Ch. 2 Obtaining a Health History

Techniques that enhance data collection

1. Active listening 2. Facilitation 3. Clarification 4. Restatement 5. Reflection 6. Confrontation 7. Interpretation 8. Summary

Summary

A summary condenses and orders data obtained during the interview to help clarify a sequence of events. This is useful when interviewing a patient who rambles on or does not provide sequential data.

Age Related Variations in a Pregnant Woman's Health History

- A comprehensive health history is obtained at the first prenatal visit to establish baseline data. - This is similar to the information presented in this chapter, but with a special emphasis on data that could impact pregnancy outcomes. - Prenatal visits are considered episodic visits to monitor the health of the pregnancy

Review of Systems

- A review of systems is conducted to inquire about the past and present health of each of the patient's body systems - Conduct symptom analysis when patient indicates presence of symptoms. - Define medical terms, when necessary. - Additional health promotion data may be collected during review of systems. - In a comprehensive health assessment, you will ask most of the questions. - In a focused health assessment, you ask questions about systems related to reasons for seeking care. - In an episodic or follow-up assessment, the questions are limited to asking the patient about changes that have taken place since the last visit.

Managing Awkward Moments Includes Dealing With:

- Answering Personal Questions - Silence - Displays of Emotion

Family and Social Relationships (Personal and Psychosocial History)

- Ask about general satisfaction with interpersonal relationships, including significant others, people with whom the patient lives, and the patient's role within the family. - Sometimes health information about significant others, sexual partners, and roommates is relevant to the patient's health. - Ask about the current state of health of these family members. - Ask about social interactions with friends, participation in social organizations (community, school, work), and participation in spiritual or religious groups. - If interactions are limited, find out what makes the patient avoid social interaction—perhaps this is by choice, or there could be an underlying problem. Be aware of issues associated with domestic violence; make a point of screening all patients for this

Personal Status (Personal and Psychosocial History)

- Ask the patient for a general statement of his/her feelings about him/herself. - Ask about cultural/religious affiliations and practices. - Ask about education; occupational history, work satisfaction, perception of having adequate time for leisure and rest; and current hobbies and interests.

Health Promotion Activities (Personal and Psychosocial History)

- Ask the patient which activities are regularly performed to maintain health. - Ask specifically about exercise, stress management, sleep habits, routine examinations, and safety practices such as seatbelt use. Health promotion practices can be assessed further when reviewing specific body systems.

What is included in a individual system review?

- General symptoms - Integumentary system - Head and neck - Breasts - Respiratory system/chest - Cardiovascular system - Gastrointestinal system - Urinary system - Reproductive system - Musculoskeletal system - Neurologic system

Health History Based on Functional Health Patterns (This concept is expanded upon in our Fundamentals course)

- Health perception-Health Management - Nutrition-Metabolic - Elimination - Activity-Exercise - Cognitive-Perceptual - Sleep-Rest - Self-Perception-Self-Concept - Role-Relationship - Sexuality-Reproductive - Coping-Stress Tolerance - Values-Belief

Medications (Present Health Status)

- Inquire about prescription, over-the-counter, and herbal preparations. Include the reason for taking the medication, how long the patient has been taking it, the dose and frequency, any adverse effects, and the patient's perception of its effectiveness. - In addition, ask the patient about any home remedies they may be using for health conditions.

Alternative Health History Formats

- Not all histories are organized by body systems. - Nurses may use an alternative format based on a health status approach:e.g., Gordon's functional health patterns

Others In The Room

- Patients may be accompanied by other individuals. When this is the case, don't assume the relationship among those present. Ask the others, "What is your relationship to the patient?" The parent or guardian of a child usually answers interview questions on behalf of the child. When adults are unable to answer questions for themselves, others may assist with the interview. However, all patients should be involved with the interview to the extent that their mental or physical ability allows. When adult or adolescent patients are able to speak for themselves, they should be interviewed directly and in private if possible. If other individuals are present, the nurse should obtain the patient's permission for them to remain in the room during the interview. - At times, the individuals who accompany patients are disruptive to the interview. For example, sometimes a parent, spouse, or friend will answer questions for the patient. Usually these individuals are trying to be helpful, but this may also suggest a dominant personality. Such situations can adversely affect the accuracy of data collected, and the nurse must validate with the patient that the information is correct. If others persist in answering for a patient, the nurse can specifically request them to allow the patient to answer or ask them to leave until the end of the interview. - A disruptive interview may also occur when others are present and create a distraction for the patient and/or nurse. As one example, attempting to conduct an interview with a woman who is accompanied by two active young children often causes constant distractions. If children are too young to wait in the waiting room, the nurse should find developmentally appropriate activities for them while the interview is completed.

The Art of Asking Questions

- Questions must be clearly spoken and understood by patients. - Define the words patients may not understand, but do not use so many technical terms that the definitions become confusing - Encourage patients to be as specific as possible. - Ask one question at a time and wait for the reply before asking the next question - Be attentive to the feelings that accompany the patient's responses to some question

How does a nurse deal with sensitivity during questioning?

- Some areas of questioning (such as sexuality, domestic violence, or the use of alcohol or drugs) are more sensitive than others. - What is perceived as sensitive may vary from patient to patient. - When asking questions about sensitive issues, nurses explain that they need to ask personal or sensitive questions and that all nurses ask these questions of patients. - Another technique is referred to as permission giving. For example, the nurse could say, "Many people have experimented with drugs; have you ever used street drugs?" or "Many young people your age have questions about sex. - What questions or concerns do you have?" With the permission-giving technique, the nurse communicates to the patient that it is safe to discuss such topics.

