Chapter 2 Interviewing Patients to Obtain a Health History DSN Kevin Dobi, MS, APRN Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Interviewing Patients to Obtain a Health History Two primary components of health assessment: Health history. Physical examination. Health history = Subjective data Database used to create plan, prevent disease, resolve problems, and minimize limitations. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. The Interview Nurse facilitates discussion to determine patient’s beliefs: How does the patient define health? Beliefs about attaining and maintaining health. View of responsibility for health, health behaviors currently practiced, and unhealthy behaviors patients are willing to change. Health expectations based on life experiences: self, family, friends, and culture. Nurse’s broader view compares patient’s health with optimal health standard. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Three Phases of the Interview Introduction: Prepare patient for what to expect. Discussion: Facilitate, collect, and record health history and data. Keep it patient centered—that is, patients share their concerns, beliefs, and values in their own words. Nurse facilitates, collects, and records data. Nurse prompts questions and takes brief notes. Summary: Data collected is the foundation for personalized and effective health care. Allows for clarification of data and provides validation of accurate understanding. Provides closure. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Therapeutic Communication: The Foundation for Interviewing Single-most important factor for successful interviewing is the communication skill of the nurse. Professional communication gains the patient’s trust. Affected by numerous factors: physical setting, nurse behaviors, type of questions asked, how questions are asked, as well as: The personality and behavior of patient. How patient is feeling at the time of interview. Nature of information being discussed or problem being confronted. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Foundation for Interviewing (contd.) Affected by numerous factors: Physical setting Nurse behaviors Type of questions asked How questions are asked Personality and behavior of patients How patient is feeling at the time of interview Nature of information being discussed or problem being confronted Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Physical Setting Private, quiet, comfortable room without distractions. Privacy is essential for sensitive issues: Openness and honesty. Health care facilities are not always conducive to privacy; draw curtains, when available. Physical comfort for patient and nurse. Try to minimize distractions. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Professional Nursing Behavior First impression starts with nurse’s appearance and warm professional demeanor Interpersonal skills important to successful interview: Use active listening to show interest and understanding of patient’s point of view. Communicate acceptance and treat patient respectfully. Watch word usage and patient interpretations. Avoid extreme nonverbal reactions. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Patient-Related Variables Consider patient age and physical, mental, and emotional status. Ideally, the patient will be alert and in no physical or emotional discomfort. If in distress, limit the number and nature of necessary questions. Save additional questions for later. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

The Art of Asking Questions The art of obtaining information and listening carefully is an essential competency of nurses: Questions should be clearly spoken and understood. Define words, avoid using technical definitions, and use slang only if necessary for certain conditions. Adapt questions consistent with patient level of understanding and knowledge. Encourage patients to be specific and to clarify meanings. Ask one question at a time, and wait for reply. Be attentive to patient’s feelings that may indicate need for additional data. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

The Art of Asking Questions (contd.) Some areas of questioning are sensitive, and sensitivity varies. Explain that you may have sensitive or personal questions. Use technique referred to as permission giving – Ensure your patient knows that it is safe to discuss a certain uncomfortable topic. Seek clarification: “Tell me more about what you are thinking.” Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Types of Questions Begin with open-ended questions to encourage a free-flowing, open response: Focus on questions about patient’s health. May need to refocus questions if patient unable to focus on topic or takes excessive time. Close-ended questions yield more precise data Give patient options for response. Directive questions lead patient to focus on one set of thoughts. Most often used in reviewing systems and evaluating functional status. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Techniques That Enhance Data Collection Active listening concentrates on patient responses and subtleties. Avoid formulating the next question during responses. Avoid making assumptions about patient responses. Facilitation uses verbal and nonverbal phrases to encourage patients to continue talking further. Clarification is used to gather more information. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Techniques That Enhance Data Collection (contd.) Restatement is repeating what patient says in different words to confirm interpretation. Reflection is repeating what patient said and encourages elaboration or more information. Confrontation is used when inconsistencies are noted between patient report and nurse’s observations. Use tone of voice to convey confusion or possible misunderstanding. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Techniques That Enhance Data Collection (contd.) Interpretation is used to share conclusions drawn from data. Patient may then confirm, deny, or revise. Summary condenses and orders data to clarify sequence of events for patient. Emphasizes data related to health promotion, disease protection, and resolving health problems. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Techniques That Diminish Data Collection (contd.) Using medical terminology confusing to patient: Patient may not understand question or may be embarrassed to request clarification and therefore may give inaccurate responses. Expressing value judgments. Interrupting while patient is talking. Having an authoritarian or paternalistic demeanor. Asking “Why” questions that may threaten patient and make him or her defensive. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Managing Awkward Moments Answering personal questions: Brief direct answer. Share experiences that support patient. Enhance relationship and increase credibility. Silence: Necessary for patients to reflect and gather courage to address painful topics or issues. Feedback that patient is not ready to discuss topic or that the approach needs to be evaluated. Become comfortable with silence. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Managing Awkward Displays of Emotion Crying is natural and should be expected. Postpone further questioning until the patient is ready. A compassionate response enhances relationship. Anger is uncomfortable for patient and nurse: Deal with it directly. Identify source of anger. Discuss approaches and acknowledge feelings. If patient is unable to continue, honor request to work with another nurse. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Challenges to the Interview Managing overly talkative patients: Overly detailed problems may become a distraction. Refocus interview on events relative to the present. Redirect conversation with closed-ended questions that may help reduce distractions. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Challenges to the Interview (contd.) Others in the room: Do not assume relationships; it is best to clarify. Parent or guardian may answer for child. Interview adolescents directly. For adults unable to answer, another person may assist. Language barriers: Interpreter should be objective observer, of same gender, but not a family member. Takes more time to obtain the most important data. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Cultural Considerations Cultural differences: Nurse accountable for cultural competence Demonstrate communication skill between or among cultures and outside own culture. Identify cultural factors that may influence patients’ beliefs about health and illness. Interact with patients as unique persons with experiences, beliefs, and values learned or passed down. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. The Health History Types of health histories: Comprehensive health history establishes complete database. Problem-based or focused health assessment includes data limited to the scope of problem. Episodic or follow-up assessment focuses on specific problems for which patient is already receiving treatment. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Components of the Comprehensive Health History Biographic data – initial visit Reason for seeking care Present health status Past medical history Family history Personal and psychosocial history Review of all body systems Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

