INTRODUCTION TO HEALTH

ASSESSMENT INTERVIEW AND

HISTORY TAKING

GALANG, JAMES LORD CABALDE

HEALTH ASSESSMENT
 NURSING PRELIMS
REVIEWER | FIRST SEMESTER HEALTH ASSESSMENT

NURSING PROCESS BODY SYSTEM ASSESSMENT

a dynamic process that uses information in GENERAL SURVEY, VITAL SIGNS, AND PAIN
a meaningful way through problem-solving
strategies to place the patient, family, or • Skin, hair, & nails
community in an optimal state. • Head, Neck, & Regional Lymphatics
• Eyes
Covers physical, emotional, mental, • Ears, nose, mouth, & throat
developmental, spiritual, & cultural assessment • Breast & regional nodes
• Thorax & lungs
PHASES OF NURSING PROCESS:
• Heart & peripheral vasculature
1. ASSESSMENT • Abdomen
2. DIAGNOSIS • Musculoskeletal system
3. PLANNING • Mental Status & neurological techniques
4. IMPLEMENTATION/INTERVENTION • Female or Male genitalia
5. EVALUATION • Anus, Rectum, & Prostate

ASSESSMENT 3. DIAGNOSTIC and LABORATORY DATA

• It is the orderly collection of information • Document all findings.

concerning the patient’s health status. • Nursing process is DYNAMIC.

SOURCES OF INFORMATION NURSING DIAGNOSIS

1. HEALTH HISTORY • Is a clinical judgment about individual,

• Gathering SUBJECTIVE data, usually
from the patient. Includes what the
patient says and thinks. (attitudes/
beliefs)
• Some cannot be verified; while
others can be confirmed through
PHYSICAL ASSESSMENT.
WHERE TO OBTAIN HEALTH HISTORY?
FOUR COMPONENTS:
2. PHYSICAL ASSESSMENT
• FINDINGS - this includes OBJECTIVE
DATA or information that is
observable & measurable, can be
verified by more than one person
using the senses; this describes the
systematic and comprehensive
physical examination techniques
that will elicit data.
• Data can be obtained in a BODY
SYSTEM or HEAD-TO-
TO/CEPHALOCAUDAL approach.
family, or community responses to actual
or potential health problems/ life
processes
• Provides a basis for the selection of nursing
interventions to achieve outcomes for
which the nurse is accountable by NANDA-
I (NORTH AMERICA NURSE DIAGNOSE
ASSOCIATION INTERNATIONAL)
1. DESCRIPTOR/QUALIFIER
• describes or qualifies the human
response – IMPAIRED, INEFFECTIVE,
READINESS FOR ENHANCED
2. LABEL or HUMAN RESPONSE
• actual or potential health problem or
wellness factors
3. RELATED FACTORS
• origin of the patient’s health problem
and can be changed with nursing
interventions “RELATED TO”

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4. DEFINING CHARACTERISTICS
• signs, symptoms, & statements made
by the patient that validate the
existence of the nursing actual or
wellness nursing diagnosis. “AS
EVIDENCED BY”
GOAL
• Directed toward the removal of related
factors or patient response to an
adverse condition
• Broad statement; not measurable
OUTCOME
• Expected change in patient behavior
demoting progress toward resolution of
the altered human response over
specified period of time.
• With time frame – short term and long
term
PLANNING
• PRIORITIZATION of nursing diagnoses and
care and the selection of nursing
interventions.
PRIORITIZATION
• determination of problems which
are most vital to the patient’s
well-being at that particular time
IMPLEMENTATION/INTERVENTION
• Executes the interventions to meet the
predetermined outcomes.
EVALUATION
• Patient’s progress in achieving the
outcomes is determined. (Continual and a
dynamic process)- MET, UNMET, PARTIALLY
MET.
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HEALTH ASSESSMENT
NURSING INTERVIEW
Assessment of a comprehensive information
about the total patient (holistic), which includes P,
M, E, D, S, C aspects. Patient’s past and present
states of health, family status & relationships,
cultural background, developmental level. Other
factors: self-concept, religious affiliation, social
supports, sexuality, and reproductive processes.
PMEDSC ASPECTS:
• PHYSICAL
• MENTAL
• EMOTIONAL
• DEVELOPMENTAL
• SOCIAL
• COGNITIVE
FACTORS INFLUENCING THE INTERVIEW:
(Which may affect the patient’s comfort level)
• Approach - prior to approaching the
patient, gather all available patient
information
• Introduction
• Explain what will follow and state an
approximate time frame for the interview
• Environment
• Confidentiality
• Note Taking
• Time, Length, and Duration
• Biases & Perceptions - personal beliefs and
value systems, attitudes
STAGES OF THE INTERVIEW PROCESS
STAGE I “JOINING”
• establish TRUST and get to know each
other; define the relationship
STAGE II “WORKING PHASE”
• bulk of the patient data is collected;
includes refocusing and redefining the
goals established in the 1st stage
2
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STAGE III “TERMINATION” OTHER INTERVIEWING TECHNIQUES