The Link Between Professional Nurses Behavior and Appearance

- The first impression nurses make starts with their appearance. - Dressing and grooming are important in establishing a positive first impression. - Modest dress, clean fingernails, and neat hair are imperative. Avoid extremes in dress and manner so appearance does not become an obstacle or a distraction to the patient's responses.

Functional Ability (Personal and Psychosocial History)

- The functional ability (or functional assessment) focuses on a person's ability to perform self-care activities such as dressing, toileting, bathing, eating, and ambulating. - Functional ability also includes a person's ability to perform skills needed for independent living such as shopping, cooking, housekeeping, and managing finances. - Ask patients questions related to their perceived ability to complete these tasks. - An assessment of functional ability is especially important for adults with physical or mental disabilities and for older adults.

Age Related Variations in Infant, Children, and Adolescent Health History

- The pediatric health history is similar to that of the adult, with the addition of questions about pregnancy, prenatal care, growth and development, and behavioral and school status, as applicable. - Most data are obtained from the adult accompanying the child, but the nurse should include the child as much as appropriate for his or her age. - When obtaining a health history from an adolescent, the nurse determines whether an adult or pediatric database and history format is more appropriate. - In addition, a decision is made whether to interview the adolescent with the parent present or alone

Introduction Phase

- To begin the introduction phase, the nurse introduces himself or herself and informs the patient about the nurse's role in the patient's care. - This is the opportunity to make an important first impression with the patient and begin establishing rapport. - How the nurse conducts himself or herself, includes not only what is said to the patient, but also the nurse's personal appearance, body language, and tone of voice. Address patients by their title (e.g., Mr., Mrs., Miss, or Ms.) and surname. Avoid using their first name unless they request it or when they are adolescents or children. Also avoid substituting their role for their name (e.g., referring to the patient as "mom" or "grandpa"). - During the introduction the nurse should also explain to patients what to expect during the interview and how long the process should take.

History of Present Illness

- When patients seek health care for a specific problem, the nurse documents the present illness or problem as a chief complaint or presenting problem (described previously), but should then further investigate the history of the present problem. - This is best accomplished by conducting a symptom analysis (a systematic method of collecting data about the history and status of symptoms). Because not all individuals seeking health care have a specific problem or illness, recording a history of the present illness or a symptom analysis is not always indicated.

Present Health Status

focuses on the patient's conditions (acute and chronic), medications the patient is currently taking, and allergies the patient has experienced

What are the most important things the nurse should do to ensure a successful interview with a patient?

1.) Make a good first impression. 2.) Be prepared. 3.) Be an attentive listener throughout the interview. 4.) Use questioning techniques to optimize the conversation 5.) Avoid using medical jargon

What are the 3 types of questions asked during an interview?

1.) Open ended questions 2.) Close ended questions 3.) Directive questions

Factors that affect Therapeutic Communication (The Interview)

1.) the physical setting 2.) the nurse's behavior 3.) the type of questions asked 4.) how the questions are asked. 5.) the personality and behavior of patients 6.) how the patient is feeling during the interview 7.) the nature of information being discussed or the problem confronted

Family History

A family history of the patient's blood relatives (biologic grandparents, parents, aunts, uncles, and siblings), spouse, and children is obtained to identify illnesses of genetic, familial, or environmental nature that may affect the patient's current or future health. - As recommended in the Essentials of Genetic and Genomic Nursing, trace back at least three generations. - Specifically ask about the presence of any of the following diseases among family members: Alzheimer's disease, cancer (all types), diabetes mellitus (specify type 1 or type 2), coronary artery disease (including myocardial infarction), hypertension, stroke, seizure disorders, mental illness (including depression, bipolar disorder, schizophrenia), substance abuse, endocrine diseases (specify), and kidney disease

Genograms (Family History)

A genogram is a tool consisting of a family-tree diagram depicting members within a family over several generations. - This tool is useful in tracing diseases with genetic links. - Symbols are used to indicate males and females and those who are alive and deceased. - Include the current ages of those who are alive and the cause of and age at death of those who are deceased

What is a health history? (This term is very repetitive so know this concept for the exam)

A health history is obtained from patients on every visit; the amount of data collected for a history depends largely on the setting and the purpose of the visit. - A history is a component of all the types of health assessments, including a comprehensive assessment, a problem-based or problem-focused assessment, and an episodic or follow-up assessment. - If the patient has a preestablished health record available, the nurse should access the record and review it before the patient visit, if possible.

Active Listening

Active listening involves listening with a purpose to the spoken words as well as noticing nonverbal behaviors. - This is performed by concentrating on what the patient is saying, and the subtleties of the message being conveyed, together with the facial expressions and body language observed. - The nurse must pay full attention to the patient's response rather than trying to predict how the patient will respond to the question or formulate the next question. - When assumptions are made, the nurse may ask an illogical question; or, if the nurse is concentrating on how the next question will be worded, attention is shifted away from the information that the patient is providing.

How Does Interrupting The Patient Diminish Data Collection?

Allow patients to finish sentences; do not become impatient and finish their sentences for them. - The ending the nurse might add to a sentence may be different from the one that the patient would have used. - Associated with interrupting is changing the subject before a patient has finished giving information about the last topic discussed. - Nurses may feel pressured for time and eager to move on to other topics, but they should allow patients the opportunity to complete their thoughts.

