Interviewing and Health history

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Learning objectives

By the end of this lesson, students will be able to:

¾Explain the purpose of patient history

¾ Explain basic history taking sequences

¾ Explain the characteristics of effective interview

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Learning objectives Con’t

¾Explain contents of patient history

¾Conduct effective history taking

¾ Identify ethical considerations during history

taking

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 Patient interview

¾ The health history forms the foundation for care as 
patterns emerge and problems are identified.

¾ Is clinician –patient therapeutic conversation.

¾ Unlike social conversation, in which you express your

own needs and interests with responsibility only for
yourself, the primary goal of the clinician–patient
interview is to improve the well-being of the patient.
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 Cont…..
¾ During history taking and interviewing, the nurse
establishes trust with patients

Interviewing and Therapeutic Communication

¾ All nursing practice revolves around the nurse–

patient relationship.

¾ In some situations, patients disclose information to

nurses not even shared with family members.

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 Conti…
¾Effective interviewing skills evolve through
practice and repetition.
¾They encourage patients to further expand
initial brief answers and also help redirect
patients who wander from topic.

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 Purpose of history taking
¾To establish a trusting relationship b/n the nurse
and the client.

¾Develop understanding about the patient condition.

¾Helps the patient feel understood.

¾Guides on which body parts or systems to focus

during physical examination.

¾ To induce immediate psycho-logic therapy.

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 Sequence of an interview

¾Preparatory

¾Greeting the patient and establishing rapport

¾Inviting the patient’s story

¾Establishing the agenda for the interview

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 1.  Preparatory phase
I. Taking time for self-reflection

¾Self-reflection is a continual part of professional

development in clinical work.

¾It enables clinicians to look inward to clarify how

their own reactions may affect patients.

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 Preparatory Con’t
‰ Think about establishing relationships with
individuals from a broad spectrum of ages,
social classes, ethnicities, and states of health
in respectful manner.
‰ Be sensitive to Posture, gestures, eye contact,
and tone of voice that can all express
interest, attention, acceptance, and
understanding. 10
II. Reviewing the chart
‰Before seeing the patient, review his or her medical
record, or chart to gather information and to develop
ideas about what to explore with the patient.

III. Setting goals for the interview

‰Before you begin talking with a patient, it is

important to clarify your goals for the interview

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 Setting goals for the interview con’t
¾As a student, your goal may be to obtain a
complete health history so that you can submit a
write-up to your teacher.
¾As a clinician, your goals can range from
completing forms needed by the health care
facility to managing patients.
IV. Improving the environment
¾Try to make the setting as private and comfortable
as possible. 12
 2. Greeting the patient and establishing rapport

¾The initial moments of your encounter with the

patient lay the foundation for your ongoing
relationship.
¾As you begin, greet the patient by name and
introduce yourself, giving your own name.
¾If this is the first contact, explain your role,
including your status as a student and how you will
be involved in the patient’s care.
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 3. Inviting the patient’s story
¾ Pursue the patient’s reason for seeking health care.
¾Begin with open-ended questions that allow full
freedom of response. like “What concerns bring you
here today?” or “How can I help you?”
¾Listen to the patient’s answers without interrupting.
¾After you have given the patient the opportunity to
respond fully, inquire again or even several times,
“Anything else?” 14
4. Establishing agenda for the interview

‰Clinician needs to focus the interview by asking the

patient which problem is most pressing as time

management is an issue.

¾Eg.Can you tell me which one you are most

concerned about?

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5.  Clarifying the health history(patient perspective)

¾Here clinician guides the patient to elaborate areas

of the health history.

¾For the clinician, each symptom has attributes that

must be clarified .So it is critical to fully
understand essential characteristics of each
symptom.

¾Always carry out the following seven elements.

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 The seven attributes of a symptom
¾Location; Where is it? Does it radiate?

¾Quality; What is it like?

¾Quantity or severity; How bad is it? (For pain,

ask for a rating on a scale of 1 to 10.)

¾Timing; When did (does) it start? How long did

(does) it last? How often did (does) it come?

