Health History

Health and Physical Assessment in Nursing, 1eBy Donita D’Amico and Colleen Barbarito

© 2007 Pearson Education, Inc.Pearson Prentice Hall

Upper Saddle River, NJ 07458

Health & Physical Assessment in Nursing

First Edition

Chapter 10

The Health History

Donita D’Amicoand

Colleen Barbarito




LEARNING OBJECTIVE ONE





Nursing Health History - Definition





Purpose of the Nursing Health History





Difference Between the Nursing Health History and the Physician Medical History





Components of the Health History• Wellness assessment

– Nutrition

– Stress management

– Social interaction




LEARNING OBJECTIVE TWO





Communication - Exchange of Information Between Individuals




Figure 10.1 The communication process.





Interactional Skills




Box 10.1 Guidelines for Interviewing Clients Who Do Not Speak English





Interactional Skills• Listening




Figure 10.2 The nurse conveys attentive listening through a posture of involvement.





Interactional Skills• Attending• Paraphrasing• Leading• Questioning• Reflecting• Summarizing





Listening - Paying Undivided Attention to What the Client Says and Does





Attending - Giving Full Attention to Verbal and Nonverbal Messages





Paraphrasing - Restating the Client’s Basic Message





Leading - Used to Encourage Open Communication• Techniques

– Direct leading

– Focusing

– Questioning





Questioning - Direct Way of Speaking with Clients to Obtain Subjective Data for Decision Making and Planning Care• Closed and open-ended questions





Reflecting - Repeating the Client’s Verbal or Nonverbal Message for the Client’s Benefit to Show that the Nurse Has Empathy with the Client’s Thoughts, Feelings, or Experiences





Summarizing - The Process of Gathering the Ideas, Feelings, and Themes That Clients Have Discussed Throughout the Interview and Restating Them in Several General Statements




LEARNING OBJECTIVE THREE





Barriers to Effective Client Interactions• False reassurance• Interrupting or changing the subject• Passing judgment• Cross-examination• Using technical terms• Encountering sensitive issues





False Reassurance - Occurs When the Nurse Assures the Client of a Positive Outcome with No Basis for Believing in It





Interrupting or Subject Changing - Shows Insensitivity to the Client’s Thoughts and Feelings, and May Occur When the Nurse Is Not Comfortable with the Conversation





Passing Judgment - Conveys Messages to Clients That They Are Not Meeting the Nurse’s Values





Cross - Examination - Asking Questions During the Interview May Cause the Client to Feel Threatened and Reveal Less Information





Technical Terminology - Should Be Avoided, as Well as Jargon, Slang, or Clichés, to Facilitate Client Understanding





Encountering Sensitive Issues - May Make the Client Feel Uncomfortable or Defensive




LEARNING OBJECTIVE FOUR





Diversity and Impact on the Nurse - Client Interactions




Figure 10.3 Differences in cultural or regional background may become barriers to effective nurse-client communication.





Diversity and Impact on the Nurse - Client Interactions• Factors

– Culture– Body language– Ethnicity– Religion





Diversity and Impact on the Nurse - Client Interactions• Factors

– Nationality– Education– Health status– Level of intelligence





Cultural Stereotypes





Body Language





Ethnicity





Language




Box 10.1 Guidelines for Interviewing Clients Who Do Not Speak English




Figure 10.4 A translator may help facilitate interaction with a client who does not speak English.




LEARNING OBJECTIVE FIVE





Establishing the Nurse - Client Relationship





Characteristics• Positive regard• Empathy• Genuineness• Concreteness





Positive Regard - Respect for Another’s Worth and Dignity





Empathy - Capacity to Respond to Another’s Feelings and Experiences as If They Were One’s Own





Genuineness - Ability to Present Oneself Honestly and Spontaneously





Concreteness - Speaking in Specific Terms




LEARNING OBJECTIVE SIX





Health History Interview Phases• Preinteraction phase• Initial interview• Focused interview





Preinteraction Phase - Occurs Before You Meet the Client, When Data Is Collected from Previous Records





Initial Interview - Planned Meeting in Which the Nurse Gathers Information from the Client





Focused Interview - To Clarify Previously Obtained Assessment Data and Gather Missing Information




LEARNING OBJECTIVE SEVEN





Health History Interview - A Planned, Formal Interaction Between the Nurse and the Client





Components of the Health History




Table 10.2 Health History Format





Components of the Health History• Biographical data• Present health–illness• Past history• Family history• Psychosocial history• Review of body systems





Biographical Data• Demographic data about the client

– Name

– Address

– Age

– Date of birth






– Birthplace– Gender– Marital status– Race






– Religion




Box 10.2 Cultural Assessment




Box 10.2 (continued) Cultural Assessment






– Occupation– Insurance coverage





The Present Health or Illness History• Past and current health problems and

concerns– Reason for seeking care

– Health beliefs and practices

– Health patterns

– Medications





Past History• Childhood diseases• Immunizations• Allergies• Blood transfusions• Major illnesses• Injuries





Past History• Hospitalizations• Childbirths• Surgeries• Psychiatric problems• Use of alcohol, tobacco, and other

substances





Family History - Determines whether Genetic or Familial Patterns of Health Impact the Client’s Current or Future Health Status• Genogram





Psychosocial History• Occupation• Education• Finances• Roles and relationships• Ethnicity and culture• Family• Spirituality• Self-concept





Review of Body Systems - Provides Subjective Information About Each Body System and Its Organs




Box 10.3 Review of Body Systems





Sources of Information for the Health History• Primary source

– Client

• Secondary sources– Other individuals

– Client records and charts




LEARNING OBJECTIVE EIGHT




LEARNING OBJECTIVE EIGHT

Health History and Interview




LEARNING OBJECTIVE NINE




LEARNING OBJECTIVE NINE

Genogram - Pictorial Representation of Family Relationships and Medical History




Figure 10.5 Genogram. A. Standard symbols used in constructing the family genogram. B. Combining symbols to provide additional information. C. A family genogram.

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Health History