1. The Interview & Complete Health History
YEO JIN IM, RN, PhD, BC-PNP. Health Assessment
Kyung Hee Univ. 2016/Fall
IMYJ 2016/Fall Health Assessment

2. What is Health? Holistic approach
Biomedical model: western tradition views health as the absence of disease
Expanding the concept of health
Holistic approach
Health promotion & disease prevention
IMYJ 2016/Fall Health Assessment

3. Nursing Process Assessment: data collection
: A way of thinking (ANA, 1998)
Assessment: data collection
Diagnosis: actual or potential health problems
Planning: outcome identification-pt centered expected outcome
Implementation: it is the term for the actions that you take in the care of your pts.
Evaluation: Did it work?
IMYJ 2016/Fall Health Assessment

4. Assessment: Data Collection
Types of data: Subjective vs. Objective
Methods of Data Collection
Interview & Health History: subjective (what the pts TELLS you about him/herself during history taking)
Physical Examination: objective
Diagnostic & Laboratory Data: objective (e.g., chest x-rays, blood tests)
Reviewing medical record: objective
IMYJ 2016/Fall Health Assessment

5. The Interview: Health History
Goal of the interview:
To record a complete health history
To identify the person’s health strengths and problems
A bridge to the next step in data collection, the physical examination
The first & most important part of data collection
It collects subjective data!
IMYJ 2016/Fall Health Assessment

6. The Process of Communication (Vehicle of interviewing !)
Sending: verbal/nonverbal communication
Receiving: be interpreted in a specific context to have meaning
Greater risk for misunderstanding exists in the health care setting
Communication = the vehicle of interviewing !
= much more than talking and hearing (all behavior, conscious and unconscious verbal and non verbal)
IMYJ 2016/Fall Health Assessment

7. Physical Environment Room temperature Sufficient lighting Reduce noise
Remove distracting objects or equipment
Place the distance (x2 arm length)
Arrange equal-status seating AVOID STANDING!
Arrange face-to-face position
IMYJ 2016/Fall Health Assessment

8. Techniques of Communication
Introducing the interview
Introduce yourself (state your role)
Give the reason for the complete history
Ask an open-ended question
IMYJ 2016/Fall Health Assessment

9. The working phase Open-Ended Questions Asks for narrative information
Encourages the person to respond in paragraphs
Use it to begin the interview
Listen carefully “Tell me about it”, “Anything else?”
Examples
“Tell me how I can help you”
“What brings you to the hospital?”
“You mentioned shortness of breath. Tell me more about that.”
IMYJ 2016/Fall Health Assessment

10. Closed or Direct Questions
Ask for specific information
Elicit a short, “yes” or “no”, one- or two-word answer, forced choice
Limit answer
Use after the person’s opening narrative to fill in any details
NOT to overuse
Ask only one direct question at a time
“ Have you ever had pain, double vision, watering, or redness in the eyes?”
Choose language the person understands
IMYJ 2016/Fall Health Assessment

11. Closing the interview
Is there anything else you would like to mention?:
Give the pt. a final opportunity for self-expression
Give a summary
IMYJ 2016/Fall Health Assessment

12. Ten Traps of interviewing : Moments of tension
Providing false assurance/reassurance: “Now, don’t worry, I am sure …. ”
Giving unwanted advice: “If I were you, I’d…”
Using authority: nurse knows best
Using avoidance language: 완곡하게 말하는 것
Engaging in distancing: use of impersonal speech ‘there is a lump in the Lt. breast’
1. Providing false assurance/reassurance” 여기 몽우리가 잡히는데 암인것 같아요”
Now don’t worry, I am sure you will be all right!
you are really worried about the lump, aren’t you?
I feel so lost here since they transferred me to the medical center. No one comes to see me. No one here care what happens to me
I care what happens to you. I am here today and I want you to know that I’ll be here all week.
2. giving unwanted advice: know when to give advice and when to avoid giving it
Dr. Kline just told me my only chance of getting pregnant is to have an operation. I just don’t know. What would you do?
giving advice or reflection ?
3. Your doctor/nurse knows best : dependency, inferiority.
equally worthy roles in the health process, each respecting the other!!
4. using direct language is the best way to deal with frightening topics
5. Use distancing does not work because it communicates to the pt that you also are afraid of the procedure.
IMYJ 2016/Fall Health Assessment

13. Using Professional jargon: adjust vocabulary to the pt.
Using leading or biased questions: you don’t smoke, don’t you?
Talking too much: listen more than you talk!
Interrupting
Using “why” questions: why=implies blame
심근경색 vs. 심장마비, 뇌경색 뇌출혈 vs. 중풍
ex. You don’t smoke, do you?
8. Just the opposite is true. Listen more than you talk!!!!!
9. Even when you think you know what the person will say, don’t interrupt and cut the person off! Don’t preoccupied with yourself by thinking of your next remark while the person is talking!!
10. Why did you take so much medication? answer is …. (may not know the answer)
Use what!
10.
IMYJ 2016/Fall Health Assessment

