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NVCC EMS 207 - K Deal & E Stern
Health & Physical Assessment in Nursing
First Edition
Chapter 10
Health History
Donita D’Amicoand
Colleen Barbarito
NVCC EMS 207 - K Deal & E Stern
Health History - Definition
A comprehensive accounting of the patients past and current health
• Two key focuses• General Medical
• Whole lifestyle• Affect of “activities of daily living”
(ADL)
NVCC EMS 207 - K Deal & E Stern
Effective Communications
NVCC EMS 207 - K Deal & E Stern
Effective Communications
Communication - Exchange of Information Between Individuals
NVCC EMS 207 - K Deal & E Stern
Effective Communications
In a communications cycle, the “sender’s” idea (comment) is interpreted by the receiver and validated in one of many ways
NVCC EMS 207 - K Deal & E Stern
Effective Communications
Interactional Skills• Listening• Attending• Paraphrasing• Leading• Questioning• Reflecting• Summarizing
NVCC EMS 207 - K Deal & E Stern
Effective Communications
Listening - Paying Undivided Attention to What the Client Says and Does
I’m all ears!
NVCC EMS 207 - K Deal & E Stern
Effective Communications
Attending - Giving Full Attention to Verbal and Nonverbal Messages
NVCC EMS 207 - K Deal & E Stern
Effective Communications
Paraphrasing - Restating the Client’s Basic Message
“So what you’re saying Dad is that you and Mom are drug dealers?”
NVCC EMS 207 - K Deal & E Stern
Effective Communications
Leading - Encourages Open Communication• 3 Type of Leading Techniques
– Direct (Obtain specific info)• Let’s discuss the back pain
– Focusing (Zero in on a point)• How does it feel when your back hurts
– Questioning (seek specific info via a question)• What do you mean your back feels like it’s breaking
NVCC EMS 207 - K Deal & E Stern
Effective Communications
Reflecting - Repeating the Client’s Verbal or Nonverbal Message for the Client’s Benefit to Show that you have Empathy with their Thoughts, Feelings, or Experiences
So you’re saying you feel like you were adopted and it’s been difficult for you.
NVCC EMS 207 - K Deal & E Stern
Effective Communications
Questioning - Direct Way of Speaking with Clients to Obtain Subjective Data for Decision Making and Planning Care• Closed and open-ended
questions
NVCC EMS 207 - K Deal & E Stern
Effective Communications
Summarizing - The Process of Gathering the Ideas, Feelings, and Themes That Clients Have Discussed Throughout the Interview and Restating Them in Several General Statements
NVCC EMS 207 - K Deal & E Stern
Barriers to Effective
Communications
NVCC EMS 207 - K Deal & E Stern
Communication Barriers
Barriers to Effective Client Interactions• False reassurance• Interrupting or changing the subject• Passing judgment• Cross-examination• Using technical terms• Encountering sensitive issues
NVCC EMS 207 - K Deal & E Stern
Communication Barriers
False Reassurance - Occurs When you Assure the Client of a Positive Outcome with No Basis for Believing in It
You’re Not You’re Not Going To Going To
Die!Die!
NVCC EMS 207 - K Deal & E Stern
Communication Barriers
Interrupting or Subject Changing - Shows Insensitivity to the Client’s Thoughts and Feelings.
• May Occur When Distracted or you’re Not Comfortable with the Conversation
NVCC EMS 207 - K Deal & E Stern
Communication Barriers
Passing Judgment - Conveys Messages to Clients That They Are Not Meeting Your Values
NVCC EMS 207 - K Deal & E Stern
Communication Barriers
Cross - Examination - Asking Questions During the Interview May Cause the Client to Feel Threatened and Reveal Less Information
NVCC EMS 207 - K Deal & E Stern
Communication Barriers
Technical Terminology - Should Be Avoided to Facilitate Client Understanding
• As Well as Jargon, Slang, etc
NVCC EMS 207 - K Deal & E Stern
Communication Barriers
Encountering Sensitive Issues - May Make the Client Feel Uncomfortable or Defensive
NVCC EMS 207 - K Deal & E Stern
Diverse Communications
Diversity and Impact on the Medic - Client Interactions
The Most difficult part of the job:
“Leave your judgment at the door and open your mind to the diversity of your community”
NVCC EMS 207 - K Deal & E Stern
Box 10.1 Guidelines for Interviewing Clients Who Do Not Speak English
NVCC EMS 207 - K Deal & E Stern
Figure 10.3 Differences in cultural or regional background may become barriers to effective communication.
NVCC EMS 207 - K Deal & E Stern
Diverse Communications
Diversity and Impact on the Medic - Client Interactions• Factors
– Culture– Body language– Ethnicity– Religion
NVCC EMS 207 - K Deal & E Stern
Diverse Communications
Diversity and Impact on the Medic - Client Interactions• Factors
– Nationality– Education– Health status– Level ofintelligence
NVCC EMS 207 - K Deal & E Stern
Diverse Communications
Cultural Stereotypes
NVCC EMS 207 - K Deal & E Stern
Diverse CommunicationsCultural Stereotypes
NVCC EMS 207 - K Deal & E Stern
Diverse CommunicationsCultural Stereotypes
NVCC EMS 207 - K Deal & E Stern
Diverse Communications
Patient Body Language
NVCC EMS 207 - K Deal & E Stern
Diverse Communications
Your Body Language
NVCC EMS 207 - K Deal & E Stern
Diverse Communications
Ethnicity
Things have changed and continue to change
“We must learn to live together as brothers or perish together as fools” (MLK)
NVCC EMS 207 - K Deal & E Stern
Diverse Communications
Language
NVCC EMS 207 - K Deal & E Stern
Figure 10.4 A Interpreter may help facilitate interaction with a client who does not speak English.
