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Course: Health Assessment�Unit Title: The Patient Interview

Mary A-Boateng, MSN-Ed, BSN, RN, WOCN

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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Module Goals

Learner Outcome:

At the completion of these modules the learner will demonstrate knowledge and skills to perform a complete health assessment of an individual.

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Module Objectives

Identify key components of a successful patient interview.
Describe a structured process for interviewing patients.
Compare and contrast the different patient interview approaches in various clinical settings.
Discuss importance of using open & closed-ended questions
Describe use of and differentiate between facilitation, reflection, clarification, empathetic responses, confrontation, & interpretation when completing a health assessment
Identify strategies for promoting patient trust and openness when collecting data about sensitive or uncomfortable topics.

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Interviewing the Patient

Patient interview is the primary way of obtaining a comprehensive information about the patient in order to provider effective patient-centered care. A complete patient interview includes inquiring about the following:
Includes pertinent information about the patient and the patient’s family
Age, previous illness, and surgical history
Medications history and family medical history
Allergies

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Things for Nurses To Consider!

Privacy
Interruptions
Physical Environment
Dress
Note taking
Biases and misconceptions

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Privacy-Aim for geographical privacy (unoccupied room or a place where the client feels secure that no one can overhear the conversation.

Refuse interruptions inform staff of your interview and ask that they not disturb you during this time. This assists you with client rapport.

Physical environment room temperature at a comfortable level, sufficient lighting, reduce noise ( TV, radio’s etc), remove distracting objects from view, place the distance between you and the client at 4 to 5 feet which doesn’t invade his or her private space, arrange equal status seating –eye level (standing communicates haste and assumes superiority) and arrange a face to face position when interviewing a bedridden hospitalized patient.

Dress the client should remain in street clothes unless hospitalized and your dress should meet professional standards (uniform, or lab coat over street clothes name tag)

Note taking Some use of history forms and note taking may be unavoidable. Note taking disadvantages to be aware of: breaks eye contact, shifts your attention away from the client to often, interrupts the client’s narrative flow, impedes observations of the client’s non-verbal behavior, and may be threatening to the client)

Biases and misconceptions Recognize your own biases and provide a non judgmental environment for the interview. Clarify any information not clearly understood by both the client and yourself

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Things for Nurses To Consider!

Climate:

Temperature
Lighting
Formal/Informal

Barriers:

Is the patient/families opinions & feelings considered?
Is the information frightening?
Time allowance?
Is the information important to them?
Is the patient in pain?
Can the patient/family hear you?

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When Conducting the Interviewing

Conduct the interview in private
Introduction of yourself
Direct Eye contact
Explain the process of the interview to the patient
Provide confidentiality
Ensure the environment is clean and welcoming

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Things To Consider! HIPAA

Provide patient with written notice of their practices regarding use and disclosure of health information.
Facilities may not use or disclose protected information for any purpose that is not in the privacy notice.
Patient consent is required when information is disclosed.
Privacy notice must be posted.

HIPAA (Health Insurance Portability and Accountability Act of 1996) is United States legislation that provides data privacy and security provisions for safeguarding medical information.

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Things To Consider! Patients Rights

All data that you obtain are subject to legal and ethical considerations.
American Hospital Association’s Patient's Bill of Rights written in 1973 and revised in 1992.
Each state encourages healthcare workers to be aware of and follow this document.

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Humor & Right Sided Heart Failure

A way to introduce humor and fun is by using props.
And remember the old saying “a picture is worth a thousand words.”

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Using Therapeutic Interviewing Techniques

Open-Ended questions
Closed-Ended question
Using silence
Reflection
Empathy
Clarification
Interpretation

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Facilitation & Confrontation

Posture, actions, or words should encourage the patient to say more
Making eye contact or saying phrases such as “Go on” or “I’m
listening” may help the patient to continue

Confrontation

Some issues or responses may require you to confront patients about their feelings and may go beyond confrontation that will require you to make an inference

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Therapeutic Interviewing Techniques

Be effective listener
Be broad minded
Be aware of nonverbal cues
Be aware of body language

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Communication Skills

Open-Ended Questions
Active Listening
Building Rapport
Probing Question
Leading Questions

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Non-Therapeutic Interviewing Techniques

What Nurses Should NOT Do

Give Advice
Ask biased Questions
Express false Reassurance
Use “Why Questions”

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What Would The Nurse Do?

