NUR 103: Health Assessment Health History Factors influencing the interview • Approach • Environment • Confidentiality • Note Taking • Time, Length, Duration, Biases and Preconceptions Interview Contract • • • • • • • • Time and Place Introductions Purpose Length Expectations Presence of others Confidentiality Costs Interview Approach • Privacy • Interruptions • Physical Environment • Dress • Note taking • Biases and misconceptions Stages of the Interview Process • Introduction • Working ( subjective and objective information) • Closing or Termination Therapeutic Interviewing Techniques • • • • • • • • • Open ended questions Closed ended questions Facilitating Using silence Reflection Empathy Clarification Interpretation Summary Non-Therapeutic Interviewing Techniques • Biased Questions • False Reassurance • Giving Advice • Why Questions Elements of a Comprehensive Health History • • • • • • • • Biographic Data Chief complaint History of present illness (symptom analysis) Past medical history (family history) Review of systems Functional assessment Alternative therapies Cultural influences Elements of a Comprehensive Health History • Biographical data Name address age birthday, year of birth sex marital status race ethnic origin occupation phone number Elements of a Comprehensive Health History • Chief Complaint This is a brief spontaneous statement in the person’s own words that describes the reason the client is seeking medical care. What ever the client states is the reason for seeking care is recorded, and enclosed in quotation marks to indicate the client’s exact words. Elements of a Comprehensive Health History • History of Present Illness ( symptom analysis) 1. For a well client, this is a short statement of general health 2. For the client who is experiencing alterations in health status, this is a chronological record of the reason for seeking care and should include a symptom analysis Elements of a Comprehensive Health History • Past Medical History should include: Childhood illnesses Accidents or injuries Serious or chronic illnesses Hospitalizations Operations Obstetric history Immunizations Last examination date Allergies Current Medications Family History Elements of a Comprehensive Health History • Components of a Review of the Systems General overall state of health Skin Ears Hair Head Eyes Nose and sinuses Mouth and throat Neck Breast and axilla Elements of a Comprehensive Health History • Components of a Review of the Systems Respiratory Cardiovascular Peripheral vascular Gastrointestinal Urinary Male/female genital Sexual health Musculoskeletal Neurologic Hematologic Endocrine Health Promotion Elements of a Comprehensive Health History • Components of a Functional Assessment Self esteem/Self concept Activity/Exercise Sleep/rest Nutrition/elimination Interpersonal relationships Coping and stress management Personal habits Environmental Hazards Occupational health Alternative therapies Cultural influences Elements of a Comprehensive Health History • Documentation Guidelines – Normal health findings – Alterations in health findings