Chapter 2 - Interviewing Patients to Obtain a Health History Flashcards
Subjective data used to create plan, prevent disease, resolve problems, and minimize limitations
Health history
2 primary components of health assessment
Health history
Physical exam
3 phases of the interview
Introduction
Discussion
Summary
Prepare patient for what to expect.
Introduce self: name, what you’re doing, about how long it will take and ask for permissions
Introduction of interview
Facilitate, collect, and record health hx and data.
Keep it patient centered.
Nurse prompts questions and takes brief notes.
Discussion of interview
Data collected is the foundation for personalized and effective HC.
Allows for clarification of data and provides validation of accurate understanding.
Provides closure.
Summary of interview
Single most important factor for successful interviewing
Communication of the nurse (builds repore)
Types of questions
- Open-ended questions
- Close-ended questions
- Direct questions
Questions that encourage a free-flowing, open response
What make the pain worst?
Open-ended questions
Questions that allows pt to give more precise data
Yes or no!, When was your last period?
Close-ended questions
Questions that lead patient to focus on one set of thoughts; often used in reviewing systems and evaluating functional status
(How far are you able to walk without SOB?)
Directive questions
Techniques that enhance data collection used by repeating what pt says in different words to confirm interpretation
Restatement
Techniques that enhance data collection used by repeating what pt said and encourages elaboration or more information
Reflection
Techniques that enhance data collection used when inconsistencies are noted btw pt report and nurse’s observations
(Act confuse to get further information by using tone of voice)
Confrontation
Techniques that enhance data collection used to share conclusion drawn from data
(Allow pt to confirm, deny, or revise)
Interpretation
