Conducting the Interview #2

Question 1

Purpose of the Nursing Health History?

Answer 1

To obtain health history of patient including:

Their physical status, wellness practices & ADLs

Past health history

Current health issues

The psychosocial, cultural, & environmental factors that influence their health status.

Clarify previously obtained data

Gather missing information

Update & identify new diagnostic cues

Guide direction of physical assessment

Identify or validate nursing diagnoses

Question 2

Components of the Health History?

Answer 2

Biographical data

Present health or illnesss

Past history

Family history (discussed in class # 1)

Psychosocial history (discussed in class # 1)

Review of body systems

Question 3

Biographical Data to be collected?

Answer 3

Patient’s Name
Gender
 Age
 Phone #
 Address
 Birth date
 Birth place 
Marital Status
Race/Ethnic Origin
 Living Arrangements (Ex. Lives with spouse, lives alone, lives in residence)
 Religion/Spirituality
 Occupation
 Source of reliability of the information provided (credible)

Question 4

Present Health or Illness collection?

Answer 4

Brief statement in patient’s own words about why they’ve sought care-Reason for seeking health care

Best if in person’s exact words (in “quotes”)
“I’ve had chest pain for 2 hours.”
“This ulcer in my foot just won’t heal.”
“I want to start exercising and need a checkup.”

Avoid interpreting or diagnosing
If many reasons, ask what prompted seeking help now
Brief statement in patient’s own words describing feelings about seeking care.

Question 5

Exploring symptoms: The history of the present health concern/chief complaint- (PQRSTU)?

Answer 5

P: Provocative or palliative (what brings it on? What makes it better/worse? Has it been the same since it started?)

Q: Quality or quantity (how does it look, feel, sound?)

R: Region or radiation (where is it? Does it spread?)

S: Severity Scale (how bad is it on a scale from 1 (barely noticeable) – 10 (excruciating)? Is it getting better/worse/staying constant?)

T: Timing (onset, duration, frequency)

U: Understand Patient’s Perception (what does it mean or represent to the patient to have this symptom? Will you be able to continue to work or do leisure activities?)

Question 6

Past History?

Answer 6

Childhood illnesses
Allergies
Medical
Surgeries
Accidents
Hospitalizations
Outpatient care
Childbirth experiences (where delivered? Any complications?)
Mental health problems
Have you ever sought help for an emotional problem?
Have you ever been so upset/down that you’ve had trouble managing?
Immunizations (tetanus boosters for adults)
Use of substances (type, amount, duration & frequency of use – even if no longer using)

Question 7

Family History?

Answer 7

Immediate family- physical & mental illness

Extended family

Genogram

Question 8

Psychosocial History?

Answer 8

Occupation (can cause certain health risks)
‘How does work affect your health?’ ‘ Are you able to work now?’

Education (literacy can effect access to care)
‘Tell me about your educational background.’

Financial resources (low income strongly associated with ill health)
‘Are you feeling financially stressed because of this illness?’
‘Are you able to buy all the things you need to deal with this illness?’

Family/community roles
‘Who do you live with?’ ‘What type of relationship do you have with them?’ ‘What demands do these relationships put on you?’

Support systems (lack of social support strongly associated with ill health, especially in elderly)
‘Who do you turn to in times of need?’  (‘Significant’ others)

Ethnicity & Culture
‘What is your ethnic heritage? ‘ ‘What should I know about your culture and the way you make health care decisions?’

Religious beliefs & practices (important in helping client make healthcare decisions)
‘Do you have a particular religious affiliation? Is there anything about your religion that I should know in helping you improve your health?’
Self-concept
‘How would you describe yourself to others?’
‘What do you like about yourself?’ ‘What would you change?’
Sexuality
‘Are you satisfied with your sexual life, or do you have some concerns? ‘
Stress & coping
‘What do you do to reduce stress when life gets hectic?’

Question 9

Review of Body Systems?

Answer 9

▪ General Wellness
▪ Skin, Hair, Nails
▪ Head, Neck, and Lymphatics
▪ Eyes
▪ Ears, Nose, Mouth, and Throat
▪ Cardiovascular
▪ Respiratory
▪ Peripheral Vascular
▪ Breasts and Axillae

▪Abdomen
▪ Urinary
▪ Male reproductive
▪ Female reproductive
▪ Musculoskeletal
▪ Neurological

▪ A guide/tool outlining the specific assessments to do for a ‘review of body systems’ will be provided prior to lab.

Question 10

Assessment-Specific Documentation Guidelines?

Answer 10

Record pertinent positive and negative assessments
Document any parts of the assessment that are omitted or refused by patient
Avoid using judgmental language
State time intervals precisely
Use specific measurements
Draw pictures when appropriate
Use anatomic landmarks when possible
Use the face of a clock to describe findings that are in a circular pattern