HEALTH ASSESSMENT (RLE)

NCM 101 | J. DUMAGPI, M. L NAPONE

INTERVIEW TECHNIQUES BIOGRAPHIC DATA

 ACTIVE LISTENING Usually include information that identifies the client

- paying attention to every detail. such as name, address, age, gender, civil status,
 ADAPTIVE QUESTIONING birthdate, birthplace, nationality, religion, educational
- general question first level, occupation, who provided the information – the
-how genuine client or significant others, date and time of interview.
 NON-VERBAL COMMUNICATIONS
- facial expressions
NPI- NURSE PATIENT RELATIONSHIP
CHIEF COMPLAINT: Reason for Hospitalization
- helping relationship Examples of chief complaints:
-aiming for goals  Chest pain for 3 days
 EMPATHY, VALIDATION AND REASSURANCE  Swollen ankles for 2 weeks
Empathy- putting ourselves in the patient’s position  Fever and headache for 24 hours
Validation- validating the emotions of the patients.
Reassurance- reassuring the confidentiality. HISTORY OF PRESENT ILLNESS
 PARTNERING AND SUMMARIZATION
 This takes into account several aspects of the
- give and take
 TRANSITIONS AND EMPOWERMENT
health problem and asks questions whose
-if the patient is answering the same questions again answers can provide a detailed description of
and again e.g. “lets proceed” the concern.

SKILLS FOR BUILDING RELATIONSHIP  First encourage the client to explain the health
1. Active listening problem or symptom in as much detail as
2. Empathy possible by focusing on the onset, progression,
3. Concern/Caring and duration of the problem; signs and
symptoms and related problems; and what the
COMMON INTERVIEW MISTAKES
1. Too many focused questions client perceives as causing the problem.
2. ignoring the patient's emotion
3. arriving at a diagnosis or shortening the differential  You may also ask the client to evaluate what
too early in the interview process makes the problem worse, what makes it better,
4. Refusing to return to the patient for further information which treatments have been tried, what effect
or clarification. the problem has had on daily life or lifestyle,
5. no introductions, no regard for patients comfort and what expectations are held about recovery, and
no relationship building.
what is the client’s ability to provide self-care.
6. no open-ended questions
7. interruptions to the interview process

STEPS IN CONDUCTING PATIENT INTERVIEW

1. Formal Introduction
-name, level, school or course, purpose-
“I am your student nurse for today, for the start, I will
have some questions please be informed that these
information will be dealt with confidentiality

2. Nurse elicits information using adaptive questions as

for the reason of seeking care

3. Nurse summarizes information obtained.

4. Nurse makes sure anything else worries clients.

-asking for further questions, final validations

5. Nurse politely terminates the conversation

HEALTH HISTORY

The health history is an excellent way to begin the

assessment process because it lays the groundwork for
identifying nursing problems and provides a focus for the
physical examination.
HEALTH ASSESSMENT (RLE)
NCM 101 | J. DUMAGPI, M. L NAPONE
that may skip a generation such as autosomal
recessive disorders. Include the client’s spouse
but indicate that there is no genetic link.
Identifying the spouse’s health problems could
explain disorders in the client’s children not
indicated in the client’s family history.

SOCIO-CULTURAL HISTORY / MEDICATIONS

 Questions about social activities help the nurse

to discover what outlets the client has for
support and relaxation and if the client is
involved in the community beyond family and
The mnemonic COLDSPA (Character, Onset,
work.
Location, Duration, Severity, Pattern, and Associated
factors/how it affects the client) is designed to help the
 Information in this area also helps to determine
nurse explore symptoms,signs, or health concerns.
the client’s current level of social development.

 The information gathered about medication and

PAST HEALTH HISTORY substance use provides the nurse with
information concerning lifestyle and a client’s
 This portion of the health history focuses on self-care ability. Medication and substance use
questions related to the client’s past, from the can affect the client’s health and cause loss of
earliest beginnings to the present. function or impaired senses. In addition, certain
 Information covered in this section includes medications and substances can increase the
questions about birth, growth, development, client’s risk for disease.
childhood diseases, immunizations, allergies,
previous health problems, hospitalizations,
surgeries, pregnancies, births, previous
accidents, injuries, pain experiences, and
emotional or psychiatric problems.

ENVIRONMENTAL HISTORY

 Ask questions regarding the client’s environment

to assess health hazards unique to the client’s
living situation and lifestyle. Look for physical,
chemical, or psychological situations that may
FAMILY HISTORY put the client at risk. These may be found in the
clients neighborhood, home, work, or
 The purpose of family health history is to learn recreational environment. They may be
about the general health of the client’s blood controllable or uncontrollable.
relatives, spouse, and children and to identify
any illness of environmental, genetic or familiar
nature that might have implications for the
client’s health problems.

 The family history should include as many

genetic relatives such as the client can recall.
Include maternal and paternal grandparents,
aunts and uncles on both sides, parents,
siblings, and the client’s children. Such
thoroughness usually identifies those diseases
HEALTH ASSESSMENT (RLE)
NCM 101 | J. DUMAGPI, M. L NAPONE

OBSTETRICAL HISTORY (For OB-Gyne Cases)

>Pre-partum
Age of Menarche _____
Menstrual Cycle (days) _____
Duration of menstruation _____
Interval of menstruation _____
Number of pads used during menstruation _____

>Intra-partum
Gravity/Parity _____
Type of delivery _____
AOG _____
Fundic Height _____
Contractions (Duration/Interval/Frequency _____
Fetal Heart Rate _____
Fetal Position _____
Fetal Presentation _____

>Post-partum
Gravity/Parity _____
Type of Delivery _____
Lochia_____
Type of Episiotomy_____