical, sociologic, and psychological health status may ide)