Language Barriers Between the Nurse and Patient

As the population of the country becomes progressively diverse, there are a growing number of patients who have limited English proficiency (LEP). When the nurse and patient do not share a common language, a certified translator should be used when conducting a health history to gain accurate data. State and Federal laws mandate the provision of interpreting services for patients with LEP; this is also an element within the accreditation guidelines for health care agencies. - Although it is tempting to use a family member as a translator, this is discouraged because the family member may alter the meaning of what is said or describe what he or she thinks is wrong. - Keep in mind that conducting an interview through a translator takes considerably more time than a typical interview because everything said must be repeated.

Allergies (Present Health Status)

Ask patients about allergies to foods, medications, environmental factors, and contact substances. - Be sure to ask specifically about substances to which patients could be exposed in the health care setting such as latex and iodine. - The nurse should explain the term allergy to ensure that patients understand it. - Many people do not know the difference between an adverse effect (such as nausea) and a true allergic reaction (such as a rash or difficulty in breathing). - When patients indicate that they have an allergy to a medication or substance, ask them to describe what happens when they are exposed to it to determine whether the reaction is an adverse effect or an allergic reaction.

Mental Health (Personal and Psychosocial History)

Ask the patient about personal stress and the sources of stress. - Common causes of stress include recent life changes such as divorce, moving, family illness, new baby, new job, and finances. - Also ask about feelings of anxiety or nervousness, depression, irritability, or anger. - Explore with the patient personal coping strategies for stressful situations and previous counseling or mental health care.

How is the interview process performed?

During the interview the nurse facilitates discussion to collect and record data. - Structured patient assessment formats are used in patient care settings to enhance the quality and consistency of data collected in an interview. - In many settings, patients are asked to complete a health history questionnaire. Questionnaires typically consist of a series of yes-or-no questions pertaining to specific problems or symptoms that they may have experienced. Although questionnaires are useful for collecting a health history, the information should only be considered adjunct data—they are never a substitute for an interview. - Any past medical problems or symptoms identified by patients on a questionnaire should be investigated further.

The Physical Setting

Before conducting an interview, consider the physical setting, which can impact the exchange of information. - Ideally, an interview is conducted in a private, quiet, comfortable room free from environmental distractions where the nurse and patient can sit face to face.

Open Ended Questions

Begin the interview with open-ended questions such as, "How have you been feeling?" This broadly stated question encourages a free-flowing, open response. The aim of open-ended questions is to elicit responses that are more than one or two words. Patients may respond to this type of question by describing the onset of symptoms in their own words and at their own pace. However, the open-ended question should focus on the patient's health. A question that is too broad such as, "Tell me a little about yourself," may be too general to provide useful information. The risk of asking open-ended questions is that patients may be unable to focus on the specific topic of the question or take excessive time to tell their story. In these cases, the nurse needs to refocus the interview. However, flexibility is necessary when using this type of question because patients' associations may be important and the nurse must allow them the freedom to pursue them.

Biographic Data

Biographic data are collected at the first visit and updated as changes occur. These data begin to form a picture of the patient as a unique individual. - Go to Box 2.2 in the textbook for more info

Episodic or follow-up assessment

The history associated with an episodic or follow-up assessment generally focuses on a specific problem or problems for which a patient has already been receiving treatment. - An interview for an episodic visit focuses on the changes that have taken place since the last visit, particularly with an interest in disease management and the early detection of complications or a decline in health. - An example is a cancer patient going for episodic visits for a treatment

Clarification

Clarification is used to obtain more information about conflicting, vague, or ambiguous statements. - As an example, if the patient said "I was so angry I almost lost it," the nurse seeking clarification may respond by asking "What do you mean by 'almost lost it'?" or, as another example, if the patient said, "I just wasn't able to return to work," the nurse might ask "What do you think kept you from returning to work?"

Confrontation

Confrontation is used when inconsistencies are noted between what the patient reports and observations or other data about the patient. - For example, "I'm confused. You say you're staying on your diet and exercising three times a week, yet your weight has increased since your last visit. Can you help me to understand this?" The nurse's tone of voice is important when using confrontation; use a tone that communicates confusion or misunderstanding rather than one that is accusatory and angry

Directive Questions

Directive questions lead patients to focus on one set of thoughts. This type of question is most often used in reviewing systems or evaluating an individual's functional capabilities. An example would be, "Describe the drainage you have had from your nose."

Past Health History

The past health history is important because past and present conditions may have some effect on the patient's current health needs and problems - focuses on important health history Includes: - Childhood illnesses - Surgeries - Hospitalizations - Accidents or injuries - Immunizations - Obstetric history - Last examinations

Health conditions (Present Health Status)

Examples include diabetes, hypertension, heart disease, sickle cell anemia, cancer, seizures, pulmonary disease, arthritis, mental illness. - Ask patients how long they have had the condition(s) and the impact of the illness on their daily activities

Childhood Illnesses (Past Health History)

Examples include: measles, mumps, rubella, chickenpox, pertussis, Haemophilus influenzae infection, streptococcal throat infection, otitis media (ask if there were complications in later years such as rheumatic fever or glomerulonephritis that can occur after streptococcal throat infection)

Urinary System

General: characteristics of urine (color, contents, odor); hesitancy; frequency; urgency; change in urinary stream; nocturia (excessive urination at night); dysuria (painful urination); flank pain (pain in back between ribs and hip bone); hematuria (blood in the urine); dribbling or incontinence; polyuria (excessive excretion of urine); oliguria (decreased urination) • Health promotion: measures to prevent urinary tract infections (females); Kegel exercises (performed to strengthen muscles of the pelvic floor to help prevent urine leakage)

Facilitation

Facilitation uses phrases to encourage patients to continue talking. - These include verbal responses such as, "Go on," "Uh-huh," and "Then?" and nonverbal responses such as head nodding and shifting forward in your seat with increased attention.