14. Developmental Care & special consideration
Interviewing children with the Parents
Should build rapport with the child and the parent
Focus more on the parent if pt is a younger child (1-6yr)
Provide toy, refer to the child by name, do not ignore the child completely
Nonverbal communication: important to children >adult
Understand developmental characteristics
Infant, preschooler, school-age child, adolescent
IMYJ 2016/Fall Health Assessment

15. Interviewing the older adult
Knowledgeable about physiologic, sociologic, and psychological changes a/w aging.
Speak slowly and clearly! Ask short question!
Consider physical limitation: difficulty in hearing, impaired visual perception, confused memory (esp. recent events)
IMYJ 2016/Fall Health Assessment

16. Culturally Competent Care
Family.asp?language=KR&mc=M0031
IMYJ 2016/Fall Health Assessment

17. Cross-cultural care: Culturally sensitive Health History interview
Cross-cultural or intercultural communication=the HCP (health care provider) and a pt, different cultural backgrounds
 Increased the probability of miscommunication
Cultural sensitivity: etiquette, cultural code
Working with an interpreter (NOT a family member or a friend) – our responsibility to ensure a pt’s right
Phone interpreter
In-person interpreter
IMYJ 2016/Fall Health Assessment

18. The Complete Health History
IMYJ 2016/Fall Health Assessment

19. Complete Health History***
1. Biographical(Demographic) data
2. Source of history=informant
3. Reason for Seeking Care (Chief Complaints, C.C.)
4. History of Present Illness(HPI) = Present Health History
5. Past Health = Past Medical/Surgical History (PM/SH)
6. Family History
7. Review of Systems (ROS)
8. Functional Assessment (Activities of Daily Living )
9. Perception of Health
IMYJ 2016/Fall Health Assessment

20. 1.Biographic (Demographic) Data
name, address, phone #, age, birth date
birthplace, gender, marital status, race, ethnic origin, occupation
primary language, communication needs, authorized representative (if any)
2.Source of History(Hx): Informant
Who provide information? client herself or himself, relative, friend, parents, spouse, etc
Judge how reliable the informant seems and how willing to communicate? Any special circumstances e.g. use of interpreter
IMYJ 2016/Fall Health Assessment

21. 3. Reason for seeking care, C.C.(Chief Complaint)
Find out the pt’s main concern
Brief spontaneous statement in pt’s own words that describes the reason for the visit.
“ ” enclosed in quotation marks
NOT a diagnostic statement
“shortness of breath” vs. “emphysema”
One (or two) symptoms or signs & duration
If lists many reasons  try to focus on “the most pressing concern”
Examples
“chest pain” for 2 hours,
“Earache and fussy all night”
“Here for the yearly exam,
IMYJ 2016/Fall Health Assessment

22. Sign vs. Symptom Sign: objective abnormality
You, as the examiner could detect on physical examination or in laboratory reports
Symptom: subjective sensation
The person feels from the disorder.
IMYJ 2016/Fall Health Assessment

23. 4. Present Health or History of Present Illness: HPI
For the well person: short statement about the general state of health: “I am healthy and active”
For the ill person: chronologic record of the reason for seeking care, from the time the symptom first started until now
Collect all the date first (do NOT JUMP to conclusions)
8 critical characteristics
IMYJ 2016/Fall Health Assessment

24. HPI – 8 critical characteristics
Location
Be specific
Note the precise site “Head pain” vs. “pain behind the eyes”, “jaw pain”, “occipital pain”
“Is the pain localized to this site or radiating?”
“Is the pain superficial or deep?
Character or quality
Burning, Sharp, Dull, Aching
Gnawing, Throbbing, Shooting, Viselike
IMYJ 2016/Fall Health Assessment

25. HPI – 8 critical characteristics
Quantity or Severity
Attempt to quantify the sign or symptom
Examples
profuse menstrual flow soaking 5 pads per hour
Quantify the symptom of pain using the scale “ On a 10-point scale, with 10 being the most pain you can possibly imagine and 1 being mild pain you barely notice, tell me how your pain feels right now”
Ask how it affects daily activities: “I was able to go to work, but then I came home and went to bed”
IMYJ 2016/Fall Health Assessment

26. HPI – 8 critical characteristics
Timing (Onset, Duration, Frequency)
When did the symptom first appear? (Onset)
Give the specific date and time
State specifically how long ago the symptom started prior to arrival (PTA).
Example: Pain started yesterday ( ) pain started 2 days ago ( )
How long did the symptom last (duration)?
Was it steady (constant), or did it comes and go during that time (intermittent)?
Did it resolve completely and reappear days or weeks later (cycle of remission and exacerbation)?
IMYJ 2016/Fall Health Assessment

