Nursing Health History Guidelines Flashcards
Comprehensive record of a client’s past and current health, as well as client’s perception about state of wellness.
HEALTH HISTORY
Database Sources:
A.
B.
C.
D.
A. Health history
B. Physical assessment
C. Laboratory and diagnostic tests
D. Materials contributed by other health personnel
Health History gives _________ on how a health condition came about.
subjective information
Example: “Ang bigat ng pakiramdam ko. Baka
may COVID-19 ako.”
- Level of Wellness
Example: “Noon kaya ko pa magbuhat, pero ngayon ay hindi na kasi sumasakit na ang mga tuhod ko.”
- Changes in Life Patterns
Example: “Bawal akong magkasakit dahil ako
ang breadwinner ng pamilya.”
- Socio-Cultural Role
Example: “Para na akong mababaliw sa pag-quarantine.”
- Mental and Emotional Reactions to Illness
Example: “May altapresyon ako.”
- Other Health Conditions
The place of health history in the nursing process occurs at the __________ where subjective and objective data are collected, validated, and documented.
assessment phase
Data that did not come from the client.
Example: Findings of Physical Examination; Laboratory Test Results; Medical and Health Records
Objective Data
Data that came from the client themselves.
Subjective Data
Example: Pattern of recurrence of certain
conditions (allergies, asthma).
- Identify Patterns of Health and Illness
Example: Identification of risk factors for CVD (modifiable: sedentary lifestyle; non-modifiable: age)
- Risk Factors for Physical and Behavioral Health Problems
Example: Delays in fine motor skills.
- Deviations From Normal
Example: Supportive family system and stable income.
- Available Resources for Adaptation
Is usually the best and, therefore, primary source of information for the health history interview.
PRIMARY SOURCE: CLIENT
A person or record that provides additional information about the patient that is used only if the patient is unable or unwilling to communicate.
SECONDARY SOURCES: FAMILY OR SIGNIFICANT OTHERS, HEALTH TEAM MEMBERS & CLIENT’S HEALTH RECORD
Most common secondary sources used are:
- (1) __________
- Information obtained from (2) __________
(1) Medical records
(2) significant others
States that the nurse must obtain the patient’s permission before requesting information from another person.
Health Insurance Portability and Accountability Act (HIPAA)
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.
(1) professional judgment
(2) incapacitated
Means of collecting subjective data.
A formal, planned interaction.
Preparations are done prior to the interview.
INTERVIEW (HEALTH HX INTERVIEW)
FOCI OF INTERVIEW: Establishing ________ and a ________ with the client.
rapport / trusting relationship
PHASES OF THE HEALTH ASSESSMENT INTERVIEW
1. __________
2. __________
3. __________
- Pre Interaction
- Initial Interview
- Focused Interview
● 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.
PRE-INTERACTION
● 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.
INITIAL INTERVIEW
This is the start of the planned meeting where nurses start to gather information.
INITIAL INTERVIEW
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.
therapeutic communication
● 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.
FOCUSED INTERVIEW
GUIDELINES FOR AN EFFECTIVE INTERVIEW
- Start by using ________.
- Be _______.
- Ask questions in a _______ way.
- Let the interview ________.
- Obtain ______ about which part of the data collected requires ________.
- _______ the interview.
(1) icebreakers
(2) observant
(3) non-threatening
(4) flow naturally
(5) cues / in-depth investigation
(6) Control
● Highly structured.
● Elicits specific information.
● Nurse controls the subject matter.
● Used when time is limited.
DIRECTIVE
● 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.
NON-DIRECTIVE/RAPPORT-BUILDING
● 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?
CLOSED
● 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?
OPEN-ENDED
● 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?
NEUTRAL
● 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?
LEADING
● Provides important cues to what the patient is feeling.
NON-VERBAL COMMUNICATION
● 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.
DIRECTED INTERVIEW
● Allow you to control the interview.
● Ask a broad question.
● May not be a skilled interviewer.
NON-DIRECTED INTERVIEW
