Interviewing pt to obtain health history

3 primary components of health assessment:

• Health history – Subjective Data

• Physical examination – Objective 

• Documentation of data

Health history = subjective data

• Database used to create a plan, prevent disease, resolve problems, and minimize limitations.

why should we learn health assessment

• Health assessment is a systematic method of collecting and analyzing data.​

• Used to create a patient-centered plan of care​

• Utilize the American Nurses Association’s (ANA) Standards of Practice, which incorporates the nursing process.​

data collection

symptoms of what the patient feels/states, signs (clinical findings) collected during the exam, clinical manifestations - combo of both collected during physical exam

context of care health assessment

providers office, emergency room, a setting to recieve care and where the assessment occurs

patient need health assessment

patient condition and concern determines the depth of the assessment. someone with more illnesses with have a more detailed assessment compared to someone coming in for a minor issue

health assessment skills

The nurse’s ability to perform accurate and thorough assessments influences the quality of data collected. Skilled nurses can identify subtle signs and symptoms that may otherwise be missed.

comprehesive health assessment

patient history (everything)

problem based or focused assessment

targets a specific issue or complain

shift assessment

hospital, nurses receive assessment in the beginning of their shift and continue care

episodic assessment/follow up assessment

intervention (pain or surgery) and need to follow up on that and continue care accommodating that: A follow-up visit after starting blood pressure medication.

screening assessment

• A quick check for certain conditions or risk factors, often in community or outpatient settings.

• Example: Blood pressure screening or cholesterol check.

documentation

is needed to improve patient care, is a document of patient health, baseline for eval and changes and decisions related to care. has to be accurate.

health promotion

behavior motivated by the desire to increase wellbeing and actualize human health potential

health protection

behavior motivated by the desire to actively avoid illness detected early or maintain functioning within its constraints

first level of health promotion

prevention: flu shots, immunizations, hand hygiene, healthy lifestyle

secondary prevention of health promotion

screenings: EKGs, BP screening, mammograms

tertiary prevention of health promotion

patient has a problem, but we want to minimize effects in the future: patient with diabetes have huge risks for other health problems, so we want to prevent it from creating other health problems

healthy people: 4 overarching goals

1) Attain high quality, longer lives, free from preventable diseases

2) Achieve health equity, eliminate disparities, and improve the health of all groups

3)Promote quality of life, healthy development, and healthy behaviors across all life stages

4)Create social and physical environments that promote health for all

nurses engage in

therapeutic communication

in order to recieve a health history you need to have

• Health history – Subjective Data​

• Physical examination – Objective Data​

components of the comprehensive health history

• Biographic data—initial visit​

• Reason for seeking care​

• History of present illness​

• Present health status​

• Past medical history​

• Family history​

• Personal and psychosocial history​

• Review of all body systems

what we should respect when it comes to patients

• Age​

• Culture/Language​

• Gender Identity andExpression​

• Physical or EmotionalDistress​

• Sensory/CognitiveImpairment

Phases of the Interview​

• Orientation​

• Identification​

• Exploitation​

• Resolution/Termination

orientation

nurse introduction, explain purpose and establish trust

identification

The nurse gathers information to identify the patient’s needs, concerns, and health priorities. have mutual respect for each other.

exploitation

The nurse and patient work together to explore resources, provide education, and address identified needs.

resolution/termination

The interview concludes by summarizing key points, clarifying next steps, and ensuring the patient feels supported. problem is solved, and relationship has ended.

facilitation

patient needs a prompt, or guidance or step. like “go on” to continue sharing information

affirmation

responses that valiate and support what the patient has shared

What is the chief complaint or presenting problem in a health history?

A brief statement regarding the purpose for the visit, recorded in the patient’s own words.

How should multiple reasons for seeking care be documented?

List and prioritize them according to importance

What determines the next step after documenting the chief complaint?

The patient’s condition

symptomology

Onset (when did the (e.g.) pain start), location (where is the pain) and duration (how long has the pain), related and alleviating factors (what did you do for your pain), attempts at self-treatment (what have they tried to treat themselves).​

present health status

health conditions, allergies, medications

patient health status: health conditions

Chronic or recurring​

How does it affectt heir activities of daily living.

present health status: allergies

Food,Environmental,and Medication​

What does thereaction look

present health status: medications

Name, Route,why do they take this medication

Past History​

• Childhood diseases​

• Immunizations​

• Blood transfusions​

• Major illnesses

• Childhood diseases​

• Immunizations​

• Blood transfusions​

• Major illnesses

Family History​

• Three generations of blood relatives - parent, grandparent and siblings (and if possible, get their age when diagnosed)​

• Genetically linked diseases

Psychosocial History​

• Personal Status​

• Family and Social Relationships​

• Education (highest level of communication in order to communicate properly at their level)​

• Finances​

• Roles and relationships​

• Ethnicity and culture​

• Environment / Safety issues​

• Access to Care

• Health Promotion Activities​

• Spirituality​

• Mental Health​

• Use of alcohol, tobacco, andIllicit Drug Use​

• Diet / Nutrition​

• Functional Ability

basically, how they see themselves

individual system review

• General symptoms​

• Integumentary system​

• Head and neck​

• Breasts​

• Respiratory system/chest​

• Cardiovascular system​

• Gastrointestinal system​

• Urinary/Reproductive System​

• Musculoskeletal/Neurological system

language barrier: interpreter or family member

• Always Use interpreters:

  • face-to-face with patients and families or by phone or video medical interpretation.

• Family members should not be used as interpreters.