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 Seven attributes of a symptom Con’t
¾Setting in which it occurs; Include environmental
factors, personal activities, emotional reactions, or
other circumstances that may have contributed to the
illness.
¾Remitting or exacerbating factors; Does anything
make it better or worse?
¾Associated manifestations; Have you noticed
anything else that accompanies it?
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 6. Generating diagnostic hypotheses
(the clinician’s perspective)

¾As listening to the patient’s concerns, she/he will

begin to generate and test diagnostic hypotheses
about what disease process might be the cause.

7. Negotiating a plan

¾ Planning for further evaluation (physical

examination, laboratory tests, consultations, etc.)
and negotiating a treatment plan. 19
 8. Planning for follow-up and closing
¾ Give notice that the end of the interview is
approaching and allows time for the patient to ask any
final questions.

¾ Make sure the patient understands the agreed-upon

plans you have developed

¾ For example, before gathering your papers or standing

to leave the room, you can say “We need to stop now.
Do you have any questions about what we’ve covered?
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Characteristics of skilled
interviewing

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 Interview techniques

¾Adaptive questioning ¾Empathic

¾Nonverbal responses
communication ¾Reassurance
¾Facilitation ¾Summarization
¾Echoing

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1. Adaptive Questioning

¾These are several ways you can ask questions that

add detail to the patient’s story.

I. Directed questioning
‰Is useful for drawing the patient’s attention to specific areas
of the history.

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 Adaptive Questioning Con’t

‰Should proceed from general to specific.

‰A possible sequence, for example, might be

¾“Tell me about your chest pain?” (Pause)

¾ “What else?” (Pause)

¾“Where did you feel it?” (Pause) “Show me.

¾Anywhere else?” (Pause)

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 Adaptive Questioning Con’t

II. Questioning to elicit a graded response

¾Ask questions that require a graded response rather

than a single answer.

¾ “What physical activity do you do that makes you

short of breath?”

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 Adaptive Questioning Con’t
III. Offering multiple choices for answers

¾Sometimes patients seem quite unable to describe

their symptoms without help.

¾So to minimize bias, offer multiple-choice answers.

Example

¾“Is your pain aching, sharp, pressing, burning,

shooting, or what?”
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 Adaptive Questioning Con’t
IV. Clarifying what the patient means

¾At times patients use words that are ambiguous or

have unclear associations.

¾To understand their meaning, you need to request

clarification, like “Tell me exactly what you meant
by ‘the flu’”

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 2. Nonverbal Communication
¾Becoming more sensitive to nonverbal messages
allows you to both “read the patient” more
effectively and to send messages of your own.

¾Pay close attention to eye contact, facial

expression, posture, head position and movement
such as shaking or nodding, interpersonal distance,
and placement of the arms or legs, such as crossed
or neutral. 28
3. Facilitation
¾ Nodding of the head ,remaining silent, leaning
forward, making eye contact, and using continuers like
“Mm-hmm,” “Go on,” or “I’m listening” all maintain
the flow of the patient’s story.
4. Echoing
¾ Simple repetition of the patient’s words encourages the
patient to express factual details.
¾ Reveal not only the location and severity of the pain
but also its meaning to the patient and the clinician.
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 Echoing   Con’t
¾Patient: The pain began to spread. (Pause)
¾Response: Spread? (Pause)
¾Patient: Yes, it went to my shoulder and I am
going to die (Pause)
¾Response: Going to die?
¾Patient: Yes, it was just like the pain my father
had when he had his heart attack, and I was afraid
the same thing was happening to me. 30
 5. Empathic Responses
¾Conveying empathy is part of establishing and
strengthening rapport with patients.

¾Once you have identified the feelings, respond with

understanding and acceptance.
¾Responses may be as simple as “I understand,”
“That sounds upsetting,”
¾Empathy may also be nonverbal—for example,
9Offering a tissue to a crying patient or gently
placing your hand on the patient’s arm to show
understanding. 31
 6. Reassurance
¾When you are talking with patients who are anxious
it is important to reassure them.
¾You may find yourself saying
9“Don’t worry, everything is going to be all
right.” While this may be appropriate in
nonprofessional relationships, in your role as a
clinician such comments are usually
counterproductive.
¾The first step to effective reassurance is identifying
and accepting the patient’s feelings without offering
reassurance at that moment. 32
 Reassurance Con’t
¾The actual reassurance comes later after you have
completed the interview, the physical examination,
and perhaps some laboratory studies.

