Obtaining A Health History

Front 1

Phases of an Interview

Back 1

Introduction

Discussion

Summary

Front 2

Introduction Phase

Back 2

Nurse:

Introduces self to patient

Describes purpose of interview

Describes the interview process

Front 3

Discussion Phase

Back 3

Nurse:

Facilitates and maintains a patient-centered discussion

Uses various communication techniques to collect data

Front 4

Summary phase

Back 4

Nurse:

Summarizes data with the patient

Allows the patient to clarify data

Communicates an understanding of the problems to the patient

Front 5

What is the purpose of the health history?

Back 5

To obtain subjective data from the patient so the nurse and print can create a plan to promote health, prevent disease, resolve acute health problems, and minimize limitations related to chronic health problems

Front 6

How should one alter a necessary interview if the patient is in physical or emotional distress?

Back 6

Use a focused assessment to limit the number and nature of questions to those which are absolutely necessary for the given situation. Save any additional questions for later.

Front 7

Permission giving technique

Back 7

The nurse communicates to the patient that it is safe to discuss sensitive topics.

E.g. "Many young people your age have questions about sex. What questions or concerns do you have?"

Front 8

If the patient asks broad questions or questions that the nurse is unprepared to answer, what should she do?

Back 8

Ask the patient for more information about the situation to gain direction in how to answer or to what resources to refer.

Front 9

How should a nurse begin the interview?

Back 9

Open ended questions

Front 10

If the patient is rambling, how should the nurse handle the situation?

Back 10

By refocusing the interview

Front 11

How should a nurse gain more precise details?

Back 11

By asking closed ended questions

Front 12

Facilitation

Back 12

Using phrases such as "uh-huh", "then?", and "go on" along with head nodding, shifting forward, etc. to encourage patients to continue talking.

Front 13

Restatement

Back 13

Repeating what the patient has said to confirm the interpretation.

"Let me make sure I understand what you said. The pain occurs before you eat and is relieved by eating. Is that correct?"

Front 14

Reflection

Back 14

Gain clarification by restating a phrase used by the patient in the form of a question.

E.g.

Patient: "I got out of bed and didn't feel right"

Nurse: "you didn't feel right?"

Front 15

Comprehensive health history

Back 15

May be performed during a hospital admission or any initial assessment. A full, extensive history is taken

Front 16

Problem-focused health assessment

Back 16

Limited in scope to a specific problem while being detailed enough so that the nurse is aware of other health related data that may affect the current problem

Front 17

Episodic/Follow up assessment

Back 17

Focuses on a specific problem for which a patient has already been receiving treatment

Front 18

Components of health history

Back 18

Biographic data

Reason for seeking care

History of present illness

Present health status

Past health history

Family history

Personal and psychosocial history

Review of systems

Hint 18

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