SUBJ

• Plan when interviewing

  1. Discuss the phases of health history

  2. Guidelines when taking health history

  3. Differentiate types of health history

  4. Discuss the components of health history
• Verbal Communication


  Open-ended questions, Closed-ended questions, Laundry list, Rephrasing, Well-placed phrases, Inferring, Providing information
• Types of Communication

  Nonverbal communication, Verbal communication
• Interviewing


  Obtaining a valid nursing health history requires professional, interpersonal, and interviewing skills
• At the end of virtual discussion, the students will be able to

  1. Understand Health history

  2. Discuss Subjective data

  3. Explain the meaning of interviewing and the phases

  4. Differentiate the types of communication

  5. Discuss special consideration
• Phases of Interview

  Introductory phases, Working phase, Summary phase or Closing phases
• Collecting Subjective Data

  Subjective data consists of: Sensation or symptoms, Feelings, Perceptions, Desires, Preferences, Beliefs, Ideas, Values, Personal information
• Nonverbal Communication


  Appearance, Demeanor, Facial Expression, Attitude, Silence, Listening
• Special Consideration

  • Gerontologic
  • Cultural
  • Emotional
• Method of Collecting Data - Interviewing

  1. Two Approaches of interview: Directive

  2. Non-directive
• Verbal Communication


  • Open-ended questions
  • Closed-ended questions
  • Laundry list
  • Rephrasing
  • Well-placed phrases
  • Inferring
  • Providing information
• 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 unstructured manner 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
• 1. 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
• 1. Environmental History purpose: "to gather information about surroundings of the client", including physical, psychological, social environment, and presence of hazards, pollutants and safety measures
• 1. 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
• 1. 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)