the interview
The Interview
Chapter 4
Subjective Data
- Definition: What the patient says about themselves.
- Purposes of the interview:
- To gather complete and accurate data.
- To establish rapport and trust with the patient.
- To facilitate teaching and health promotion for the patient.
- To consider the Social Determinants of Health affecting patient care.
Communication
- Emphasized in course 1511.
- Considerations:
- Physical, mental, and emotional dimensions of communication.
- Importance of both verbal and non-verbal communication.
- Skills Required:
- Unconditional Positive Regard: Accepting and supporting the patient without judgment.
- Empathy: Understanding and sharing the feelings of the patient.
- Active Listening: Engaging fully with the patient to understand their message.
Physical Setting
- Privacy:
- Geographical: Ensure a private space.
- Psychological: Create an atmosphere that feels safe for the patient to share.
- Minimizing Interruptions:
- Essential for building good rapport and gathering comprehensive data.
- Environment Considerations:
- Ensure personal space is respected.
- Arrange the space to be conducive to conversation.
- Sit at eye level with the patient.
- Maintain a comfortable atmosphere (appropriate lighting, temperature, reduced noise).
Physical Setting Cont’d
- Professional dress:
- Dress appropriately to maintain professionalism during interactions.
- Notes:
- Taking notes can often be necessary but may have disadvantages such as disrupting the flow of conversation.
- Nurse should judge when to note-take, ensuring it does not impede communication.
- Telehealth Considerations:
- All aspects of the physical setting apply, even in a virtual format.
- Telehealth is time effective and increases accessibility for many patients.
Interview Techniques
- Introducing Phase:
- Keep it short and simple.
- Example: “Hi (patient's name), My name is ____ and I will be your Nursing Student today. I am here to ask you some questions about your health.”
- Explain to the patient that redundancy is acceptable. Questions may be rephrased based on previous responses to gain more information.
Interview Techniques Continued
- Working Phase:
- Comparison of Open-Ended and Closed Questions:
- Open-Ended Questions:
- Purpose: Used for narrative information; calls for longer answers.
- Encourages the expression of feelings, experiences, understandings, opinions, and ideas.
- Benefits: Builds and enhances rapport with patients.
- Closed Questions:
- Purpose: Used for specific information; calls for short (one- to two-word) answers.
- Elicits facts but can limit rapport and neutrality in interaction.
Assisting the Conversation
- Facilitation Skills:
- Silence: Use appropriately to allow time for thoughts.
- Reflection: Repeat what the patient has said to show understanding.
- Empathy: Connect with the patient's feelings.
- Clarification: Help clear up any confusion in communication.
- Interpretation: Offer an explanation based on what the patient has shared.
- Explanation: Provide information clearly and concisely.
- Summary: Recap important points made during the discussion.
Ten Traps of Interviewing
- Providing false assurance or reassurance.
- Giving unwanted advice.
- Using authority.
- Using avoidance language.
- Engaging in distancing.
- Using professional jargon.
- Using leading or biased questions.
- Talking too much.
- Interrupting.
- Using “why” questions.
Nonverbal Skills
- Physical Appearance: Maintain a professional presentation.
- Posture: Convey attentiveness and engagement.
- Gestures: Use appropriate gestures to enhance communication.
- Facial Expressions: Non-verbal cues that reflect empathy and understanding.
- Eye Contact: Necessary for building rapport and trust.
- Voice Tone: Should be warm and inviting, avoiding harshness.
- Silence: Can be powerful in allowing the patient to express themselves.
- Bodily Exposure and Touch: Be aware of appropriateness in context.
Closing the Interview
- Ask:
- “Is there anything else you would like to mention?”
- “Are there any questions you would like to ask?”
- “Are there other areas I should have asked about?”
- “Did we accomplish what you had hoped?”
Considerations
- Safety and comfort for:
- Hearing impaired patients.
- Acutely ill patients.
- Patients influenced by drugs or alcohol.
- Patients exhibiting sexual advances/inappropriateness.
- Patients who are crying or expressing emotional distress.
- Patients threatening violence.
- Anxious patients.
- Language barriers affecting communication.
Chapter 5
The Complete Health History
Biographical Data
- Collect relevant patient information that allows patient self-identification.
- Source of History:
- Identify who provided the information: the patient or another source (family, case files).
- Reason for Seeking Care:
- Record the patient's reason as a quote.
- Document relevant signs, symptoms, and their duration.
Current Health or History of Current Illness
- Use the PQRSTU method:
- P: Provocation/Palliation
- Q: Quality/Quantity
- R: Region/Radiation
- S: Severity Scale
- T: Timing (Onset, Duration, Frequency)
- U: Understanding the patient’s perception.
Past Health History
- Include:
- Childhood history.
- Accidents and injuries.
- Chronic conditions and their management.
- Hospitalizations and/or surgical history.
- Obstetrical history for women.
- Immunization status.
- Date of the last examination.
- Allergies (include reactions).
- Medications (current and previous).
Family Health History
- Document the age, health status, and cause of death of blood relatives (parents, grandparents, siblings).
- Analyze the impact of family health history on the patient.
- Include family history of conditions such as:
- Heart disease.
- High blood pressure.
- Diabetes.
- Cancer.
- Mental illness.
Review of Systems
- Conduct a thorough review of the following systems:
- General overall health state.
- Skin, Hair, and Nails.
- Head, Eyes, Ears, Nose, and Throat.
- Neck, Breast, Axilla.
- Respiratory system.
- Cardiovascular system.
- Peripheral vascular system.
- Gastrointestinal system.
- Urinary system.
- Genital system and Sexual health.
- Musculoskeletal system.
- Neurologic system.
- Hematologic system.
- Endocrine system.
Functional Assessment, Including Activities of Daily Living
- Measure a patient’s self-care ability through Activities of Daily Living (ADLs), including:
- Examples of ADLs:
- Bathing.
- Dressing.
- Toileting.
- Eating.
- Walking.
- Instrumental Activities of Daily Living (IADLs):
- Activities necessary for independent living, e.g., housekeeping, shopping, cooking, laundry, phone use, financial management.
Functional Assessment Continued
- Assess the following factors:
- Self-esteem and self-concept.
- Activity and exercise level.
- Sleep and rest patterns.
- Nutrition and elimination habits.
- Interpersonal relationships and resources.
- Spiritual resources.
- Coping and stress management strategies.
Functional Assessment Continued
- Evaluate personal habits:
- Tobacco use.
- Alcohol consumption.
- Substance use and abuse.
- Consider environmental hazards that may affect health.
- Review occupational health considerations, including exposure to risks in their work environment.
- Identify any experiences of intimate partner violence.
Perception of Health
- Questions to discuss:
- “How do you define health?”
- “How do you view your current situation?”
- “What are your concerns or goals regarding your health?”
- “What do you anticipate will happen in the future concerning your health?”
- “What are your expectations from your healthcare providers?”
Reminder
- Labs commence this week.
- Complete Chapters 4 & 5 of your lab manual prior to lab session.
- Bring your textbook to the lab.
- Review the Nursing Lab Code of Conduct from the welcome PowerPoint.
- If you have purchased a uniform pair of scrubs and they have not arrived, wear professional attire to the lab in the meantime.
- Order/Purchase a stethoscope for use in the upcoming week.