How can a nurse encourage patients to be as specific as possible? Provide an example.

For example, if the nurse asks how many glasses of water the patient drinks each day and the patient says, "Oh, a few," the nurse clarifies what the patient means by asking, "How many is a few? Three? Four? Five?" This approach yields a more specific answer and provides the patient's interpretation of "a few."

Why should a nurse ask one question at a time and wait for the reply before asking the next question?

If several questions are asked at a time, a patient may become confused about which question to answer, or the nurse may be uncertain about which question the patient is answering. For example, the nurse asks, "Have you had immunizations for tetanus, hepatitis B, and influenza?" If the patient answers "yes", it is not clear whether the patient means "yes" to all three or to one only. - If something a patient says is confusing, the nurse must ask for clarification. The explanation may clear up the confusion, or it may indicate that the patient has been misinformed or there is some underlying emotional or thought-processing difficulty that impairs understanding.

Hospitalizations (Past Health History)

Includes illnesses that required hospital care, dates or time frame of hospitalization, outcomes of hospital care

What are some challenges to the interview?

Includes: - Managing the Overly Talkative Patient - Managing Others in The Room - Managing a Language Barrier - Cultural Differences

Surgeries (Past Health History)

Includes: types of surgeries, dates of surgeries, outcomes of the surgery

Restatement

Restatement involves repeating what the patient has said to confirm the interpretation of what was said. - For example, "Let me make sure I understand what you said. The pain in your stomach occurs before you eat and is relieved by eating. Is that correct?"

Purpose of the Interview

Nurses learn about patients' health concerns and the social, economic, and cultural factors that influence their health and their responses to illness. Data generated from an interview provide the foundation for personalized, safe, and effective health care for each individual

How Does Being Authoritarian or Paternalistic Diminish Data Collection?

Nurses who use the approach, "I know what is best for you, and you should do what I say," risk alienating the patient. - Despite personal beliefs held by the nurse, a patient's health is his or her own responsibility. The patient may choose to follow or ignore the advice and teaching offered by the nurse.

Cultural Differences Between the Nurse and Patient

Nurses work with patients from many different cultural backgrounds. Patient-centered care is provided when nurses develop cultural competence to accept and respect differences, and identify cultural factors that may influence patients' beliefs about health and illness. - The health care system places accountability for cultural competence with all heath care professionals. - Cultural competence, as defined by Campinha-Bacote, refers to "The ongoing process in which the health care professional continuously strives to achieve the ability and availability to work effectively within the cultural context of the patient (individual, family, community)." - To deliver culturally competent care, nurses must interact with each individual as a unique person who is a product of past experiences, beliefs, and values that have been learned and passed down from one generation to the next. However, remember that all individuals within a specific cultural group do not think and behave in a similar manner. - Avoid stereotyping patients because of their culture or ethnicity. There may be as much diversity within a cultural group as there is across cultural groups. - The nurse should ask patients about experiences that illustrate what has been of value to them and that characterize their culture. This increases the nurse's understanding and demonstrates interest in them as individuals.

OLD CARTS Symptom Analysis (History of Present Illness cont.)

O= Onset L= Location D= Duration C= Characteristics A= Aggravating/Alleviating Factors R= Related Symptoms T= Treatment (Self) S= Severity

General Symptoms

Pain; general fatigue, weakness; fever; problems with sleep; unexplained changes in weight

How does a nurse deal with answering personal questions?

Patients may ask questions about nurses from time to time. They may be curious about the nurse and his or her personal life. A brief, direct answer usually satisfies their curiosity. Sharing personal experiences that are supportive of patients may be helpful (such as parenting issues or stress management) and may enhance the relationship with patients and increase the nurse's credibility.

What procedures should a nurse follow when a patient asks him/her a question?

Patients may ask the nurse questions during the interview. - The nurse can answer them using terms that the patient understands, but avoiding giving in-depth answers or providing more information than necessary. - If the patient asks broad questions or questions which the nurse is unprepared to answer at that time, the nurse asks the patient for more information about the situation, "Tell me more about what you are thinking." - This gives the nurse better direction in answering the broad questions or allows the nurse to refer the patient to the appropriate resources.

How does a nurse deal with displays of emotion?