27. HPI – 8 critical characteristics
Setting
Where was the person or what was the person doing when the symptom started?
What brings it on?
Example: “did you notice the chest pain after jogging?
Aggravating or Relieving Factors
What makes the pain worse?
Is it aggravated by weather, activity, food, medication, standing bent over, fatigue, time of day, season, and so on?
What relieves it?
E.g. rest, medication, ice pack?
What have you tried?, what seems to help?
IMYJ 2016/Fall Health Assessment

28. HPI – 8 critical characteristics
Associated Factors
Is this primary symptom associated with any others?
Urinary frequency and burning associated with fever and chills?
Review of system, Review medication regimen (side effect or toxic effect?) can be needed at this point
Patient’s Perception
Find out the meaning of the symptom by asking how it affects daily activities
“How has this affected you?”
“What do you think it means?”
IMYJ 2016/Fall Health Assessment

29. PQRSTU Provocative or Palliative Quality or Quantity
Region or Radiation
Severity Scale
Timing: Onset, Duration, Frequency
Understand Patient’s Perception
IMYJ 2016/Fall Health Assessment

30. 5. Past Health History
Past health are important: may have residual effects on the current health status
Use date (mo/yr) ex. 3년전(X), 2007년 8월 (O)
Childhood illnesses: measles, mumps, rubella, chickenpox, pertussis
Accidents or injuries
Serious or Chronic illnesses: including psychiatric illness,
asthma, depression, diabetes, hypertension, heart disease, hepatitis etc
Hospitalizations: cause, how the condition treated, how long, name of hospital, physician
Operations: type, how the person recovered
IMYJ 2016/Fall Health Assessment

31. Ask about: Obstetric History: Immunizations
Gravida (# of pregnancies), term (# of full term deliveries), preterm(# of preterm pregnancies), abortions (# of incomplete pregnancies), living (# of children living)
Immunizations
Allergies: allergen & reaction
Last exam date
Physical, dental, vision, hearing, ECG, chest x-ray, mammogram, pap test, etc
Current Medications
Prescribed AND over-the-counter medication
Include Vitamins, birth control pills, aspirin,
Ask about:
DRUGS
FOOD
ENVIRONMENTAL
ANESTHESIA
LATEX
If not, then: “Denies….”
IMYJ 2016/Fall Health Assessment

32. 6.Family Health(FH) History
Use pedigree or genogram : graphic family tree
Gender, relationship, age of immediate blood relatives
At least 3 generations (parents, grandparents, siblings)
Record the medical condition of each relative & other significant health data (age, cause of death, twin, tobacco use, heavy alcohol use)
Ask specifically for
Coronary heart disease
High blood pressure
Stroke
Diabetes
Obesity
Blood disorders
Breast/ovarian cancer
Colon cancer
arthritis
Allergies
Alcohol or drug addiction
Mental illness
Suicide
Seizure disorder
Kidney disease
Tuberculosis (TB)
M: DM age 65
F: CABG age 67
Brother:  age 36 from MVA
Sister: hypothyroidism
PGM: Breast Ca age 66
PGF:  MI age 50s
Paternal sister: CVA age 60
Paternal uncle:  MI age 43
Maternal side: unknown, mother adopted
IMYJ 2016/Fall Health Assessment

33. IMYJ 2016/Fall Health Assessment

34. IMYJ 2016/Fall Health Assessment

35. 7. Review of Systems order: roughly “head to toe”
(1) to evaluate the past and present health state of each body system
(2) to double-check in case any significant data were omitted in the HPI section
(3) to evaluate health promotion practices
order: roughly “head to toe”
Ask about specific SYMPTOMS under each system
Be directive and specific!
IMYJ 2016/Fall Health Assessment

36. Write out pertinent (+)’s and (-)’s or “denies” Unacceptable:
“no problems”, “denies s/s”, “WNL” within normal level, “no complaints”, etc.
Only list what you ask
IMYJ 2016/Fall Health Assessment

37. NOT physical finding or objective data
Review of System
NOT physical finding or objective data
SUBJECTIVE data ONLY: Limited to patient statements
IMYJ 2016/Fall Health Assessment

38. ROS General overall health state
Present weight (gain or loss, over what period of time, by diet or other factors)
Fatigue, weakness, fever, chills, sweats or night sweats
Skin
History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion
Hair
Recent loss, change in texture, Nails (change in shape, color, or brittleness)
Head
Any unusually frequent or severe headache, any head injury, dizziness(syncope), or vertigo
Eyes
Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia(double vision), redness or swelling, watering or discharge, glaucoma or cataracts
Ears
Earaches, infections, discharge, tinnitus, vertigo
Nose & sinuses
Discharge and its characteristics, unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, change in sense of smell.
IMYJ 2016/Fall Health Assessment