Interpreter vs Translator
NVCC EMS 207 - K Deal & E Stern
Establishing theMedic - Client Relationship
NVCC EMS 207 - K Deal & E Stern
Establishing the Relationship
Characteristics• Positive regard
• Empathy
• Genuineness
• Concreteness
Starts With a Simple Hand Shake
NVCC EMS 207 - K Deal & E Stern
Establishing the Relationship
Positive Regard - Respect for Another’s Worth and Dignity
NVCC EMS 207 - K Deal & E Stern
Establishing the Relationship
Empathy - Capacity to Respond to Another’s Feelings and Experiences as If They Were One’s Own
NVCC EMS 207 - K Deal & E Stern
Establishing the Relationship
Genuineness - Ability to Present Oneself Honestly and Spontaneously
NVCC EMS 207 - K Deal & E Stern
NVCC EMS 207 - K Deal & E Stern
LEARNING OBJECTIVE FIVE
Concreteness - Speaking in Specific Terms
I need this for my report
I need this so I can document all of your medical history
What happened here?
When did you 1st notice the swelling in your ankles?
NVCC EMS 207 - K Deal & E Stern
Health History Interview Phases
NVCC EMS 207 - K Deal & E Stern
Health History Interview Phases
Health History Interview Phases• Preinteraction phase
• Initial interview
• Focused interview
NVCC EMS 207 - K Deal & E Stern
Health History Interview Phases
Preinteraction Phase - Occurs Before You Meet the Client, When Data Is Collected from
Previous Records
NVCC EMS 207 - K Deal & E Stern
Health History Interview Phases
Initial Interview - Meeting in Which You Gathers Information from the Client
NVCC EMS 207 - K Deal & E Stern
Health History Interview Phases
Focused Interview - To Clarify Previously Obtained Assessment Data and Gather Missing Information
NVCC EMS 207 - K Deal & E Stern
Health History Interview
NVCC EMS 207 - K Deal & E Stern
Health History Interview
Health History Interview - A ‘Planned, Formal’ Interaction Between You and the Client
NVCC EMS 207 - K Deal & E Stern
Health History Interview
Components of the Health History
NVCC EMS 207 - K Deal & E Stern
Table 10.2 Health History Format
NVCC EMS 207 - K Deal & E Stern
Health History Interview
Components of the Health History• Biographical data• Present health–illness• Past history• Family history• Psychosocial history• Review of body systems
NVCC EMS 207 - K Deal & E Stern
Health History InterviewBiographical Data
• Name• Address• Age• Date of birth• Birthplace• Gender• Marital status• Race• Religion• Occupation• Insurance coverage
NVCC EMS 207 - K Deal & E Stern
Box 10.2 Cultural Assessment
NVCC EMS 207 - K Deal & E Stern
Box 10.2 (continued) Cultural Assessment
NVCC EMS 207 - K Deal & E Stern
Health History Interview
The Present Health or Illness History• Past and current health problems and
concerns– Reason for seeking care– Health beliefs and practices– Health patterns– Medications
NVCC EMS 207 - K Deal & E Stern
Health History Interview
Past History• Childhood diseases• Immunizations• Allergies• Blood transfusions• Major illnesses• Injuries
NVCC EMS 207 - K Deal & E Stern
Health History Interview
Past History• Hospitalizations• Childbirths• Surgeries• Psychiatric problems• Use of alcohol, tobacco, and other
substances
NVCC EMS 207 - K Deal & E Stern
Health History Interview
Family History - Determines whether Genetic or Familial Patterns of Health Impact the Client’s Current or Future Health Status
NVCC EMS 207 - K Deal & E Stern
Health History Interview
Psychosocial History• Occupation• Education• Finances• Roles and relationships• Ethnicity and culture• Family• Spirituality• Self-concept
NVCC EMS 207 - K Deal & E Stern
Health History Interview
Review of Body Systems - Provides Subjective Information About Each Body System and Its Organs
• Includes questions about functional patterns the patient may experience
• Consider that EMS traditionally does a “focused assessment” instead of a full review
NVCC EMS 207 - K Deal & E Stern
Box 10.3 Review of Body Systems
This is systems based vs the traditional EMS
“Head to Toe” review/assessment
NVCC EMS 207 - K Deal & E Stern
Health History Interview
Sources of Information for the Health History• Primary source
– Client
• Secondary sources– Other individuals– Client records and charts
NVCC EMS 207 - K Deal & E Stern
Box 10.4 Narrative Recording of the Health History
SAMPLE
NVCC EMS 207 - K Deal & E Stern
Box 10.4 (continued) Narrative Recording of the Health History SAMPLE
NVCC EMS 207 - K Deal & E Stern
You Now Have the Power