NUR 103 Health Assessment Health History Factors influencing

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NUR 103: Health Assessment Health History

NUR 103: Health Assessment Health History

Factors influencing the interview • Approach • Environment • Confidentiality • Note Taking •

Factors influencing the interview • Approach • Environment • Confidentiality • Note Taking • Time, Length, Duration, Biases and Preconceptions

Interview Contract • Time and Place • Introductions • Purpose • Length • Expectations

Interview Contract • Time and Place • Introductions • Purpose • Length • Expectations • Presence of others • Confidentiality • Costs

Interview Approach • Privacy • Interruptions • Physical Environment • Dress • Note taking

Interview Approach • Privacy • Interruptions • Physical Environment • Dress • Note taking • Biases and misconceptions

Stages of the Interview Process • Introduction • Working ( subjective and objective information)

Stages of the Interview Process • Introduction • Working ( subjective and objective information) • Closing or Termination

Therapeutic Interviewing Techniques • Open ended questions • Closed ended questions • Facilitating •

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

Non-Therapeutic Interviewing Techniques • Biased Questions • False Reassurance • Giving Advice • Why Questions

Elements of a Comprehensive Health History • Biographic Data • Chief complaint • History

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

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

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)

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

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

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

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

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 –

Elements of a Comprehensive Health History • Documentation Guidelines – Normal health findings – Alterations in health findings

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