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

2. 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.
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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.

4. 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.
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6. 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.
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7. 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
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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.
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9. 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.
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10. 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.
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11. 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.
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12. 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.”
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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.
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14. 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.
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15. 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.
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16. 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.
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17. 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.
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18. 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.
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19. 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.
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20. 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.
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21. 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.
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22. 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.
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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.
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24. 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
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25. 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.
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26. 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
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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.
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28. 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
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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
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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.
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31. 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
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32. 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
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33. 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
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34. 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.
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35. 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.
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36. 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.
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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.
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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.
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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.
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