Patients may express a variety of emotions during an interview such as sadness, fear, or anger. - Crying is a natural emotion. Saying, "Don't cry" is not a therapeutic response. A therapeutic approach is to provide tissues and let patients know that it is all right to cry by giving a response such as, "Take all the time you need to express your feelings." Postpone further questioning until the patient is ready. Crying may indicate a need that can be addressed at a later time. A compassionate response to a patient who is crying demonstrates caring and may enhance the nursepatient relationship. - At times, patients may be angry and this can be a challenge in an interview. One approach is to deal with it directly by first identifying its source. The nurse may say, "You seem angry; can you tell me what is going on?" If patients choose to discuss the anger, they may reveal whether the anger is directed at himself or herself, at someone else, or at the nurse. If patients are angry with someone else, discuss with them an approach for talking with that person about the reason for the angry feelings. When patients are angry with the nurse, encourage them to discuss their feelings. Acknowledge their feelings and, if appropriate, apologize. Nurses may be able to continue working with a patient after the angry feelings have been discussed; but, if the patient would prefer to interact with another nurse, their request should be honored. **Regardless of the outcome, nurses should model a healthy, appropriate approach to managing anger

Patient Comfort in a Physical Setting

Patients should be physically comfortable during the interview. - When possible, allow them to remain in street clothes during the interview and then have them change into a gown for the physical examination. - The nurse and patient should sit at a distance from one another that provides for a comfortable flow of conversation. - The patient's comfort level is partly related to personal space (i.e., the area that surrounds the person's body). - The amount of space the patient needs varies and is influenced by his or her culture and previous experiences in similar situations. - Be attentive to how comfortable the patient appears; if you are not sure, ask, "Is this a comfortable seating arrangement for you?" Also, if possible, be sure that the room temperature is set at a comfortable level.

Diet/Nutrition (Personal and Psychosocial History)

Patients should describe their appetite and typical daily dietary intake for both food and fluids. - Inquire about food preferences and dislikes, food intolerances, use of caffeine-containing beverages, dietary restrictions, and use of dietary supplements such as vitamins or protein drinks. - Ask about recent changes in appetite or weight, changes in how food tastes, or problems with nutritional intake (e.g., indigestion, pain or difficulty associated with eating, heartburn, bloating, difficulty chewing or swallowing). Also ask about overeating, sporadic eating, or intentional fasting.

How does a nurse deal with silence?

Silence can be awkward. There is often an urge to break it with a comment or question. However, remember that patients may need the silence as time to reflect or gather courage. Some issues can be so painful to discuss that silence is necessary and should be accepted. It may indicate that they are not ready to discuss this topic or that the approach needs to be evaluated. Nurses should become comfortable with silence; it can be useful.

Reflection

Reflection is a technique used to gain clarification by restating a phrase used by the patient in the form of a question. - This encourages elaboration and indicates that you are interested in more information. As an example: Patient: "I got out of bed and I just didn't feel right." Nurse: "You didn't feel right?" Patient: "Uh huh, I was dizzy and had to sit back on the bed before I fell over."

Managing the Overly Talkative Patient

Some patients are difficult to interview because they are overly talkative. They may feel a need to go into every detail of a problem or illness and become distracted as they tell their story. Some patients focus on events in the remote past with no apparent relevance to their present situation. Still others may want to discuss issues that do not relate directly to themselves, such as other people or current world events. - Although each situation is unique, ideally the nurse tactfully redirects the conversation. The use of closed-ended questions may help to maintain direction and flow of the conversation

Comprehensive Health History

The comprehensive health history may be performed during a hospital admission, with an initial clinic or home visit, or when the patient's reason for seeking care is for the relief of generalized symptoms such as weight loss or fatigue. - A comprehensive health history requires more time than other types of histories because a complete database is being established. - The admission process for many hospitals includes obtaining a comprehensive database. However, the patient's condition must be considered. - For example, a critically ill patient is unable to participate in a comprehensive interview; thus, it is inappropriate to pursue it at that time. Family members may be of assistance in providing important, essential information to the nurse while the patient is seriously ill. A comprehensive health history should be conducted once the patient is no longer critically ill.

Techniques that diminish data collection

The following communication techniques have been found to interrupt the flow of an interview, interfere with data collection, and possibly impair the patient-nurse relationship. These techniques can often be avoided by considering the interview from the patient's perspective. Includes: - using medical terminology - expressing value judgements - interrupting the patient - being authoritarian or paternalistic - using "why" questions

Environment (Personal and Psychosocial History)

The history also includes data related to environmental health. - Obtain a general statement of the patient's assessment of environmental safety or concerns. Variables to consider include potential hazards within the home (the lack of fire and smoke detectors, poor lighting, steep stairs, inadequate heat, open gas heaters, inadequate pest control, violent behaviors), hazards in the neighborhood or community (noise, water and air pollution, heavy traffic on surrounding streets, overcrowding, violence, firearms, sale/use of street drugs), and hazards associated with employment (inhalants, noise, heavy lifting, machinery, psychologic stress). - Also ask patients about recent travel outside the United States (when and which countries visited, length of stay).

Problem-based/focused assessment

The history for a problem-based or problem-focused health assessment includes data that are limited in scope to a specific problem. However, it must be detailed enough so the nurse is aware of other health-related data that may affect the current problem. - For example, the history for a patient with a lacerated foot should include information about the incident and symptoms and also medications that the patient is taking currently, medication allergies, other health problems that the patient has, and immunization status. Imagine the disastrous result that could occur if this patient had a history of diabetes mellitus and a severe allergy to penicillin and this information were not discovered. - A focused interview is also used when a patient seeks help to address an urgent problem such as relief from asthma attacks or chest pain. Further data may be collected once the patient has been stabilized, particularly if he or she requires ongoing care

Privacy in a Physical Setting

The importance of privacy, especially when discussing issues that are highly personal, cannot be overemphasized. - Patients may not be willing to share sensitive information openly and honestly if they are fearful of being overheard or are in the presence of friends or family members. For example, consider the potentially compromising situation if the nurse asks a patient about drug use or sexual activity in the presence of family members. - Privacy is best gained by conducting the interview in an unoccupied room such as an examination room or a private hospital room. - Unfortunately, the physical layout of some patient care areas makes it difficult to find a completely private place to conduct an interview; thus, the nurse must take measures to allow for as much privacy as possible. If the interview occurs in an environment with multiple treatment areas or in a semiprivate hospital room, drawing the curtains helps provide some degree of privacy and blocks out visual distractions.

