Health History Interview

Nursing 330

Shirley Comer

History and Physical – Overview of The Classic Format

Biographical Info Chief Complaint – Reason for seeking Treatment History of the Present Illness – (Current Health Status) Past Health History Family History Psychosocial Profile Review of Systems Summary of Findings Physical Assessment

– Findings and Plan for treatment

Biographical and Chief Complaint

Biographical Data– Name, address, phone#, Sex, marital status, race,

ethnic origin, occupation, religion, dependants, education level, Insurance, advanced directives

Source of Information– From pt or family or other

Chief Complaint– Why did pt seek services- In pt own words & in

quotes

History of Present Illness

Elaborates on the Chief Complaint– Onset, Duration & severity

Pain rating if warranted

– Symptoms– Precipitating, Alleviating or aggravating factors– Home treatments– Any medical treatments– Why seeking treatment now

Past History

Childhood Illnesses– Measles, Chicken Pox, Mumps ect

Accidents or Injuries– Dates and causes

Hospitalizations and operations (get dates) Major Health Conditions

– Dates, current state of condition Immunizations- including flu, pneumonia, Hep B, gardisil, &

tetanus vaccines Allergies

– Environmental, food and medication– Describe reaction

Health History (cont)

List of current medications – include doses and times – OTC meds – Health food supplements– Complimentary or alternative medicine

treatments

Recent Travel/Military Service

Family History

Age and health or cause of death of each immediate blood relative, including grandparents

Age and health or cause of death of each natural child

Genogram

Genogram pix

Psychosocial Assessment

Heath care practices and beliefs Typical day 24 hour diet recall Spiritual assessment

– Religion if any– Is a Chaplin needed– Special practices of religion

Blood transfusions Abortion Surgery Dietary concerns

Psychosocial Assessment cont

Assess activities of daily living Assess self care abilities

– Self-Esteem Education, financial, values, religious practices

– Activity Amount and ability to perform

– Sleep Patterns and use of aids, naps

Psychosocial Assessment cont

– Interpersonal relationships Support systems

– Coping Perceptions of stress, major life changes

– Personal habits Can they care for themselves

– Drugs, ETOH, Tobacco use– Environmental Hazards

Throw rugs, inadequate heat, water– Occupational

Hazards of work place

Review of Systems

General health status sexual Skin nose lungs MS Hair sinuses CV Neuro Nails mouth PV Hemo Head throat GI Endocrine Eyes Neck GU Ears Axilla Genital

Example of Subjective Write up of Review Of Systems

Skin Hair and Nails:– Pt denies psoriasis, itching, rashes, scars, sores,

ulcers, and warts. Reports mole on left cheek that has been present and unchanged since early childhood. Pt reports no changes in hair textures, or reaction to hot and cold. Denies hair loss or changes to nails. Reports longitudinal ridges have been present in nails since childhood. Pt reports she colors her hair every 6 weeks at a salon and shampoos her hair daily.

Example of Objective information write up

Skin, Hair and Nails:– Uniform skin color with slightly darker exposed

areas. No jaundice, cyanosis, pallor or erythema. Mucus membranes and conjunctiva pink. No unusual odors. Hair evenly distributed, no alopecia. Nails well groomed and convex. No clubbing noted.

Getting Started

Choose comfortable room Provide privacy Reduce noise, distractions Sit 4 to 5 feet from pt. Avoid standing Remain at pt’s level Introduce your self and explain procedure Don’t use first name unless invited to

Strategies in Interviewing

Use open ended questions to invite elaboration.– “Tell me about your cancer treatment”

Use closed ended questions to inhibit elaboration or refine answer.– “Did you have Chemotherapy.”

Strategies cont

Facilitation- encourage pt to continue– “uh-Huh”, “go on”, “yes”

Silence- Allows interviewer and pt to gather thoughts

Reflection- Focuses on last topic– “You said your head hurts after dinner”

Empathy- Allows pt to express feelings– “This must be very hard for you”

Strategies cont

Clarification- clears up confusion– “What do you mean by tired blood”

Confrontation- Allows interviewer to focus on topic not brought up by pt

– “You say your arm doesn’t hurt but you’re not moving it”

Interpretation- allows interviewer to link topics– “ It seems that you get a headache after every vacation”

Explanation- Teach Summary- Condenses all information

Ten Traps of Interviewing

1. Providing false reassurance– “I’m sure you’re going to be OK”

2. Giving unwanted advise– “If I were you I’d ________”

3. Using authority– “Your Doctor knows best”

4. Using avoidance Language- using euphemisms– “Passed on, I’ve got sugar ect”

Traps cont

5. Distancing- impersonal speech– “the left breast has a lump”

6. Using Professional jargon– “When did you void last”

7. Using leading or biased questions– “You don’t smoke, do you?”

Traps cont

8. Talking too much– prevents pt from focusing on task

9. Interrupting– let pt finish own sentences– Don’t share personal info

10. Asking “why” questions- implies blame– “Why would you go near an x-ray machine if you’re

pregnant”

Tools of Physical Assessment

Introduction to assessment techniques

Classic sequence used during physical assessment– Inspection – observation– Percussion – assessing underlying

structures by taping technique– Palpation – touch– Auscultation – listening with stethoscope

Assessment Techniques (cont)

All physical assessments should follow this structure

Only exception is in the abdomen– Auscultation done before palpation and

percussion to avoid stimulating bowel sounds

Note that auscultation is done last.

Inspection

Uses sense of sight, hearing and smell to assess pt

Palpation

Uses sense of touch Allows assessment

surface texture, consistency, temperature, symmetry

Pulsations, rigidity, chest excursion

Percussion technique

Lightly place only the middle finger of your nondominant hand on the surface to be percussed

Quickly strike with the pad of the middle finger of your dominate hand

Assess the quality of the sound– Dull = underlying solid tissue– Resonant/tympanic = air

filled space

Auscultation

Uses stethoscope to assess sound

Breath sounds, bowel sounds, murmurs, bruits, egophony ect..

The Stethoscope pix