• information is summarized & validated; LISTENING RESPONSES
allow opportunity to give additional
information & make comments or • accurately Receive, Process, Respond
statements to patient’s messages
1. Making observations
FACTORS AFFECTING COMMUNICATION 2. Restating
3. Reflecting
1. LISTENING “ACTIVE LISTENING” 4. Clarifying
• act of perceiving what is said verbally
5. Interpreting
and nonverbally; primary goal is to 6. Sequencing
decode patient messages in order to 7. Encouraging comparisons
understand the situation or problem 8. Summarizing
as the other persons sees it.
2. NONVERBAL CUES MAKING OBSERVATIONS
• Message without words
3. DISTANCE • Verbalize perceptions about the
• Intimate Distance – approx. 1.5ft patient’s behavior—to validate
• Personal Distance Nurse: “Speaking about these symptoms
• Social Distance seems to make you tense.”
• Public Distance
RESTATING
PROXEMICS – study of human spaces.
• Involves repeating or rephrasing the
EFFCTIVE INTERVIEWING TECHNIQUES main idea expressed by the patient;
provides the patient with an opportunity
1. OPEN – ENDED QUESTIONS
• provides general rather than focused to explain or elaborate on an issue/
concern
information; provides the patient a
sense of control Patient: “I don’t sleep well anymore. I find
• ***WHY – ALERT!!! myself waking up frequently at night.”
2. CLOSED QUESTIONS
• which regulate or restrict patient’s Nurse: “You’re having difficulty sleeping.”
response; answered by YES or NO; REFLECTING
can pinpoint specific areas of
concern, elicit valuable information • It focuses on the content of the patient’s
quickly & efficiently message as well as the patient’s
3. FACILITATING/FACILITATION feelings, & ideas back to the patient &
• verbal and nonverbal means to provides opportunity for the patient to
encourage patients to continue reconsider or expand on what was just
talking said
4. SILENCE
Patient: “I told the doctor that I had
• can help structure & pace the
problems with this medication, and he just
interview; convey respect &
didn’t listen.”
acceptance
Nurse: “Sounds as if you are angry with
him.”

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CLARIFYING
• to make clear or to pinpoint the
message when the patient’s words &
nonverbal behavior do not agree.
Patient: “I have an awful pain in my back.”
Nurse: “Tell me what you mean by awful.”
“I’m not sure that I follow you…when does
this pain occur?”
INTERPRETING
• RN has the opportunity to share
inferences or conclusions gathered from
the patient’s interview.
Nurse: “Your headache seems to occur
every time you eat nuts and chocolate.”
Patient: “Your headache seems to occur
every time you eat nuts and chocolate.”
SUMMARIZING
• A brief concise review of the important
points covered helps the patient identify
anything that has been left out;
opportunity to make sure that what he
understood the patient to say is actually
what was said.
Nurse: “During the past hour, you shared
with me several health concerns of which
is most disturbing to you is your difficulty in
losing weight, is that correct?”
INTERVIEWING THE PATIENT WITH SPECIAL NEEDS
HEARING IMPAIRED
• Lip reading, do not shout
• Face the client
• Sign language
• Written communication

Nurse: “From what you have just told me,
could It be the stress of your teaching job
(pt works from September to May) that is
causing your pain?”
SEQUENCING
VISUALLY IMPAIRED
• Look at the patient, as if the patient is
sighted
• Voice intonation, volume, and inflection
• Inform the client or patient (orient, touch)

• Knowledge of time frame which WITH SPEECH IMPAIRMENT/APHASIA

symptoms/ problems developed or
• Yes or No
occurred; proper sequence of events; • Give time
patterns of behavior • Written interview format
Nurse: “Did this sharp pain occur each time NON-ENGLISH-SPEAKING CLIENT
you had sexual intercourse or only when
you didn’t empty your bladder first?” • Interpreter (institutional) – colloquialism
ENCOURAGING COMPARISONS LOW LEVEL OF UNDERSTANDING
• Deal more effectively with unfamiliar • Time and patience
situations in a context of something else • Supplemental information (significant
familiar others)
Nurse: “Have you had similar ACUTELY ILL
experiences?”
• Brief and concise
CRYING
• Empathy