Discussion Phase

The nurse collects the health history by facilitating a discussion regarding various aspects of the patient's health. - Although the role of the nurse is to facilitate the direction of conversation, ideally the conversation is patient-centered, meaning that patients are free to share their concerns, beliefs, and values in their own words. - During the discussion phase, a variety of communication skills and techniques are used to enhance the conversation and data collection.

Interpretation

The nurse uses interpretation to share with patients the conclusions drawn from data they have given. After hearing the conclusion, patients can confirm, deny, or revise the interpretation. - For example, "Let me share my thoughts about what you have just told me. The week you were out of the office you exercised, felt no muscle tension, felt relaxed, and slept well. I wonder if your work environment is contributing to the anxiety that you're experiencing."

Personal and Psychosocial History

The personal and social history explores a variety of topics, including any information that affects or reflects the patient's physical and mental health. Includes: - Personal status - Family and social relationships - Diet and nutrition - Functional ability - Mental health - Personal habits: Tobacco, alcohol, illicit drugs - Health promotion activities - Environment

Tobacco, Alcohol, and Illicit Drug Use (Personal and Psychosocial History)

The personal habits most detrimental to health include tobacco use, excessive intake of alcohol, and the use of illicit street drugs. Obtain specific information, including the substance used, the amount used, and the duration of the habit. • Tobacco: identify the type of tobacco used (cigarette, cigars, pipe, chewing tobacco) and the frequency of use. For cigarette smokers, record the smoking history in pack-years (the number of packs smoked per day multiplied by the number of years smoked). For example, a patient who has smoked one-half pack a day for 20 years has a 10 pack-year smoking history. • Alcohol: identify the type and amount of alcohol consumed. Ask how many alcoholic drinks are consumed in a day; if not daily, then the weekly or monthly use. Ask about driving under the influence of alcohol. Screening questionnaires such as the Alcohol Use Disorders Identification Test (AUDIT) can be used to assess problem drinking and are discussed further in Chapter 7. • Illicit drug use: Ask specifically about the use of marijuana, cocaine, crack cocaine, barbiturates, and amphetamines. Ask about high-risk behaviors such as sharing needles or driving under the influence of drug

Reason For Seeking Care

The reason for seeking care is a brief statement of the patient's reason for requesting the services of a health care professional. - The patient's reason for seeking care is often recorded in direct quotes. Often the reason for seeking health care is described in terms of a chief complaint or presenting problem. - As an example, the patient's reason for seeking health care may be recorded as chief complaint: "back pain for two days". - Some patients present for a routine examination or well visit and thus do not have a chief complaint or presenting problem. - When multiple complaints or problems are verbalized, list them all and ask the patient to prioritize the problems. - Some patients may initially be uncomfortable giving the nurse the actual reason for seeking care. When this is the case, they may not divulge the true reason they came until the end of the visit, when they begin to feel more comfortable. - The patient's condition dictates how the nurse proceeds. Urgency dictates expediency. Patients with severe pain, dyspnea, or injury should not be subjected to a prolonged history. Biographic data may be delayed to pursue the health concern. This approach enables the nurse to analyze the data quickly, identify the cause of the health concern, prioritize the patient's needs, and plan how to alleviate the signs or symptoms

Summary Phase

The summary phase of the interview is the time for closure. - Summarize with patients the main points and emphasize data that have implications for health promotion, disease prevention, or the resolution of their health problems. - The summary allows for clarification of data and provides validation to patients that the nurse has an accurate understanding of their health issues, problems, and concerns.

Why should a nurse be be attentive to the feelings that accompany the patient's responses to some question?

These responses may signify that additional information is needed during the interview or that problems exist that need to be addressed in the future. For example, if the patient reports that her mother died of breast cancer and she begins to cry, this may indicate a future need to discuss coping or adjustment strategies with her.

Interpersonal Skills and Professional Nurses Behaviors

They must convey a professional yet warm demeanor. - A stiff, formal attitude may inhibit communication; yet being too casual or displaying a "laid-back" attitude may fail to instill confidence. - Actively listen to patients and project a genuine interest in them and what they are saying. Patients have the need to feel understood; nurses should make every attempt to understand their point of view, communicate acceptance, and treat them with respect. Failure to do so jeopardizes the flow of information. - Nurses must also avoid being careless with words. What may seem like an innocent comment to the nurse may be interpreted differently by a patient. As an example, the nurse may comment on the appearance of a child "She is nice and thin, very healthy looking" not realizing that the child may have an underlying nutritional disorder that has caused a great deal of stress to the parents. - Finally, nonverbal behavior is as important as words. Avoid extreme reactions (e.g., startle, surprise, laughter, grimacing) as patients provide information. Also avoid focusing on recording data instead of focusing on the patient. - Ideally, the nurse should listen first and then document.

