The Health History & Interview

What are the important components of nonverbal communication in nursing?

Physical appearance; facial expression; posture; positioning in relation to the patient; gestures; eye contact; voice tone; use of touch.

True or False: Touch is considered an essential, dominant component of the physical exam.

Yes—touch is an essential, dominant component.

Where should a nurse communicate to maintain rapport during nonverbal interaction?

At the patient’s eye level.

Name the key components of nonverbal communication besides touch.

Physical appearance; facial expression; posture; positioning; gestures; eye contact; voice tone.

What are characteristics of verbal communication skills in effective interviewing?

Effective interviewing skills learned via practice; moderate pace and volume; clear articulation; simple language for patients with limited English; caring, patient, confidential.

How should communication be adapted for patients with limited English proficiency?

Use simple, clear language at normal volume.

What are the main 'Other Techniques of Communication' mentioned?

Restatement, Reflection, Elaboration (facilitation), and Silence.

What is the purpose of restatement in therapeutic communication?

To relate to the content and ask patients to elaborate.

What is reflection in therapeutic communication?

Summarizing the main themes of the patient’s communication.

What does elaboration (facilitation) accomplish?

Assists patients to describe difficulties more completely.

What is the purpose of silence in communication?

To allow patients time to gather thoughts and provide accurate answers.

What is focusing in patient communication?

Redirecting patients to the pertinent topic being discussed.

What is clarification in patient communication?

Questions to ascertain the patient’s meaning when word choice or ideas are unclear.

What is summarizing in patient communication?

Reviewing and condensing important information into two or three most important findings.

Name examples of nontherapeutic responses to avoid.

False reassurance; Sympathy; Unwanted advice; Biased questions; Changes of subject; Distractions; Technical or overwhelming language; Interrupting.

Is the statement 'Reflection restates content' true or false?

False; Reflection summarizes the main themes rather than simply restating content.

How does reflection differ from restatement?

Reflection summarizes main themes; restatement repeats content.

What are the four phases of the interview process?

Preinteraction phase; Beginning phase; Working phase; Closing phase.

What characterizes the Working phase?

Closed-ended or direct questions for specific information and open-ended questions for broad answers in the patient’s own words; avoid 'why' questions.

What occurs in the Closing phase of the interview?

Summarizing and stating the two to three most important problems or patterns.

What factors relate to intercultural differences in health interviews?

Group/ethnicity; region; age; degree of acculturation into Western society; combination of factors.

What intercultural communication considerations involve language?

Limited English skills; working with an interpreter.

What social factors influence intercultural communication?

Gender and sexual orientation issues.

Who is the primary data source in a health history?

The patient (subjective data).

What are secondary data sources?

Documentation and family members; other sources as needed.

What role does the nurse play regarding data sources?

Assess reliability; note discrepancies; identify additional sources to confirm history; review previous medical records.

What are the key components of the health history?

Demographic data; Reason for seeking care; History of present illness (Location, duration, intensity, quality/description, aggravating/alleviating factors, pain goal); Functional goal.

What subcomponents are included in the History of Present Illness (HPI)?

Location; duration; intensity; quality/description; aggravating/alleviating factors.

What sections typically follow the History of Present Illness on a health history form?

Past health history; Current medications; Medical history; Current symptoms; Allergies.

Give examples of symptoms listed under Current Symptoms.

Cough/Sputum (>3 weeks); Fever; Weight loss/anorexia; Night sweats; Fatigue.

Name examples of chronic conditions listed in the health history form.

Breast cancer; Thyroid disease; High blood pressure; Depression.

What is covered in the Review of Systems (ROS)?

General health state; Nutrition/hydration; Skin; Head/neck; Eyes/Ears/Nose/Mouth/Throat; Thorax/Lungs; Heart/Vessels; Breasts; Abdominal-Gastrointestinal; Abdominal-Urinary; Musculoskeletal; Neurological; Genitalia; Anus/Rectum/Prostate; Endocrine; Hematologic.

What psychosocial and lifestyle factors are assessed in the health history?

Social, cultural, spiritual assessment; Coping/stress tolerance; Mental health assessment and history; Medications in use; Alcohol/illegal drug use; Human violence assessment; Sexual history and orientation; Education needs.

What special situations in interviews should be considered?

Hearing impairment; Low level of consciousness; Cognitive impairment; Mental illness; Anxiety; Crying; Anger; Alcohol/drug use; Personal questions; Sexual aggression.

What is suggested by the 'Interview in a nutshell' guidance?

Prepare, read available material; Allow time with the patient; Review history (past and present) including medications; Review chief complaint; Diagnosis comes after testing.