Health History (UNRS 220, HealthAssess)

What is the health history?

A structure conversation designed to obtain relevant data about a client's health

What is the difference between a directive and nondirective interview?

A directive interview is highly structured; a nondirective interview is open-ended, and the client largely controls the pace and direction

What are the strengths of a directive interview?

It efficiently produces the specific details that are most relevant to the nurse

What are the strengths of a nondirective interview?

It more effectively builds rapport with the client and allows the client to reveal their perceived needs

What is a closed-ended question?

A question with a limited set of responses, often either yes or no

What are the strengths of closed-ended questions?

Efficient, less threatening, and easily documented

What is an open-ended question?

An open-ended question leaves room for the client to elaborate on their response

What are the strengths of open-ended questions?

It gives the client the opportunity to phrase answers the way they would like to, and it allows the nurse to actively listen

What are the potential downsides of open-ended questions?

Compared to closed-ended questions, answering open-ended questions requires more time; the client might share unnecessary information because they are not aware of what is and is not relevant; the responses are more difficult to document

Is the following question closed-ended or open-ended?

"How have you been feeling?"

Open-ended

Is the following question closed-ended or open-ended?

"Do you feel sad right now?"

Closed-ended

Is the following question closed-ended or open-ended?

"What are your health goals?"

Open-ended

Is the following question closed-ended or open-ended?

"Would you like to lower your cholesterol?"

Closed-ended

Is the following question closed-ended or open-ended? "Describe the symptoms you have had since the start of your illness"

Open-ended

Is the following question closed-ended or open-ended?

"Have you had a fever in the last 7 days?"

Closed-ended

What is the problem with asking, "Have you been experiencing tinnitus?"

Uses jargon the client may be unfamiliar with

What is the problem with asking, "You've quit smoking, haven't you?"

It is a leading question

What is the problem with asking, "Why haven't you been taking your insulin?"

Questions that begin with "why" tend to sound judgmental

What is the problem with saying, "I think you should limit the amount of alcohol you are drinking"

It is authoritarian and limits the client's autonomy

What are common phrases to avoid during the health history?

"You should..."

"Why haven't..."

"I believe you should..."

"Surely you don't..."

"Let's discuss this later..."

"Don't worry..."

"If I were you..."

At the conclusion of the interview, the nurse should:

Look over the information to see if anything needs verification or clarification, if seemingly contradicting information needs to be reconciled, or if more information is needed, then interpret the data

When using an interpreter, should the nurse speak to the interpreter or to the client?

Speak directly to the client, not to the interpreter

The nurse should document the source of the information for the health history; typically this is the client, but it may also be:

A family member, friend, organization representative, or a medical record

Reason for seeking care

Also known as the "chief complaint" or "presenting problem," this is a brief statement in the client's own words, usually no longer than a single sentence

History of present illness

A chronological account of relevant information from the beginning of symptoms all the way up to the current time; this is typically about a paragraph in length

What are the broad categories of the health history?

Current health, history, review of systems, functional assessment

What is included in the "current health" portion of the health history?

Biographic data, reason for seeking care, and history of present illness

What is included in the "history" portion of the health history?

Medical and surgical history, including all significant illnesses and interactions with the health care system and important family history

What is included in the "review of systems" portion of the health history?

Subjective data about each of the client's major organ systems

Functional assessment

Information about the client's ability to care for themselves when they are not experiencing an acute illness

What is included in the "functional assessment" portion of the health history?

A lot of information can be included in the functional assessment, including internal factors such as health literacy, stress, and spirituality, and external factors such as occupation, housing, and relationships

The patient had frequent illnesses as a child.

This information should be charted under this part of the health history:

History

The patient was in significant motor vehicle collision years ago.

This should be charted under this part of the health history:

History

The patient had surgery 2 years ago.

This should be charted under this part of the health history:

History

The patient takes several medications.

This information should be charted under this part of the health history:

History

The patient has several family members with heart issues.

This information should be charted under this part of the health history:

History

What is the medication reconciliation?

The process of recording an up-to-date list of medications a patient is taking and comparing it with what is ordered

The patient has itchy skin.

This should be charted under this part of the health history:

Review of systems

The patient has a headache.

This should be charted under this part of the health history:

Review of systems

The patient has difficulty hearing.

This should be charted under this part of the health history:

Review of systems

The patient has muscle pain.

This should be charted under this part of the health history:

Review of systems

The patient has difficulty breathing.

This should be charted under this part of the health history:

Review of systems

The patient feels accomplished with her life.

This should be charted under this part of the health history:

Functional assessment

The patient has difficulty understanding instructions about his health:

Functional assessment

The patient has difficulty dressing herself.

This should be charted under this part of the health history:

Functional assessment

The patient is Roman Catholic.

This should be charted under this part of the health history:

Functional assessment

The patient lives with his direct family and 5 other extended family members.

This should be charted under this part of the health history:

Functional assessment

What is the FICA tool?

A tool to guide data collection about a client's spirituality

What does the F stand for in the FICA tool?

Faith - Prompts the nurse to ask the client about any FAITH-based beliefs or practices that they would like the healthcare team to be aware of

What does the I stand for in the FICA tool?

Influence - Prompts the nurse to ask the client how their faith INFLUENCES their health choices

What does the C stand for in the FICA tool?

Community - Prompts the nurse to ask the client whether they are part of a faith-based COMMUNITY

What does the A stand for in the FICA tool?

Address - Prompts the nurse to ask the client if there are any spiritual preferences that they feel need to be ADDRESSED