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ANXIOUS/ANGRY/HOSTILE • interrupting
• WHY?
• Recognize and bring it to the patient’s
attention HEALTH HISTORY
• Limit-setting
FOUR TYPES OF HEALTH HISTORY
SEXUALLY AGGRESSIVE
1. COMPLETE
• “Matter of fact” responses • comprehensive history of the
patient’s past & present health status
UNDER THE INFLUENCE OF DRUGS/ALCOHOL 2. EPISODIC
• Unique challenge • shorter / specific to patient’s current
reason for seeking health care
PERSONAL QUESTION 3. INTERVAL/FOLLOW-UP
SUMMARY OF INTERVIEW • shows progress from a prior visit,
preceding visit to a healthcare facility
• Present with professional appearance 4. EMERGENCY
• Appropriate environment • only information required
• Sit at patient’s eye level immediately to treat the emergent
• Avoid use of medical jargons need; life-threatening
• Never assume. Clarify frequently
• Reserve intimate questions when rapport is IDENTIFYING INFORMATION
established I. BIOGRAPHIC DATA
• Be flexible in obtaining Health history II. CHIEF COMPLAINT – history of present illness
• Remind that all information is treated III. MEDICAL HISTORY
confidentially IV. FAMILY HISTORY PAST HEALTH
INTERVIEW – AGE GROUP V. PSYCHOSOCIAL HISTORY
VI. ADLs
• INFANT: crying, body feelings, sensory
stimuli, gentle handling BIOGRAPHICAL DATA
• TODDLER & PRE-SCHOOLER (2 – 7 y.o): ✓ Name
expressive and receptive, egocentric, ✓ Address
literal, magical thinking, animism ✓ Phone number
• SCHOOL AGE (7 – 12 y.o): objective & ✓ Birthdate and place
realistic, decrease intimidation ✓ Age
• ADOLESCENT (12-18 y.o): honest, avoid ✓ Marital status
jargons, peers, nonjudgmental attitude ✓ Religion
• Older: adjust pace, formal name ✓ Language
10 TRAPS OF INTERVIEW ✓ Nationality
✓ Gender
• providing false reassurance ✓ Emergency contact
• giving unwanted advice
• using authority
• using avoidance language – euphemism
• engaging in distancing
• use of medical jargon
• biased questions
• talking too much

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CHIEF COMPLAINT (HISTORY OF THE PRESENT REVIEW OF SYSTEMS & STRUCTURES

ILLNESS)
1. SKIN, HAIR, AND HEAD
• Signs and symptoms 2. EYES
• Record as direct quote from the patient 3. EARS
4. NOSE
EX: “What concern(s) brings you here 5. MOUTH & THROAT
today?” & “How long has this condition 6. NECK
been concerning you?” 7. RESPIRATORY
PQRSTU MNEMONIC 8. CARDIOVASCULAR
9. BREAST
P – PRECIPITATING/PROVOCATIVE 10. GASTROINTESTINAL TRACT
(aggravating factor); PALLIATIVE (alleviating 11. RENAL
factor) 12. REPRODUCTIVE
Q – QUALITY OR QUANTITY (gnawing, 13. MUSCULOSKELETAL
pounding, burning, stabbing, pinching, 14. NEUROLOGIC
aching, throbbing, crushing 15. ENDOCRINE
16. HEMATOLOGIC
R – REGION (location)/RADIATION 17. PSYCHOLOGICAL
S – SEVERITY FUNCTIONAL ASSESSMENT TESTS
T – TIMING/TEMPORAL APGAR SCORE OF NEWBORNS (Virginia Apgar)
U – UNDERSTANDING 1st & 5 minutes of life
PAST HEALTH HISTORY • A – ACTIVITY (muscle tone)
• P – PULSE (heart rate)
MEDICAL HISTORY
• G – GRIMACE (reflex irritability)
✓ Allergies • A – APPEARANCE (skin color)
✓ Medications • R – RESPIRATION (breathing & effort)
✓ Previous Hospitalization – surgical history Feature
0 points 1 point 2 points
✓ Immunizations evaluated
✓ Obstetric history Heartbeat None <100 bpm >100 bpm
Breathing Absent Irregular, shallow, or Full breaths, strong
FAMILY HISTORY gasping breaths, cry
weak cry
PSYCHOSOCIAL HISTORY Muscle Tone Limp Weak, some Actively moving
movement arms and legs
Reflexes/ No Grimace Cry or active
• Occupation, education, economic
Irritabilityreflexes avoidance
status, lifestyle. Skin color Pale or Pale or blue in Completely pink
blue all hands and feet
ACITIVITES OF DAILY LIVING (ADLs) over
Maximum score is 10; minimum score is 0
✓ Diet & elimination
✓ Exercise
✓ Work & leisure
✓ Use tobacco, alcohol, other drugs
✓ Sexual practice
✓ Religion
✓ Safety measures

