Gerolaga 1Nur-3 Health Assessment Lab

Patient interview

I. Preparatory phase 2. Patient identifiers

1. Nurse must collect background o Ask the patient for their name
information from previous charts  “Pwede po ba’ng malaman
o Helps gather information and yung name and birthday
niyo?”
plan what areas need to be o Use formal title to address the
explored patient; use first name for
o Note identifying data: age, children or adolescents
gender, address, insurance o Check the patient’s tag
o Focus on: problem list, 3. Obtains consent
medication list, allergies, past o Obtain verbal consent
diagnoses and treatments  “Sir, pwede po ba akong
mag-conduct ng interview?
2. Ensure environment is conducive Ito po ay para malaman
for interviewing natin kung ano po ang
o Private and comfortable inyong health status, at para
o Proper air ventilation, lighting, malaman kung pa’no magp-
and room temperature provide ng care sainyo.”
o If the patient did not give their
o Minimize noise
consent, reiterate the
3. Arrange seating importance of that interview
o Nurse and patient should be 4–5  “Kasi po baka nagbago
feet apart and of the same level yung current condition ng
 Also to prevent infections katawan niyo compared dun
4. Allow adequate time for interview sa nakaraang interview.”
4. Provides purpose of interview
o Let the patient think and
(goal or task to be attained)
verbalize thoughts properly o Goals: completing forms for
o Take into account the time of health care institutions; following
interview (ex. sleeping time, up on health care issues;
meal time, meeting visitors) obtaining a basis for developing
o If the patient is busy: a plan of care
 “Ito po’ng interview na ito ay
 “Sige po, sir, babalik nalang
para malaman ang inyong
po ako. Mga anong oras po current condition.”
kayo pwede balikan?” 5. Ensure confidentiality of
information
II. Introductory phase o Tell the patient that only you and
1. Nurse introduces self to patient the other HCP assigned to them
o Wear nametag will know
o Explain role, including status as  “Ma’am, ito po’ng papag-
a student and involvement in the usapan natin ay sa’tin lang
patient’s care po at sa mga healthcare
 “Good morning po, ako po si providers na naka-assign
Student Nurse Jason from sainyo. Lahat ng data na
UST College of Nursing. makukuha natin ay para po
Ako po yung naka-assign sa overall treatment niyo.”
mag-interview sainyo.”
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 Gerolaga 1Nur-3 Health Assessment Lab

o Let the patient decide if visitors or b. Location. Where is it?

family can remain in the room Does it radiate?
 “I am comfortable with having c. Duration. How long does it
your sister stay for the last?
interview, Mrs. Jones, but I d. Characteristic Symptoms.
want to make sure that this is What is it like? How severe
also what you want.” is it? (For pain, ask a rating
6. Attends to patient’s needs before on a scale of 1 to 10.)
starting. Establish rapport with the e. Associated Manifestations.
patient Have you noticed anything
 “Bago po tayo magsimula, may else that accompanies it?
gusto po ba kayong gawin muna? f. Relieving/Exacerbating
Like mag-C.R. o kumain?” Factors. Is there anything
that makes it better or
III. Working phase worse?
1. Nurse gathers information for g. Treatment. What have you
subjective data done to treat this? Was it
o All verbal information coming effective?
from the patient is subjective data  Use leading questions
o Also note nonverbal cues discretely
2. Demonstrate excellent  “Ah, ma’am, pa’no niyo
communication skills po ba made-describe
* Asking from Health History form yung sakit—parang
o Active listening tusok-tusok ba, may
hangin, parang nagt-
 A casual interview
throb?”
 Lean slightly forward, nod
 Lead the patient back to the
head, use continuers like “go
topic when they’re talking
on,” “I see,” or “ahh.”
about unnecessary topics
 Ask them to repeat something
 FIFE: Feelings, Ideas,
if you fail to understand
Function, Expectations
 Confirm understanding by
o Use of language understood by
repeating to them what you
heard for clarification the patient
 Inject NO new information  Avoid use of medical jargon;
and do NOT interrupt use layman’s terms
o Eye contact  Base the conversation on the
educational background of
 Avoid looking down to take
your patient (ex. preschool,
notes
grade school, high school,
o Employing open-ended
college, etc.)
questions
 Ask the patient what
 OLD CART
language or dialect they are
a. Onset. When did (does) it
comfortable with using
start? Setting in which it
 “Komportable po ba kayo
occurs, including
kausapin sa English o
environmental factors,
Filipino?”
personal activities,
 If the patient speaks only in a
emotional reactions, or
language you aren’t fluent
other circumstances that
with, you can ask the person
may have contributed to
with them to interpret for you
the illness.
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 Gerolaga 1Nur-3 Health Assessment Lab

IV. Termination phase

1. Inform the patient that the interview
is about to end
o Give a cue that the interview is
about to end
 “Ma’am, matatapos na po tayo.
Mga ilang questions nalang po.”
2. Review goal or task attainment
3. Ensure that the patient knows what
will happen with the information
 “Ma’am, yung mga data na nakuha
natin ngayon ay gagamitin ng doktor
at mga nurses po para mas efficient
po yung care na ibibigay sainyo.”
4. Offer patient a chance to ask
questions or add anything to what
has been shared.
o The last few minutes are not the
time to bring up new topics. If the
concern is not life-threatening,
assure the patient your interest and
plan to address it in the next
appointment
5. Summarize the highlights of the
interview and the meaning to the
nurse and the patient
o Summarize the patient’s problems
and review the plan of care and
follow-up
6. Express gratitude after the conduct
of the interview

Notes
Two main purposes of conducting an interview:
o Gather information about the patient and
maintaining their health status
o Get inside of the patient’s feelings to be
able to meet their needs
Goals should be a balance between provider-
centered goals and patient-centered goals

Medical history: focuses on the cause and

course of illness
Nursing history: focuses on the patients
themselves and their lifestyle pattern

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