39. ROS
Mouth & Throat
Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste
Neck
Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter
Breast & Axilla
Pain, lump, nipple discharge, rash, history of breast disease, any surgery on the breast / tenderness, lump or swelling, rash in axilla
Respiratory
History of lung disease, chest pain with breathing, wheezing or noisy breathing, shortness of breath, cough, sputum (color, amount), hemoptysis
Cardiovascular
Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemia
IMYJ 2016/Fall Health Assessment

40. ROS Peripheral vascular
Coldness, numbness, tingling, swelling of legs, discoloration in hands or feet, varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers
Gastrointestinal
Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal & stomach burning sensation), nausea & vomiting, history of abdominal disease, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, rectal bleeding, rectal conditions
Urinary system
Frequency, urgency, nocturia, dysuria, polyuria or oliguria, urine color, history of urinary disease, pain in flank, groin, suprapubic region, or low back
Musculoskeletal system
History of arthritis or gout. Joint: pain, stiffness, swelling, deformity, limitation of motion, noise with joint motion, muscle: pain, cramps, weakness, gait problems, back: pain, stiffness, limitation of motion, history of back pain
IMYJ 2016/Fall Health Assessment

41. ROS
Neurologic system
History of seizure disorder, stroke, fainting. Motor function: weakness, tic or tremor, paralysis, coordination problems, Sensory function: numbness, tingling, Cognitive function: memory disorder, Mental status: nervousness, mood change, depression
Hematologic
Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions
Endocrine
History of DM, thyroid disease, intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, need for hormone therapy
Sexual health
Genital system
IMYJ 2016/Fall Health Assessment

42. 8. Functional Assessment (Including Activities of Daily Living)
Measure person’s self-care ability
Activities of Daily Living (ADLs): bathing, dressing, toileting, eating, walking, instrumental activities of daily living (housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances)
Nutrition
Social relationships and resources
Self-concept and coping
Home environment
IMYJ 2016/Fall Health Assessment

43. Functional assessment questions should be included
Self-esteem, self-concept
Education
Financial status
Value-belief system (religious practice, personal strengths)
Activity/exercise
“Tell me how you spend a typical day”
Note ability to perform AD Ls: Independent or needs assistance
Sleep/Rest
Nutrition/Elimination
Recall the past 24 hours
Usual pattern of elimination or urinating
IMYJ 2016/Fall Health Assessment

44. Interpersonal relationships/resources Spiritual resources
Social roles, support system
Spiritual resources
FICA question: Faith, Influence, Community, Address
Coping & Stress management
Personal habits: tobacco, alcohol, street drugs
To screen excessive or uncontrolled Alcohol drinking: Use CAGE test: Cut down, Annoyed, Guilty, Eye opener
IMYJ 2016/Fall Health Assessment

45. Intimate Partner Violence
Environment/Hazards
Housing, neighborhood, safety of area, access to transportation hazards in workplace, at home, use of seatbelts, geographic exposure, etc
Intimate Partner Violence
“Do you feel safe?”  “Have you ever been emotionally or physically abused by your partner or someone important to you?
Occupational Health
IMYJ 2016/Fall Health Assessment

46. Developing competence: Age-appropriate “ ? ” required
Children: plus “developmental history”, “nutritional history (age-appropriate)”
Adolescent: the HEEADSSS method of interviewing
Home environment
Education and employment
Eating
Peer-related Activities
Drugs
Sexuality
Suicide/depression
Safety from injury and violence
Older adults: focus “ADL” affected by aging process or the effect of chronic illness or disability.
Always ask about depression. If yes, ask about suicidal ideation. “has she/he considered harming him or herself”
What’s missing:
H: Home life, composition, safety
E: Education/attendance/ language barrier/ comprehension
A: Activities/exercise/sports/job Abuse: (usually put in ROS on Psych )
D: Drugs/Etoh/smoke/tobacca/CAGE and Diet and Caffeine
S: Suicide/depression, Safety, Sex
(usually put Suicide/depression in ROS under Psych)
(usually put Sex in ROS under GYN/GU)
IMYJ 2016/Fall Health Assessment

47. 9. Perception of Health How do you define health?
How do you view your situation now?
What do you think will happen in the future?
What are your health goals?
What do you expect from us (nurse, physician, other health care providers)?
IMYJ 2016/Fall Health Assessment

48. Summary Make sure you got a thorough history!
Include the significant components
Did you ask enough questions to get a good HPI?
Did you ask enough questions in the appropriate ROS?
Always review PMH, Meds, ALL
Are there any hereditary possibilities? Stay focused and don’t forget a pertinent Family History
Make sure you documented thoroughly!!
IMYJ 2016/Fall Health Assessment

49. QUESTIONS?
IMYJ 2016/Fall Health Assessment