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DENVER II DEVELOPMENTAL SCREENING TEST PERFORMING GENERAL SURVEY

(DDST)
1. Assemble all the needed tools
• Shows what a child can do at a particular 2. Introduce self; explain the procedure (what,
age, not an intelligence test how long, why, position changes, and
equipment to be used)
KATZ INDEX OF INDEPENDENCE IN ADLs 3. Form initial impressions to the patient
• Is the most appropriate instrument to assess 4. Baseline data
functional status as a measurement of 5. Assessment proper
patient’s ability to perform ADLs 6. Document data
INDEPENDENTLY TIPS FOR ASSESSMENT
6 – FULL FUNCTION • Distractions
4 – MODERATE IMPAIRMENT • Void prior
2 – SEVERE FUNCTIONAL IMPAIRMENT • Hand hygiene (patient’s presence)
(Bathing, dressing, toileting, feeding, • Equipment on hand and in order
transferring) • Room – lit
• Warm hands/ equipment
BARTHEL INDEX • Nonverbal communication

• The Barthel Index consists of 10 items that OBSERVE THE PATIENT:

measure a person's daily functioning
• SYMMETRY – face & body
specifically the activities of daily living and
• OLD – appearance
mobility. The items include feeding, moving
• MENTAL ACUITY – LOC
from wheelchair to bed and return,
• EXPRESSION – ill, in pain, anxious
grooming, transferring to and from a toilet,
bathing, walking on level surface, going up
and down stairs, dressing, continence of
bowels and bladder. • TRUNK – lean, obese, barrel-chested
• EXTREMITIES – fingers clubbed, joint
0 = dependent, 5 = needs some assistance, abnormalities
10 = independent • APPEARANCE – clean, appropriately
dressed
STANDARD/UNIVERSAL PRECAUTION
• MOVEMENT – posture, gait (smooth &
• assume every person is potentially effortless, controlled, purposeful)
infected; can transmit microorganism • SPEECH – understandable, clear, slurred,
• to prevent exchange of blood & body fluid respond to questions & commands easily
Hand Hygiene
MENTAL STATUS EXAMINATION
PPEs – PERSONAL PROTECTIVE EQUIPMENT
MENTAL ACUITY/ STATUS (LOC)
✓ gloves
• ALERT (normal) – awake; readily aroused
✓ gowns
• LETHARGIC (somnolent) – not fully alert;
✓ masks
drifts of to sleep when not stimulated
✓ eye protection
(name in normal voice, drowsy)
• OBTUNDED – sleeps most of the time; needs
to shout or vigorous shake

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• STUPOR/ SEMI-COMA – spontaneously PALPATION

unconscious; only to vigorous shake or pain
• COMA – completely unconscious; no • act of touching
response to pain or stimuli • short fingernails, warm hands
• if with pain, palpate tender areas last
NUTRITIONAL ASSESSMENT • Use standard precaution
• Recount what and how much the patient • TEXTURE – rough/ smooth
ate on a certain day. • TEMPERATURE – warm/ hot/ cold
NOTE: • MOISTURE – dry, wet, moist
• FIRMNESS – soft/ hard
✓ Socioeconomic Status • MOTION – still vibrating/ mobile
✓ Work Schedule • CONSISTENCY – solid/ fluid filled
✓ Religion • PATIENT RESPONSE – any pain
✓ Ethnic Background
PERCUSSION
VITAL SIGNS
• involves striking of finger/ hands against a
• Temperature > N: 96.7º to 100.5 ºF (35.9º to body part to cause vibration to produce
38.1 ºC) sound
• Pulse Rate > N: 60 to 100 beats/min • Most frequent site: Thorax & Abdomen
• Respiratory Rate > 16 to 20 breaths/min • Intensity, duration, pitch, quality, &
• Blood Pressure location
• Pain Scale

ASSESSMENT TECHNIQUES
INSPECTION
• Ongoing process
• Vision (color, size, location, movement,
symmetry)
• Smell
• Odor
• Hearing

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AUSCULTATE
• use of stethoscope (breath sounds, heart
sounds, bowel sounds)
• note the intensity and location

PADAYON NURSING!!!

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