You are a new nurse on your first assignment in another country. The patient in the photo presents to you with a complaint of fever and diarrhea. You were raised in a conservative home, where women were not permitted to wear any jewelry. You immediately realize that you are uncomfortable at the sight of the patient’s nose ring and mark on her forehead.

How should you proceed with this patient?

Consider your answer before proceeding to the next slide

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What Would the Nurse Do?

Look at the Client while he/she is speaking
Maintain eye contact with the speaker
Be aware of nonverbal clues and body language
Use positive body cues at appropriate points such as nodding and smiling
Be effective listener
Keep and open, and relaxed posture
Take time to learn about the about other cultures and how to value their uniqueness

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Components of a Comprehensive Health History

Biographic Data
Chief Complaint
History of present and past medical
Family History
Review of Systems
Cultural Influences

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Comprehensive Health History

Biographical data
Name & Address & Phone
Age
Sex
Marital status
Race
Ethnic origin
Occupation

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History of the present illness

Location
Where is it
Does it radiate
Quality
What is it like
Quantity or severity
How bad is it
Quantify the pain

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Health History Form

Personal Data
Chief Complaint
History of Present Illness
Past Medical History
Family History
Social and Occupational History
Review of Systems

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Open-Ended Questions

Open-Ended Questions allow the client encourages the client to talk and explain in complete sentences allows the client to open up and tell his/her story. Examples of open-ended questions:
"Tell me more about your heart problems,“
“What happened next,“
“How did you feel when that happened to you,"
"What would you like to see as an outcome."

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Components of Review of the Systems-Continued

Sexual Health
Musculoskeletal
Neurologic
Hematologic
Endocrine
Health Promotion

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Components of Review of the Systems

Respiratory
Cardiovascular
Peripheral Vascular
Gastrointestinal
Urinary
Male/Female

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Basics of a Comprehensive Health History

Past Medical History should include:

Obstetric history
Immunizations
Last examination date
Allergies
Current Medications
Family History

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Basics of a Comprehensive Health History

Past Medical History should include:

Childhood illnesses
Accidents or injuries
Serious or chronic illnesses
Hospitalizations
Operations

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Patient with limitations

Do not overlook the ability of these patients to provide you with adequate information
Be alert for omissions
Severe mental retardation may require you to get information from family or friends
Patient with a hearing problem
patients with a language barrier

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The Six C’s of Charting

Client words must be recorded exactly.
Clarity is essential when describing the patient’s condition.
Completeness is required.
Conciseness can save time and space.
Chronological order and date all entries.
Confidentiality to protect the patient’s privacy.

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Glossary

Comprehensive health system: A health system that includes all the elements required to meet all the health needs of the population.
Culture: “The learned, shared and transmitted values, beliefs, norms and lifetime practices of a particular group that guides thinking, decisions and actions in patterned ways”
Active Listening:“Active listening is a communication technique that requires that the listener fully concentrate, understand, respond and then remember what is being said”
Reflection: Repeating the patient’s words encourages additional responses typically does not bias the story or interrupt the patient’s train of thought
Clarification: The act of making a statement less confused clarify ambiguous statements or words

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Graphic and/or Photo Citations

Zerwekh, J., Claborn, J.C. (1994). Memory notebook of nursing. Dallas, TX: Nursing Education Consultants, page 50

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References

Caple, C. (2011). Physical assessment: Performing- cultural considerations. Glendale, CA: Cinahl Information System

Jarvis, C. (2016). Physical examination & health assessment. (5th ed.). St. Louis, Mo.: Elsevier

Joint Commission on Accreditation of Healthcare Organizations. (2012). Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, Ill.

Shaw, M. (2012). Assessment made incredibly easy (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Venes, D. (ed.) (2013). Tabers® cyclopedic medical dictionary (22nd ed.). Philadelphia: F.A. Davis Co.

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