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Interview and Therapeutic Communication
Purpose of Health History
A health history serves as a means to gather comprehensive information about the client's background.
Primarily focuses on collecting subjective data: this is information provided directly by the client about their own symptoms and experiences.
Essential for identifying abnormal symptoms and health concerns.
Health History vs. Ill Health
For healthy individuals, the health history would typically indicate lifestyle choices such as:
Regular exercise
Healthy diet
Avoidance of substance use
Reduction of risk-taking behaviors
For individuals presenting with health issues, the health history may include chronic conditions and health concerns.
The term 'health history' is considered a screening tool for abnormal symptoms.
Goal of Interviewing
The primary goal of gathering health history is to elicit the client’s complete truth regarding their health condition.
Building trust and rapport is crucial for the client to freely share sensitive information, especially about personal topics like:
Sexual health
Substance use
Emotional well-being
Effective therapeutic communication is key to facilitating this exchange.
Elements of Therapeutic Communication
The manner of speaking, choice of words, eye contact, body language, and expression of empathy play significant roles in establishing effective communication.
It's important to balance eye contact:
Too much may be perceived as invasive; too little may suggest disinterest.
Starting the Health History
The interview typically begins with the client’s chief complaint.
Chief complaint often referred to as HPI (History of Present Illness) includes direct quotes from the client regarding their reason for seeking care.
The chief complaint should describe the symptom rather than a diagnosis.
Example: Instead of stating "patient is here to rule out MI," state "patient is here because of chest pain."
Even known chronic conditions should be contextualized with respect to the current symptoms prompting the visit.
Examples of chief complaints can include:
"Sore throat for the past three days, getting worse"
"Earache and fussy all night"
Requesting a physical exam for work-related reasons
Understanding Symptoms vs. Signs
Symptoms: Subjective data reported by the client.
Example: "I have a fever" is a symptom, as it’s based on client’s statement.
Signs: Objective data obtained through assessment or observation by the healthcare provider.
Example: Elevated temperature measured is a sign.
Another example: Swollen and warm leg is a sign, as it is visually assessed.
Collecting History of Present Illness (HPI)
Provides a record from the point of symptom onset to the current status.
Important to note: Timing, frequency, and nature of symptoms.
Summary of symptoms should include eight characteristics:
Location
Ask the client to identify the specific location of the symptom.
Example: "Where is your headache?" Specific locations provide diagnostic significance.
Quality/Characteristics
Descriptive terms for the nature of the symptom (e.g., sharp, dull, throbbing).
Similarities can be referenced (e.g., comparing blood in vomit to coffee grounds).
Quantifying the symptom can also be beneficial (e.g., pain rated from 0 to 10).
Timing
Ask about symptom onset, frequency, and duration.
Setting
Inquire about what the client was doing at the time of symptom onset.
Aggravating/Relieving Factors
Ask what exacerbates or alleviates the symptom.
Associated Factors
Identify any other symptoms associated with the primary symptom.
Client’s Perception
Understand how the symptom affects the client's daily activities.
OPQRST and U for Pain Assessment
The OPQRST acronym is used to evaluate the quality and severity of pain:
O: Onset (When did it first start?)
P: Provocation (What makes it better or worse?)
Q: Quality (Type of pain - sharp, dull, etc.)
R: Radiation (Does the pain radiate to other areas?)
S: Severity (Client rates pain on a scale of 0 to 10)
T: Timing (When did it start, frequency?)
U: Understanding (What does the client think is happening?)
Practice Questions
Example 1: A client presents with persistent lower back pain. Best nurse statement: "What makes your pain better or worse?"
Example 2: Why is HPI vital for treating a client with abdominal pain? Correct answer: "A complete description of the present illness is essential to an accurate diagnosis."
Current Medications
Key term: Medication Reconciliation refers to the process of comparing current medications with previous ones.
This process is conducted to reduce errors and ensure client safety.
Important aspects to include:
Name: Always confirm whether to use generic or trade names (generic is most commonly tested).
Dosage: Document strength and frequency.
Side Effects: Ask clients about any experiences of side effects.
Inquire about non-prescription and over-the-counter medications, as they can have significant interactions with prescribed medications.
Common examples: aspirin, herbal supplements, vitamins.
Notably, St. John’s Wort is an example that interacts with various medications, particularly SSRIs.
Family History Assessment
Technique often includes the use of a Genogram to illustrate health status within a family.
Important for identifying risks of inherited conditions.
Questions in family history should address prevalent conditions such as:
Heart disease, diabetes, hypertension, various cancers, mental health issues, etc.
Review of Systems (ROS)
This component evaluates the past and present health status of each body systems in a systematic manner.
It is conducted subjectively (not objective assessments).
Functional Assessment
Measures an individual’s ability to perform daily self-care tasks.
Includes both Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs).
ADLs: bathing, dressing, toileting, eating, walking.
IADLs: housekeeping, shopping, cooking, managing finances, etc.
Cultural and Spiritual Assessment
Understanding a client’s cultural background and spiritual needs is essential in healthcare settings.
Inquire about any cultural practices surrounding medical care, nutritional concerns, and immunization status when relevant.
Practice Questions on Cultural Assessment
It is essential to let older adult clients establish their views and preferences, ensuring they understand care implications due to cultural beliefs.