¾At that point, you can interpret for the patient what
you think is happening and deal openly with the
real concerns.

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 7. Summarization
¾Giving a capsule summary of the patient’s story in
the course of the interview can have several
functions.

9It indicates to the patient that you have been

listening carefully.

9lets the patient add other information.

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 Approaches
of
Health Assessment

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 APPROACHES

‰The systems approach

(medical model)

‰The functional health pattern

(Gordon’s approach)

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 1. Medical/System approach
¾ Clinical tool that is used to collect and organize
clinical data based on body systems.
Components
I. Socio-demographic data
¾ Gives some tentative suggestions as to what kind
of person you are talking to and what the likely
problems might be.
Includes:
¾The date and time
¾Patient Identification : full name, Age, Sex,
Address ,marital status ,ethnic origin, Religion,
Occupation, Level of education of the patient. 37
II. source of referral
¾ This is important especially when patients do not
initiate their own visits.
III. Source of history
¾ It helps to assess the value of the information. The
source can be the patient, family etc.
IV. Chief complaints(c/c)
¾ Major symptoms for which the patient is Seeking care.
¾ Should be written using the words of the patient.
¾ The duration of the complaint should be specified. 38
 V. History of present illness (HPI):
‰Is a complete, clear, and chronologic account of the
problems prompting the patient to seek care.
Includes:
¾ Pertinent positives” and “pertinent negatives”
¾Medications should be noted, including name, dose,
route, and frequency of use.

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 HPI Con’t
¾Allergies: including specific reactions to each
medication, such as rash or nausea, must be
recorded, as well as allergies to foods, insects, or
environmental factors.
¾The mode of arrival: The last paragraph of the
history of the present illness should state how the
patient came to the health institution i.e., on a
stretcher.

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The principal symptoms should be well‐
characterized, with descriptions of :‐
¾ Location ¾Setting in which they

¾Quality occur

¾ Quantity or severity ¾Aggravating and

¾ Timing, including relieving factors

onset, duration, and ¾ Associated

frequency, manifestations

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 VI. History of past illness (HPI)
¾ May have residual effect on current health status.
¾ Includes important illnesses from infancy onwards
Childhood illnesses , such as measles, rubella,
mumps, whooping cough, polio etc.
¾ Adult hood Illnesses
¾Medical-chronic disease, hospitalizations
¾Surgical-operations, accidents
¾Obstetric/gynecologic
¾ Psychiatric 42
 VII. Functional inquiry (systemic review)
¾This is a detailed account of symptoms obtained by
questioning to obtain important data that may be
overlooked in the previous section .
Purposes:
¾It gives a clear understanding of the present illness
¾ It is a double check on the history of present illness
¾ It guides the examiner to concentrate on specific
systems during the physical examination
¾Note; One should know that there is no need to
repeat complaints already recorded in the history of
present illness. 43
 Areas to be covered

¾General: Usual weight, recent weight change,

any clothes that fit more tightly or loosely than
before, Weakness, fatigue, fever, night sweats
¾H.E.E.N.T. (Head, Eye, Ear, Nose, Mouth and
Throat)
¾All body system:
LGS,RS,CVS,GIS,GUS,MCS,IGS,NS.

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 VIII .Personal and social history
Includes:
¾ Occupation; home situation; sources of stress, both
recent and long-term; important life experiences,
such as military service, job history, financial
situation, and retirement; leisure activities; religious
affiliation and spiritual beliefs, activities of daily
living (ADLs),

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¾ Lifestyle habits that promote health or create risk such as
exercise and diet, including frequency of exercise, usual
daily food intake, dietary supplements or restrictions, and
use of coffee, tea, and other caffeine-containing.
IX. Family history
¾ Is very important because it provides information about the
health status of immediate relatives.
¾ Ask about the cause of death of blood relatives.
¾ Diseases related to primary relatives are primarily
considered .
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 FUNCTIONAL
/GORDON’S/ APPROACH

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 Functional approach

¾This data collection tool organizes health data in 11

categories of information which describes specific
health problem of a patient at specific function.

¾ Assesses human health against the function to

identify functional patterns (client strengths) and
dysfunctional patterns/ nursing diagnosis.

¾Carried out by professional nurses.