History of Present Illness Chief complaint or presenting problem: Brief statement regarding purpose for visit. Recorded in direct quotes from patient. Multiple reasons: List and prioritize. Patient may not give reasons until comfortable. Patient condition determines next step. Urgencies require expediency. Bibliographic data delayed. Data analysis to determine cause and to develop plan. Include all of the following: Symptomology: Onset, location and duration, related and alleviating factors, attempts at self-treatment. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Present and Past Health Status Present history focuses on the patient’s acute and chronic conditions: Current health conditions Medication reconciliation Allergies Past health assessment focuses on important health history: Childhood illnesses Surgeries Hospitalizations Accidents or injuries Immunizations Obstetric history Last examinations Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Family History Blood relatives: Biologic parents, aunts, uncles, siblings, children, and spouse. Identify genetic, familial, environmental factors that might affect current or future health status. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Family History (contd.) Ask about specific diseases: Alzheimer’s disease Cancer (all types) Diabetes mellitus (specify type 1 or type 2). Coronary artery disease, including myocardial infarction Hypertension Stroke Seizure disorders Mental illness, including depression, bipolar disorder, schizophrenia Alcoholism and/or drug abuse Endocrine diseases Kidney disease Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Psychosocial Status Personal status: General statement of feelings about self Family and social relationships Diet and nutrition Functional ability Mental health Personal habits: Tobacco, alcohol, illicit drugs. Health promotion activities Environment Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Review of Systems Past and present health of each body system. Conduct symptom analysis when patient indicates presence of symptoms. Define medical terms, when necessary. Additional health promotion data may be collected during review of systems. In a comprehensive health assessment, you will ask most of the questions. In a focused health assessment, you ask questions about systems related to reasons for seeking care. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Individual System Review General symptoms Integumentary system Head and neck Breasts Respiratory system/chest Cardiovascular system Gastrointestinal system Urinary system Reproductive system Musculoskeletal system Neurologic system Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Alternative Health History Formats Not all histories are organized by body systems. Nurses may use an alternative format based on a health status approach: e.g. – Gordon’s Functional Health Patterns Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Health History Based on Functional Health Patterns Health Perception-Health Management Nutrition-Metabolic Elimination Activity-Exercise Cognitive-Perceptual Sleep-Rest Self-Perception-Self-Concept Role-Relationship Sexuality-Reproductive Coping-Stress Tolerance Values-Belief Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Age-Related Variations: Infants, Children, and Adolescents Pediatric health history similar to that of adult. Additions of pregnancy, prenatal care, growth and development, behavioral status, as applicable. Most data are obtained from adult accompanying child, but should include child as much as appropriate for age. Nurse determines if an adult or pediatric database format is appropriate for adolescent. Nurse determines whether to interview adolescent alone or with parent present. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Age-Related Variations: Pregnancy Comprehensive health history is obtained at first prenatal visit. Establishes baseline data. Special emphasis on data that may impact pregnancy outcomes. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Age-Related Variations: Older Adults Incorporation of various age-related questions and functional status questions. May not be necessary to collect data on childhood immunizations or develop a genogram. Many older adults have multiple symptoms, conditions, medications, and a long past health history. Time needed to complete interview may be much longer. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Question 1 Health histories can provide nurses with data needed for appropriate care. Nurses obtaining a health history should: Help the patient identify personal beliefs about health. Assess vital signs. Inquire about activities that can affect financial stability. Explain patient rights and responsibilities. Correct Answer: A Rationale: The nurse is to help the patient define health. This will allow the nurse to better understand comments made as the health history data are collected. Vital signs are not part of the health history. Financial issues may be a part of the concerns but usually are not as important as understanding the patient’s health beliefs. Patient rights and responsibilities are not part of the health history. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 37

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Question 2 Because a nurse seeks to create a patient-centered interview process, the nurse will: Ask the patient, “Do you suffer from any arthralgias?” Give the patient as little information as possible to avoid fear. Ask the patient, “Can you please tell me more about your spells?” Inform the patient, “You don’t have to share anything with me that makes you uncomfortable.” Correct Answer: C Rationale: The word “arthralgia” may be a word that many patients do not understand. The nurse needs to be careful when withholding information related to not wanting to “scare” the patient. It is best if the nurse works with the patient on identifying what information the patient wants to receive. There could be an age-appropriate component to this (i.e., children), in which case the nurse will work with caregivers to ensure that all required information is given. In option “C,” the patient has used the word "spells." The nurse should not discourage this but should investigate further. In option “D,” the nurse should not say this; often there is sensitive material that must be covered or addressed to provide adequate care. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 38

Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Question 3 Preparation for an interview with a patient requires thoughtful consideration of the physical environment. As the physical space is arranged: Desks should not be used because they bestow too much “power” on the interviewer. Desks are usable as long as they are not a barrier between interviewer and interviewee. Interviewer eye level should be six inches lower than interviewee eye level. Interviewer eye level should be six inches higher than interviewee eye level. Correct Answer: B Rationale: Desks are appropriate as long as they are not barriers between the nurse and the patient. The nurse and the patient should be at the same eye level because this conveys a sense of equality and team work. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 39