N209 - The Interview & Health Hx

Exam 1

• time and place of interview

• how long it will take

• purpose of the interview

• number of sessions involved

• expectation of participation for each person

• confidentiality

• presence of any other people

• any cost to the client

What must you let the patient know while contracting before the interview?

1. introduction

2. working phase

3. closing phase

What are the 3 phases of the interview?

Patient History (Hx)

What is the component of the traditional assessment format that includes subjective information only?

demographic information

The component of the traditional assessment format that includes the patient's gender identity, what pronouns they use, their age range, their SO, and responsible party.

Reason for Seeking Care

The component of the traditional assessment format that includes the reason that the patient went to the doctor or hospital; includes a quote from the patient.

• should not be a Dx (“I’m told I have diabetes”)

Present Health/ History of Present Illness

The component of the traditional assessment format in which the nurse asks questions to analyze the patient's reason for admit.

• isolate each reason for admit by asking more questions

Past Health

• childhood illnesses

• Accidents or injuries

• serious or chronic illnesses

• hospitalizations

• operations

• obstetric (pregnancy) history

• immunizations

• last examination date

• allergies

• current medications

Family History

The component of the traditional assessment format that includes a pedigree (genogram) and narrative (paragraph noting trends seen on genogram to determine what the patient is at risk for)

Historical Review of Systems

The component of the traditional assessment format in which the nurse reviews each bodily system in a head-to-toe order by asking questions.

developmental considerations

component of the traditional assessment format in which the nurse identifies how the patient feels about their progress in life and satisfaction with where they are in their stage of life.

• should identify Erikson's conflicts and/or Piaget's stages.

problem list

component of the traditional assessment format in which the nurse creates a list of problems that are discovered or that the patient tells you about; only a list, no explanations or interventions; must include the cc

physical exam

component of the traditional assessment format obtained by doing a hands on assessment using your senses to see, hear, smell, and feel the patient; includes objective information; done after the history assessment

health perception - health maintenance

gordon's functional health pattern that includes the perception of general health status and well being, and adherence to preventive health practices

nutritional - metabolic pattern

gordon's functional health pattern that includes patterns of food and fluid intake, fluid and electrolyte balance, and general ability to heal

elimination pattern

gordon's functional health pattern that includes patterns of excretory function (bowel, bladder, skin) and the patient's perception

activity - exercise pattern

gordon's functional health pattern that includes patterns of exercise, activity, leisure, recreation, and ADLs, and factors that interfere with desired to expected individual health pattern

cognitive - sensory perceptual pattern

gordon's functional health pattern that includes the adequacy of sensory modes such as vision, hearing, taste, touch, smell, pain perception, and cognitive functional abilities

sleep - rest pattern

gordon's functional health pattern that includes patterns of sleep and rest-relaxation periods during a 24-hour day, as well as quality and quantity

self perception - self concept pattern

gordon's functional health pattern that includes attitudes about self, perception of abilities, body image, identity, general sense of worth, and emotional patterns

sexuality - reproductive pattern

gordon's functional health pattern that includes perceived satisfaction or dissatisfaction with sexuality, reproductive state, and pattern

coping - stress tolerance pattern

gordon's functional health pattern that includes general coping patterns, stress tolerance, support systems, perceived ability to control and manage situations

role - relationship pattern

gordon's functional health pattern that includes perception of major roles and responsibilities in current life situation

value - belief pattern

gordon's functional health pattern that includes values, goals, or beliefs that guide choices or decisions

The Interview

What is the communication process that focuses on the patient's physical, psycho/social, developmental, cultural, and spiritual responses that are amendable to care?

Introducing the interview

“Good morning Mr. Smith, my name is Rebecca and I’ll be your student nurse today. I will be completing your health history and physical examination today.”

What phase of the interview is this?

The Working Phase

Rebecca listens to the pt., leaning in and mirroring their gestures. “It sounds like you are upset…”

What phase of the interview is this?

Closing Phase

“Do you have any more questions about what we’ve discussed today?”

What phase of the interview is this?

giving unwarranted advice

no

“If I were you I would…”

What is the nurse demonstrating? Is this appropriate?

distancing

no

“it seems YOUR kidney..”

“It seems the kidney is not functioning properly”

What is the nurse demonstrating? Is this appropriate? What should they do instead?

it comes off judgmental and rude

Why shouldn’t a nurse ask the pt. “why”?

interview

The ______________ is the first point of contact with a client and the most important part of data collection.

• the client remains in charge during this process (you know nothing about their own health state)

• subjective

• objective

During the interview, you collect ____________ data (e.g., what the person says). You will collect some _____________ data as you note the person’s posture, physical appearance, ability to carry on a conversation, and overall demeanor.

contract

Consider the interview a ___________ between you and your client.

the introduction

During what phase of the interview should you introduce yourself, state your role in the agency, provide privacy and give the reason for the interview?

the working phase

During what phase of the interview should you gather data?

the closing phase

During what phase is the interview ended with a summary and thanking them for their time and cooperation?

ask the person: “is there anything else you would like to mention?”

this gives the person the final opportunity for self-expression and avoids an abrupt or awkward closing.

How might you ease into the closing phase of an interview? Why is this important?

avoidance language

no

“Mr. Smith has gone to a better place.”

What is the nurse demonstrating? Is this appropriate?

can lead to misunderstandings and potentially harm the pt.

Why is it important to avoid medical jargon?

signals impatience and boredom

Why is it important to avoid interrupting the patient?

false reassurance

no

“Don’t worry. I’m sure you’ll be fine.”

What is the nurse demonstrating? Is this appropriate?

leading questions

no

“You don’t have unprotected sex, correct?”

What is the nurse demonstrating? Is this appropriate?

the nurse should always be listening to the patient more than they talk.

Why is it important to avoid talking too much?

using authority

no

“Your doctor/nurse knows best.”

What is the nurse demonstrating? Is this appropriate?

this labels the person as a “complainer”

Why shouldn’t the reason for seeking care be referred to as the “chief compliant”?

• evaluate the past and present health state of each body system

• double-check if any significant data were omitted in the present illness section

• evaluate health promotion practices

What is the purpose of the Review of Systems?

Symptoms

What are subjective sensations that the person feels from the disorder?

Signs

What are objective abnormalities that you as the examiner could detect on physical examination or through diagnostic testing

Provocative or Palliative

Quality or Quantity

Region or Radiation

Severity Scale

Timing

Understand the pt.s’ perception of the problem

What is the pneumonic for organizing present health questions?

The patient

What is a primary source when giving an interview?

family, significant other (SO),

What is a secondary source when giving an interview?

SBAR

What is the most commonly used standardized communication tool used in health care