Health History NUR 221; Fundamental (2) COURSE Dr/ Magda Bayoumi
Introduction to the HealthAssessment How do you assess the patient?
Characteristics of the NursingProcess Dynamic and cyclic■ Patient centered■ Goal directed■ Flexible■ Problem oriented■ Cognitive■ Action oriented■ Interpersonal■ Holistic■ Systematic
Communication is a process of sharing information and meaning, of sending and receiving messages.
Collecting Data Subjective findings Objective data
Levels of Preventive Healthcare Primary preventive care focuses on health promotion and guards against health problems. Secondary preventive care focuses on early detection, prompt intervention, and health maintenance for patients with health problems. Tertiary preventive care deals with rehabilitative or extended care.
Types of Assessment A comprehensive assessment examines the patient’s overall health status. A focused assessment is frequently performed on an ongoing basis to monitor and evaluate the patient’s progress, interventions, and response to treatments.
How You Communicate: Genuineness: Be open, honest, and sincere with your patient. Respect: Everyone should be respected as a person of worth and value. Empathy: Empathy is knowing what your patient means and understanding how she or he feels. Showing empathy
InterviewsWhen you use your interpersonal skills in a healing way to help your patient, this is known asTherapeutic use of self.
Types of Interviews Directive interviews :Are controlled by the nurse. Nondirective interviews :Are controlled by the patient & Nondirective interviews help you to identify what is important to the patient.
Types of Questions Closed questionsAre often those that elicit a “yes” or “no” . Open questionsElicit the patient’s perceptions.
Interviewing TechniquesIntroduce yourself.■ Don’t rush. Allow enough time for the interview.■ Avoid interruptions.■ Explain that information from the interview is confidential.■ Actively listen to what your patient is saying.■ Maintain eye contact.
Work at the same level as your patient. Pull up a chair and sit next to her or him.■ Don’t invade your patient’s personal space. Two to 4 feet away is a comfortable distance for most patients.■ Explain what you are doing and why.If the patient presents with a problem, begin by asking questions about that.■ Begin with nonsensitive issues. Leave more sensitive topics until
Consider your patient’s cultural background. How does it affect the interview and your interpretation of the data?■ Consider your patient’s developmental level. How does it affect the interview and your interpretation of the data?■ Don’t become preoccupied with writing. You may convey to the patient that the forms you are completing are more important than he or she is.■ Be nonjudgmental.■ Avoid “why?” questions; they tend to put patients on the defensive.
Nonverbal behavior is more accurate than verbal. Take a look at yours—What is it telling your patient?■ Take a good look at your patient’s nonverbal behavior. Is it consistent with what she or he is telling you?■ Now look at your patient’s nonverbal behavior another way. Does it indicate health problems?■ Never pass up an opportunity to teach.■ Present reality.■ Be honest.■ Provide reassurance and encouragement.
Phases of the Interview IntroductoryPhase Working Phase Termination Phase
Documentation Methods problem-oriented medical records (POMR. SOAPIE Method DAR Method PIE Method Narrative Method
The purpose of the healthhistory is to:■ Provide the subjective database.■ Identify patient strengths.■ Identify patient health problems, both actual and potential. Identify supports.■ Identify teaching needs.■ Identify discharge needs.■ Identify referral needs.
Types of Health Histories A CompleteHealth History Focused Health History
Critical Thinking activity Suppose you were caring for Mr. H. What questions would you ask him to assess his chest pain?
Critical Thinking activity What question(s) would you ask Mr. H; related to his past health history, family history, review of systems, and psychosocial profile?
Amount of Time Allow at least 30 minutes to an hour to obtain a complete health history
Medical History versusNursing History Physicians diagnose and treat illness. Nurses diagnose and treat the patient’s response to a health problem.
Key Points to Remember When Obtaining a Health History■ Listen to what your patient is telling you both verbally and nonverbally.■ Don’t rush. Allow enough time to obtain the data.■ Ensure confidentiality.■ Provide a private, quiet, comfortable environment.■ Avoid interruptions.■ Tell your patient how long the interview will take and why you need to ask these questions.
Do not be so concerned about completing forms that you neglect the patient.■ Start with what the patient perceives as the problem.■ Use open-ended questions to elicit the patient’s perspective.■ Attend to any acute problems, such as pain, before obtaining a detailed history.■ Remember that quality is more important than the quantity of information obtained.
Components of the HealthHistory Biographical Data. Reason for Seeking Healthcare. Current Health Status (PQRST). Past Health History Family History Review of Systems Developmental Considerations Psychosocial Profile
Documenting Your FindingsBe accurate and objective. Avoid stating opinions that might bias the reader.■ Do not write in complete sentences. Be brief and to the point.■ Use standard medical abbreviations.■ Don’t use the word “normal.” It leaves too much room for interpretation.■ Record pertinent negatives.■ Be sure to date and sign your documentation
Mrs Hesa at inpatient cardiac department, vital signs taken early morning at 6 am and reported client rates pain 7, substernal sharp chest pain like electrical thrill along to neck, shoulder to left arm increase with activity even moving, immediately the nurse give her nitroglycerin sublingual 3 tables through 15 min and then the pain relived and reported 2
P: Precipitating factor: pain increase with activity. P: Palliative factor: pain decreased with medication (nitroglycerin). Q: Quality: sharp chest pain. like electrical thrill R: Region & Radiation: chest; radiated to neck, shoulder to left arm. S: Severity: 7 and decrease to 2 after medication. T: Timing: 15 min