Close Ended Questions

To gain more precise details, nurses ask more direct, specific, closed-ended questions that require only one or two words to answer. For example, the nurse may ask, "Do you become short of breath?" or "Do you frequently get bruises?" Another reason for using this type of question is to give patients options when answering questions such as, "Is the pain in your stomach sharp, dull, or aching?" This type of question is valuable in collecting data, but it must be used in combination with open-ended questions because failing to allow patients to describe their health in their own words may lead to inaccurate conclusions

How can a nurse define words patients may not understand?

Use terms familiar to patients if possible. Slang words such as "pee" as opposed to "urinate" may be used if necessary to describe certain conditions. Adapt questions to a patient's developmental level, knowledge, and understanding. For example, the nurse may ask a young child where he or she hurts, but would ask an adult more detailed questions such as the onset, duration, and characteristics of the pain

How Does Using "Why" Questions Diminish Data Collection?

Using "why" questions can be perceived as threatening and may put patients on the defensive. - When patients are asked why they did something, the implication is that they must defend their choices. - Instead of asking, "Why did you stop taking the antibiotics" the nurse could say, "I noticed several doses of prescription are left in the bottle" and wait to see if the patient offers an explanation. If no explanation is forthcoming, the nurse can follow up with, "I'm curious to know whether you intended to take all the antibiotics."

How Does Using Medical Terminology Diminish Data Collection?

Using medical terminology, abbreviations, or jargon not known to patients interferes with the communication process. - Some examples include saying "hypertension" instead of "high blood pressure," "dysphagia" rather than "difficulty in swallowing," "CVA" rather than "stroke," or "myocardial infarction" rather than "heart attack." Using medical terminology might confuse the patients, lead them to misunderstand the question, or cause them to feel too embarrassed to ask for clarification. Such a scenario can lead to inaccurate data collection.

How Does Expressing Value Judgments Diminish Data Collection?

Value judgments expressed by the nurse have no place in an interview. - For example, the nurse should ask, "If you have had a mammogram before, do you recall the date of the last one?" rather than saying, "You have had regular mammograms, haven't you?" The latter question forces the patient to respond in a way that is consistent with the nurse's values, or it might cause the patient to feel guilty or defensive when she must answer to the contrary

Patient Related Variables

When conducting an interview, consider patient variables such as age and physical, mental, and emotional status. Ideally, patients are mentally alert and in no physical or emotional discomfort. - Conducting an interview with a patient who is in physical or emotional distress is difficult. In such a case, use a focused assessment to limit the number and nature of questions to those which are absolutely necessary for the given situation, and save any additional questions for later.

Purpose of Health History

When nurses first meet patients, they begin a database with a health history followed by a physical examination. - The purpose of the health history is to obtain subjective data from the patient so the nurse and patient can create a plan to promote health, prevent disease, resolve acute health problems, and minimize limitations related to chronic health problems. - Information gathered includes how patients define health and their beliefs about attaining and maintaining health (such as how they view their responsibility for their health, which health behaviors they currently practice, and which unhealthy behaviors they are willing to change). - A way to think about the interview is an opportunity to reveal the patient's story. This perspective is a helpful reminder that each patient is unique; thus, each interview reveals specific information about that individual. - The patient's expectations for health are based on his or her life experiences, the experiences of families and friends, and the culture in which they live. The nurse has a broader view of health and compares a patient's current state of health to a standard needed to attain or maintain optimal health and then determines how far the patient is from the desired standard.

The interview consists of what three phases?

introduction, discussion, and summary

Obstetric history (Past Health History)

number of pregnancies (gravidity), number of births (parity), and number of abortions/miscarriages if applicable. ** If working with a pregnant patient or woman in childbearing years, further information is recorded

Distractions in a Physical Setting

the interview should be conducted in a quiet setting without distractions. - Interruptions by other individuals should be avoided. - Ensure that unnecessary noise is eliminated and unnecessary equipment is removed from the area or turned off if possible. ** With the exception of emergencies, cell phones and pagers should not be answered while conducting an interview.

Immunizations (Past Health History)

tetanus, diphtheria, pertussis, mumps, measles, rubella, rotavirus, poliomyelitis, hepatitis A or B, influenza, pneumococcal pneumonia, human papilloma virus (HPV), meningococcal vaccines, and varicella.

Accidents of Injuries (Past Health History)

type (fractures, lacerations, loss of consciousness, burns, penetrating wounds), dates of injury, outcomes of injury on health

Last examinations (Past Health History)

type of examination (physical, dental, vision, hearing, electrocardiogram [ECG], chest radiograph, skin test for tuberculosis; for women: Papanicolaou [Pap] test, mammogram; for men: prostate examination), dates of examination, and outcomes

A comprehensive health history includes what components?

