Nursing Health History Guidelines

Question 1

Comprehensive record of a client’s past and current health, as well as client’s perception about state of wellness.

Answer 1

HEALTH HISTORY

Question 2

Database Sources:
A.
B.
C.
D.

Answer 2

A. Health history
B. Physical assessment
C. Laboratory and diagnostic tests
D. Materials contributed by other health personnel

Question 3

Health History gives _________ on how a health condition came about.

Answer 3

subjective information

Question 4

Example: “Ang bigat ng pakiramdam ko. Baka
may COVID-19 ako.”

Answer 4

1. Level of Wellness

Question 5

Example: “Noon kaya ko pa magbuhat, pero ngayon ay hindi na kasi sumasakit na ang mga tuhod ko.”

Answer 5

2. Changes in Life Patterns

Question 6

Example: “Bawal akong magkasakit dahil ako
ang breadwinner ng pamilya.”

Answer 6

3. Socio-Cultural Role

Question 7

Example: “Para na akong mababaliw sa pag-quarantine.”

Answer 7

4. Mental and Emotional Reactions to Illness

Question 8

Example: “May altapresyon ako.”

Answer 8

5. Other Health Conditions

Question 9

The place of health history in the nursing process occurs at the __________ where subjective and objective data are collected, validated, and documented.

Answer 9

assessment phase

Question 10

Data that did not come from the client.
Example: Findings of Physical Examination; Laboratory Test Results; Medical and Health Records

Answer 10

Objective Data

Question 11

Data that came from the client themselves.

Answer 11

Subjective Data

Question 12

Example: Pattern of recurrence of certain
conditions (allergies, asthma).

Answer 12

1. Identify Patterns of Health and Illness

Question 13

Example: Identification of risk factors for CVD (modifiable: sedentary lifestyle; non-modifiable: age)

Answer 13

2. Risk Factors for Physical and Behavioral Health Problems

Question 14

Example: Delays in fine motor skills.

Answer 14

3. Deviations From Normal

Question 15

Example: Supportive family system and stable income.

Answer 15

4. Available Resources for Adaptation

Question 16

Is usually the best and, therefore, primary source of information for the health history interview.

Answer 16

PRIMARY SOURCE: CLIENT

Question 17

A person or record that provides additional information about the patient that is used only if the patient is unable or unwilling to communicate.

Answer 17

SECONDARY SOURCES: FAMILY OR SIGNIFICANT OTHERS, HEALTH TEAM MEMBERS & CLIENT’S HEALTH RECORD

Question 18

Most common secondary sources used are:
- (1) __________
- Information obtained from (2) __________

Answer 18

(1) Medical records
(2) significant others

Question 19

States that the nurse must obtain the patient’s permission before requesting information from another person.

Answer 19

Health Insurance Portability and Accountability Act (HIPAA)

Question 20

In emergency situations, the HIPAA regulations
permit the use of (1) __________ and experience in solicitation of information from secondary sources when the patient is (2) __________ and only in an attempt to protect the patient.

Answer 20

(1) professional judgment
(2) incapacitated

Question 21

Means of collecting subjective data.
A formal, planned interaction.
Preparations are done prior to the interview.

Answer 21

INTERVIEW (HEALTH HX INTERVIEW)

Question 22

FOCI OF INTERVIEW: Establishing ________ and a ________ with the client.

Answer 22

rapport / trusting relationship

Question 23

PHASES OF THE HEALTH ASSESSMENT INTERVIEW
1. __________
2. __________
3. __________

Answer 23

1. Pre Interaction
2. Initial Interview
3. Focused Interview

Question 24

● Collection of data from medical records; previous health risk appraisals; health screenings; therapists and other health care professionals.

● Plan and guide the direction of initial interview

● Nurse reflects on his/her own strengths and limitations.

Answer 24

PRE-INTERACTION

Question 25

● Gathering information from the patient.
● Use of health history form.
● Establishing NPR (nurse-patient relationship).
● Explaining the importance of the interview, telling
what to expect.

Answer 25

INITIAL INTERVIEW

Question 26

This is the start of the planned meeting where nurses start to gather information.

Answer 26

INITIAL INTERVIEW

Question 27

In the INITIAL INTERVIEW, use __________ techniques to elicit more information and to make the patient feel that what he/she says is accepted by the nurse.

Answer 27

therapeutic communication

Question 28

● Clarify previously obtained assessment data.
● Gather missing information about a specific health
concern.
● Update and identify new diagnostic cues as they
occur.
● Guide the direction of physical assessment.
● Identify or validate probable nursing Dx.

Answer 28

FOCUSED INTERVIEW

Question 29

GUIDELINES FOR AN EFFECTIVE INTERVIEW

1. Start by using ________.
2. Be _______.
3. Ask questions in a _______ way.
4. Let the interview ________.
5. Obtain ______ about which part of the data collected requires ________.
6. _______ the interview.

Answer 29

(1) icebreakers
(2) observant
(3) non-threatening
(4) flow naturally
(5) cues / in-depth investigation
(6) Control

Question 30

● Highly structured.
● Elicits specific information.
● Nurse controls the subject matter.
● Used when time is limited.

Answer 30

DIRECTIVE

Question 31

● Nurse allows the patient to control the purpose, subject matter & pacing of the interview.
★ May be used to gather additional data that was
not gathered from the directive approach.

Answer 31

NON-DIRECTIVE/RAPPORT-BUILDING

Question 32

● Used in directive interviews.
● Generally require yes or no or short factual answers
giving specific information.

Example:
○ How old are you?
○ What medication did you take?

Answer 32

CLOSED

Question 33

● Associated with nondirective interviews.
● Specify broad topics to be discussed & invite longer answers.
★ Used to explore and identify problems and
concerns.

Example:
○ How have you been feeling lately?
○ What would you like to talk about today?

Answer 33

OPEN-ENDED

Question 34

● Can be answered by the client without direction or pressure from the nurse.
● Open-ended.
● Used in nondirective interviews.

Example:
○ How do you feel about that?

Answer 34

NEUTRAL

Question 35

● Direct the client’s answer.
● Closed.
● Used in a directive interview.
● Give clients less opportunity to decide whether
the answer is true or not.
● Can create problems if client gives inaccurate
response just to please the nurse

Example:
○ You will take your medicine, won’t you?

Answer 35

LEADING

Question 36

● Provides important cues to what the patient is feeling.

Answer 36

NON-VERBAL COMMUNICATION

Question 37

● Interviews have tight control.
● May layout process of gathering data for decision
making.
● Want control to get as much out of you as they can.
● They could be asking unstructured and structured
questions.

Answer 37

DIRECTED INTERVIEW

Question 38

● Allow you to control the interview.
● Ask a broad question.
● May not be a skilled interviewer.

Answer 38

NON-DIRECTED INTERVIEW