Health Assessment Chapter 3
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Health Assessment Chapter 3
Interviewing to obtain a health history
Phases of an Interview
Introduction Phase of an Interview
Nurse introduces self to client
Nurse describes the purpose of the interview
Nurse describes the process of the interview so client knows how long interview will take and what to expect
Discussion Phase of an Interview
Nurse facilitates discussion
Discussion is client centered
Nurse uses various communication techniques to collect data
Summary Phase of an Interview
Summarization of data
Allows for clarification of data
Provides validation to the client that the nurse understands problems.
The Physical Setting of an Interview
Comfortable (temperature, personal space, street clothes)
Free from Distraction
Professional Nursing Behavior
Good Personal Hygiene
: clean hair, nails, and modest dress
Professional yet warm demeanor
Make every attempt to understand client's POV
Avoid being careless with words
Avoid extremes of reaction-- startle, surprise, laughter, grimacing-- as clients provide information
Define words clients may not understand (but don't use a lot of technical language)
Use language that is familiar, even slang
Encourage specificity in answers
Ask one question at a time
Be attentive to client's emotional responses and follow up if necessary
Use permission giving with sensitive questions
Be concise and specific when answering client questions
lead clients to focus on one set of thoughts; this type of question is most often used in reviewing systems or in evaluating functional status.
Techniques that Enhance Data Collection
: "Go oh", "Uh-huh", "Then?"
: "What do you mean by that?"
: repeating a phrase or sentence the client just said.
: used when there are inconsistencies between what the client says and what your observations or other data show; use tone that communicates confusion or misunderstand
: when you want to share with clients conclusions you have drawn from data they have given
: condenses and orders data obtained during the interview to help clarify a sequence of events.
Techniques that Diminish Data Collection
Using medical terminology
Expressing value judgements
Interrupting the client
Behaving authoritarian or paternalistic
Using "Why" questions
Managing Awkward Moments During an Interview
Answering personal questions
: brief and direct
: do not break silence-- clients may need the silence to reflect or to gather courage. May indicated client isn't ready to discuss or approach needs to be evaluated.
Displays of Emotion
: let patient cry if they need too; acknowledge anger and discuss approach for talking to person or apologize yourself if need be.
Components of a Comprehensive Health History
Reason for seeking care
History of present illness
Present health status
Past Health History
Personal and psychosocial history
Review of systems
Symptom Analysis used when taking history of present illness
: when did the symptoms begin?
: Where are the symptoms?
: How long do the symptoms last
: Describe the characteristics of the symptom
Aggravating and Alleviating Factors
: What affects the symptoms?
: What other symptoms are present?
: describe self treatment tried before seeking care.
: Describe the severity of the symptom (number, extent, size, amount, rank 0-10)
Address and Telephone Number
Birthplace (especially if in a foreign country)
Source of Data