1. Taking HISTORY Ariani Arista Putri Pertiwi, S.Kep., Ns., MAN

2. Objectives Cognitive: –Understand some principles in taking history Affective: –Be a good listener and have emphaty

4. ASSESSMENT  Deliberate and systematic collection of data about patient.  Reveal a patient’s current and past health status, Functional status, and Present and past copping patterns

5. Two steps Collection and verification of data from a primary source and secondary source. Analysis of all data as a basis for the second step of the nursing process, developing nursing diagnosis, and identifying collaborative problem.

6. You need…

7. Data Collection Cue : information Inference: your judgment or interpretation of those cues Cues Assumes slumped postures Sighs before responding to questions States “I am so tired” States “I do not have energy to do what I like to do” Inferences Feeling fatigue Feeling too tired to perform normal activities of daily living

8. STEPS Observation assessment cues and pattern of information that suggest problem areas. Assessment model: –From general to specific –Problem-focused approach Cluster cues make inference identify emerging patterns and potential problems

9. TYPES OF DATA Subjective Data: your patient’s verbal descriptions of their health problems. Objective Data: observation or measurements of a patient’s health status.  clear, precise, consistent.

10. SOURCE OF DATA Provides information about the patient’s: –level of wellness, –risk factors, –health practices and goals, –Patterns of health and illness

11. SOURCE OF DATA Patient Family and significant other Health care team Medical records Other records and literature

12. Methods of Data Collection Interview and Health history Physical Examination Observation of Patient’s behavior Diagnostic and Laboratory data

13. INITIAL INTERVIEW Introduce your self to the patient, explain your role, and explain the role of others during care Establish a caring therapeutic relationship with the patient Gain insight about the patient’s concerns and worries Determine the patient’s goals and expectations of the health care delivery system Obtain cues about which parts of the data collection phase require in-depth investigation

14. Three phases of interview Always prepare for an interview. Orientation –Introducing yourself, your position. –Explaining the purpose of the interview –Establish trust and confidence –Begin a relationship Working –Gather information –Focus, orderly, unhurried Termination

15. Give your patient clue that the interview is coming to an end. –Exmp: “there are just two more questions” Summarize the important points Ask your patient if your summary is accurate End the interview in a friendly manner –Exmp: “Thanks Mrs.Tillman, you have given to me a good picture of your health and how you have been affected”

16. Interview Technique Good interview environment: free of distractions, unnecessary noise, and interruption Use open-ended questions –Tell me about the problems you are having –Tell me the reason you came to the hospital today. Use back-channeling –“All right”, ‘go on”, “uh-huh” –“mmm”, “iya”, “lalu”, “mmhem”

17. PHYSICAL EXAMINATION INSPECTION AUSCULTATION PALPATION PERCUSSION SMELL

18. Observation of patients behavior Level of function involves a person’s ability to perform during everyday activities.

19. Cultural consideration in Assessment What do you call your problem? What do you think caused your problem? What does your sickness do to you? Why do you come to me for treatment? What are the most important problem your sickness has caused you? What worries you and frightens you the most about your sickness?

20. Some useful expression in admission Welcome, Mr. Hari I’ll show you your room I’d like to ask you some questions Have you ever been in a hospital? When was the last time you were hospitalized? Have you had any surgery ? Do you have any allergy to anything? Do you use hearing aid? Do you smoke? How many cigarettes in a day? Could you tell me about your illness? What medicine have you taken at home?

21. Data validation Validate findings from physical examination and observation of patient behavior by comparing data in the medical record and by consulting with other health team members or even family members Then Do DOCUMENTATION !

22. THANK YOU HAPPY LEARNING