• Biographic data • Reason for seeking care • History of present illness • Present health status • Past health history • Family history • Personal and psychosocial history • Review of systems

Gastrointestinal System

• General abdominal symptoms: abdominal pain; heartburn, nausea/vomiting; hematemesis (vomiting blood); jaundice (yellowish color to skin and sclera); ascites (increase in the size of the abdomen caused by intraperitoneal fluid accumulation) • Elimination: bowel habits (frequency, appearance of stool); pain or difficulty with defecation; excessive flatus, change in stools (color, consistency); problems with diarrhea or constipation; presence of blood in stool; hemorrhoids; use of digestive or evacuation aids (stool softener, laxatives, enemas) • Health promotion: dietary analysis (compare diet to MyPlate); use of dietary fiber supplements; colon cancer screening

Breasts

• General: breast pain/tenderness; edema (swelling); lumps or masses, breast dimpling; nipple discharge; changes to the nipples • Health promotion: breast self-examination (frequency, method)

Respiratory System

• General: cough (nonproductive or productive); hemoptysis (coughing up blood); frequent colds; dyspnea (shortness of breath); night sweats; wheezing; stridor (abnormal, high-pitched, musical sound); pain on inspiration or expiration; exposure to smoke or other respiratory irritants • Health promotion: hand washing (reduction of respiratory infection); tuberculosis screening; wearing a mask for occupational or environmental respiratory irritants or hazards; annual influenza immunizations (flu shots); smoking cessation; secondhand smoke exposure

Neurologic System

• General: syncope (fainting episodes); loss of consciousness; seizures (which body parts moved, incontinence, characteristics); cognitive changes; changes in memory (short-term, recent, longterm); disorientation (time, place, person) • Motor-gait: loss of coordinated movements; ataxia (balance problems); paralysis (partial versus complete inability to move); paresis (weakness); tremor; spasm; interference with activities of daily living • Sensory: paresthesia (abnormal sensations, e.g., "pins and needles," tingling, numbness); pain (describe sensation and location)

Head and Neck

• Head: headaches; significant trauma; vertigo (dizziness); syncope (brief lapse of consciousness) • Eyes: discharge, redness, pruritus; excessive tearing; eye pain; changes in vision (generalized or field of vision); difficulty reading; visual disturbances such as blurred vision, photophobia (sensitivity to light), blind spots, floaters, halos around lights, diplopia (double vision), or flashing lights; use of corrective or prosthetic devices; interference with activities of daily living • Ears: pain; excessive cerumen (earwax); discharge; recurrent infections; changes in hearing (deceased hearing or increased sensitivity to environmental noises); tinnitus (ringing or crackling); use of prosthetic devices; change in balance; interference with activities of daily living • Nose, nasopharynx, and paranasal sinuses: nasal discharge; frequent epistaxis (nosebleed); sneezing; obstruction; sinus pain; postnasal drip; change in the ability to smell; snoring • Mouth and oropharynx: sore throat; tongue or mouth lesion (abscess, sore, ulcer); bleeding gums; use of prosthetic devices (dentures, bridges); altered taste; dysphagia (difficulty swallowing); difficulty chewing; changes to the voice or hoarseness • Neck: lymph node enlargement; edema (swelling) or masses in neck; pain/tenderness; neck stiffness; limitation in movement • Health promotion: use of protective headgear and eyewear; protection of ears from excessively loud noise; dental hygiene practices (brushing/flossing); dental care from dentist

Cardiovascular System

• Heart: palpitations; chest pain; dyspnea (shortness of breath); orthopnea (difficulty in breathing unless sitting up); paroxysmal nocturnal dyspnea (periodic dyspnea during sleep) • Blood vessels: coldness in the extremities; numbness; edema (swelling); varicose veins; intermittent claudication (leg pain with exercise that ceases with rest); rest pain (leg pain with exercise that does not cease with rest); paresthesia (abnormal sensations); changes in color of extremities • Health promotion: dietary practices to limit salt and fat intake; cholesterol screening; blood pressure screening; use of support hose if work involves long periods of standing; avoidance of crossing legs at the knees; exercise/activity

Reproductive System (Male vs. Female)

• Male genitalia: presence of lesions; penis or testicular pain or masses; penile discharge; hernia • Female genitalia: presence of lesions, pain, discharge, odor; menstrual history (date of onset, last menstrual period [LMP], length of cycle); amenorrhea (absent menstruation); menorrhagia (excessive menstruation); dysmenorrhea (painful menstruation); metrorrhagia (irregular menstruation); pelvic pain • Sexual history: ask about current and past involvement in sexual relationships; nature of sexual relationship(s) (heterosexual, homosexual, bisexual); type and frequency of sexual activity; number of sexual partners (past and present); sexual identity (being sensitive to the transgender patient); satisfaction with sexual relationships; method of contraception used (if applicable); changes in sex drive; problems with infertility; exposure to sexually transmitted infections; females: dyspareunia (pain during intercourse); postcoital bleeding (bleeding after intercourse); males: impotence; premature ejaculation • Health promotion: methods to prevent unwanted pregnancy; protection from sexually transmitted infections; testicular or vulvar self-examination; Papanicolaou (Pap) test (females); prostate screening (males)

Musculoskeletal System

• Muscles: twitching; cramping; pain; weakness • Bones and joints: joint edema (swelling); pain; redness; stiffness; deformity; crepitus (noise with joint movement); limitations in range of motion; arthritis; gout; interference with activities of daily living • Back: back pain; pain down buttocks and into legs; limitations in range of motion; interference with activities of daily living • Health promotion: amount and kind of exercise per week; calcium intake; osteoporosis screening

Integumentary System

• Skin: skin disease, problems, lesions (wounds, sores, growths); excessive dryness, diaphoresis (sweating), or odors; changes in temperature, texture, or pigmentation; discoloration; rashes, pruritus (itching); frequent bruising • Hair (refers to all body hair, not just head and pubic area): changes in amount, texture, character, distribution; alopecia (loss of hair); itching scalp • Nails: changes in texture, color, shape • Health promotion: measures taken to limit sun exposure; use of sunscreen; skin self-examination; type and frequency of nail care