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 Components of comprehensive clinical
history
¾Demographic data

¾Source of referral

¾Medical diagnosis

¾Condition on admission/general appearance.

¾Vital sign

¾Assessment of the eleven functional health patterns

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 The eleven functional health pattern
1. Health perception and health management pattern
‰ Assess how patient perceives health and its
management
‰ask questions such as: how do you describe health?
‰Where do you go when you are sick?
‰To health institutions
‰To traditional healer
‰To spiritual healer
‰Other (specify) ________________
‰Do you smoke cigarettes? Yes_______no_________
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 2. Nutrition and metabolism
¾Assess nutritional and metabolism status.

Ask the following questions

¾weight

¾Daily food intake(how many times)

¾Describe any factors influencing dietary selection

like culture, religion

¾Nutritional knowledge: Name basic food groups.

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 3. Elimination
‰Assesses both bowel and bladder elimination status.
‰Ask the following questions:
¾Any factors that influence bowel illumination?
¾Is there symptom of altered bowel illumination(diarrhea,
constipation)
‰Have you experienced any of the following
¾Rectal pain
¾Abdominal cramping
‰Do you have any problem with voiding urine? :
frequency, urgency, burning, dribbling
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 4. Activity and exercise
‰Assesses range of physical activity
‰Ask the following questions:
¾ Is there any difficulty in activity of daily
living(ADL)?
¾Which of the following, if any, is/are associated
with activity and exercise?
9Chest pain
9Dyspnea etc. 53
 5. Cognition and perception
‰Assesses conditions related to the senses and NS

‰Ask questions related to:

¾Eye

¾Ear

¾Neurological alterations etc.

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 6. Sleep and rest
‰Assesses sleep and rest condition.
‰Ask the following questions
¾Describe if there is any change in sleep
pattern
¾Describe any medication, position or
materials used to help sleep
¾Do any of the following interfere with your
sleep? Pain/illness, anxiety ,drugs, sudden
wakening.

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 7.Self concept and self perception

‰Assesses the attitude of the patient towards self.

‰Ask the following questions:

¾How do you describe your self?

¾How do your family and other describe you?

¾What is your greater physical and health concern

¾Do you feel any distress, anxiety, and fear when

you think about yourself?
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 8. Roles and relations

‰Assesses the role quality of the pt with in the society.

‰Ask the following questions:

¾What are your roles in the family ?

husband/wife/son/daughter

¾In work place: boss/subordinate

¾Is there any alteration in roles due to illness?

¾Any problem in relation with family/friends/.

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 9. Sexuality and reproduction
‰ Assesses physiological and psycho social expression of sex
and reproduction.
‰ Ask the following questions:
‰ For female:
¾Age at first menstruation /age of menopause
¾Describe period in terms of menstrual cycle /duration of
flow
¾Any problem with menses or sexual intercourse
‰ For male: describe if any Hx of STI, Prostatitis, reproductive
organ surgery etc. 58
 10.Coping and stress
‰Assesses person’s capacity of stress management.
‰Ask the following questions:
¾Describe if there is any stressful situation to
illness/hospitalization.
¾Describe how the client used to manage stress
11. Values and belief
‰Assesses the spiritual dimension of life
‰Ask questions such as:
9Does the illness interfere with your religious
practice? , cultural belief/ practice? 59
 Ethical considerations:
‰A set of principles that have been created through
reflection and discussion to guide our behavior.

‰Professional ethics are principles which guide our

professional behavior

‰Fundamental ethical principles are are as follows:

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 I. Nonmaleficence
‰Commonly stated as “First, do no harm.:
‰ In the context of an interview, giving information that
is incorrect can do harm.
‰Avoiding relevant topics or creating barriers to open
communication can also do harm.
II. Beneficence
‰ Is the act of doing good” for the patient.
‰As clinicians, our actions need to be motivated by what
is in the patient’s best interest. 61
 III. Autonomy
¾ Reminds us that patients have the right to determine what
is in their own best interest.
¾ Is consistent with collaborative rather than paternalistic
patient relationships.
IV. Confidentiality
¾ Can be one of the most challenging principles.
¾ Is an obligation not to tell others what we learn from our
patients.
¾ This privacy is fundamental to our professional
relationships with patients.
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THANK YOU

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