Practical Nursing Diploma Program - Semester 1 The Health History Interview

Orienting the patient……... to the surroundings to the rules to the team members they may come in contact with to the resources available - kitchen, showers etc. to the plan of care

Why do we do this????? if we’re going to help the patient, we need to know as much about him/her as possible the health history interview accomplishes that objective once completed, the document is placed on the chart so that other team members can review it can reduce repetition of questions to pt.

discharge planning begins on admission - we need to know if this patient is going to be able to go back to the same environment post hospitalization or if he will need support systems if help will be needed, the process can start early to avoid unnecessary delays on discharge

Information to be gathered……. Vital signs, height, weight medical history - illnesses, hospitalizations allergies current medications current symptoms next of kin head to toe assessment

does he have a power of attorney for personal care, Living will?? religious preferences re food, blood etc. all forms differ but most include the same types of information information can be gathered from: the patient, the family, old charts, other team members, family doctor etc.

Personal belongings…….. valuables should be locked up with security follow hospital protocol encourage patient to send home valuables with family members if present: storage is an issue document things like dentures, hearing aids, personal walkers etc.