Comprehensive Health History & Physical Examination Apea Review
Chapter 2: Obtaining a Health History
Introduction
The collection of a health history from a patient - that is, subjective information which focuses on the patient's symptoms - is the first step in health observation and cess, and is a primal skill for nurses working in all clinical areas. This affiliate introduces the knowledge and skills required by nurses to collect a comprehensive wellness history from a patient. Information technology begins with an caption of the place of health history in the health ascertainment and cess procedure, a description of the different types of wellness histories and their uses, and a detailed overview of the components of a comprehensive health history. This chapter goes on to explain the importance of therapeutic communication and rapport in the health history interview, and the use of questioning, interpersonal skills and other communication techniques to facilitate data drove. Finally, this chapter considers a variety of barriers and challenges to effective advice in the health history interview, and how nurses can answer finer to these.
Learning objectives for this chapter
By the finish of this chapter, we would like you lot:
- To explain the place of the health history in the health observation and assessment process.
- To discuss the different types of health histories, and their uses in different clinical contexts.
- To listing the components of a comprehensive health history.
- To explicate the utilize of therapeutic communication and rapport in the wellness history interview.
- To describe the importance of effective questioning, and the utilize of a variety of interpersonal skills and communication techniques, in the health history interview.
- To describe the various barriers and challenges to constructive communication in the health history interview, and effective responses to these to facilitate data collection.
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The health history
As y'all saw in the previous affiliate of this module, health ascertainment and assessment involves three concurrent steps:
The starting time of these steps, and the focus of this chapter, is the health history. This involves collecting subjective data - that is, data about a patient'southward symptoms (i.e. what the patient experiences). A diverseness of other important information is also nerveless during the interview - including, for example, data about a person's health-related values, beliefs and attitudes, their electric current health-related practices, the socioeconomic, cultural and other factors impacting on their health, and their willingness and capacity to make wellness-related changes, etc. Data is collected via an interview with the patient and / or significant others. Data collected at this phase may be primary (i.e. obtained from the patient themselves) or secondary (i.due east. obtained from another person, such equally the patient's family member or carer, etc.). In acute situations, the patient's health history may be communicated past another health care provider - for case, an emergency paramedic.
Health history is obtained through an interview betwixt a nurse, the patient and pregnant others (where appropriate). The nurse'south role in the interview procedure is to: (one) facilitate discussion to collect health-related data, and (ii) record this data. Data collected during a health history interview informs both the subsequent physical examination of the patient, and likewise the health care which is provided to that patient.
In many clinical settings, patients are asked to complete a questionnaire as function of the process of collecting their health history. Wellness history questionnaires typically consist of a serial of uncomplicated yeah / no questions, often related to the specific symptoms and risk factors associated with common disease (e.g. cardiovascular disease, respiratory affliction, diabetes, etc.). It is important for nurses to realise that health history questionnaires practice not replace or preclude the need for the health history interview. Although these questionnaires can be useful tools for collecting data related to a person's health history, and can prompt a patient to recall deeply well-nigh their past medical issues and symptoms, they simply collect superficial information which should so exist further investigated by a nurse in a conversation with a patient.
Types of wellness histories
It is of import for nurses to note that there are a number of different types of health histories which may be collected from a patient:
- A comprehensive wellness history. This collects detailed information virtually a patient - including their biographical information, present wellness status, past medical history, family unit history, personal situation and a review of all body systems. Information technology is usually completed on admission to a health intendance facility and during a general wellness cheque-upwardly.
- A rapid or focused health history. This collects specific information virtually a articulate wellness-related event or demand with which a patient presents. The information gathered is used to inform the firsthand care of the patient.
The type of health history nerveless from a patient depends on: (1) the context in which the patient has presented, and (2) the patient's health care bug and needs. This module volition focus on instruction the knowledge and skills required to collect a comprehensive health history from a patient, every bit it is this knowledge and these skills which as well underpin the collection of a rapid or focused health assessment.
Components of a health history
A wellness history interview typically consists of three distinct sections: (1) introduction, (ii) discussion, and (3) summary. Each of these sections is described post-obit:
| Introduction Section | Give-and-take Section | Summary Section |
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All health history interviews brainstorm with the nurse introducing themselves to the patient (and others nowadays in the interview, if relevant), and explaining their role in the provision of the patient'due south health intendance. Adult patients should exist addressed by their championship and surname, until they inform the nurse of their preferred name and provide the nurse with permission to utilize it. It is commonly acceptable, and preferable, to accost adolescents and children by their outset name. Nurses explain why the interview is beingness conducted, and besides the processes involved. The aim of this explanation is to set the patient and to raise their comfort in sharing wellness-related information.
The next section of the interview, the discussion department, is where the nurse focuses on facilitating word with the patient to collect wellness-related data. The nurse uses a range of questioning and other communication techniques - discussed in detail in the following section of this affiliate - to collect the information required to inform the concrete exam and the subsequent provision of the patient'due south health care. This give-and-take is patient-centred - that is, information technology focuses on the person and their unique bug and needs. Patients are encouraged to share their perceptions and experiences in their own words, without intermission, judgement or estimation from others (including the nurse).
The nurse focuses on collecting the following information:
| Component | Examples of Data Included | ||||||||||||||||
| Biographical information |
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| Reason for seeking health care |
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| History of presenting illness | This is best achieved by assessing the patient'due south symptoms; this can exist done using a strategy remembered by the mnemonic 'Quondam CARTS':
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| Nowadays wellness status |
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| Past health history |
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| Family history |
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| Personal and psychosocial history |
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| A review of the patient's body systems | The patient should be questioned nearly abnormalities or concerns in each of their body systems: the integumentary system, the cardiovascular arrangement, the immune / lymphatic organization, the endocrine system, the nervous system, the reproductive organization, the respiratory system, the musculoskeletal system, the digestive system and the urinary system. The patient should also be asked about whatever general or systematic symptoms they feel (e.g. fatigue, etc.). |
It is important to highlight that many health intendance organisations accept standardised templates which nurses can use to guide their collection of this information during a health history interview. Nurses must ensure they are familiar with the location of these templates, how to access them, and how they are expected to employ them in practice. Practicing using these templates (due east.g. on family, friends, colleagues, supervisors, etc.) can be useful in helping a nurse to gain confidence and competence.
The concluding section of the interview is the summary section. Nurses should summarise the key data nerveless during the interview - that is, the main points that the patient has communicated. The patient should be encouraged to clarify any errors or inaccuracies in the information the nurse has collected; often, errors occur when a nurse incorrectly interprets the data provided by a patient (note that barriers to communication when collecting a health history volition be described in detail in a later section of this unit). The nurse should also explain to the patient how the information gathered during the health history interview will be used to inform the healthcare provided to them. Although it is brief, the summary department of the wellness history is of import because it provides a patient with a sense of validation that the nurse understands, and will respond appropriately to, their wellness bug and needs.
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Therapeutic communication and rapport
The nurse's effective use of advice techniques, underpinned by therapeutic communication practices, is the unmarried well-nigh important factor in the success of a wellness history interview. Therapeutic communication focuses on developing rapport with a patient - that is, a trusting relationship with a patient which facilitates their condolement in sharing personal information. In that location are a number of important factors which impact on the development of rapport in the health care setting:
- The physical setting in which a health history interview is conducted. This can have a meaning impact on the quality of the exchange of data between a patient and a nurse. Ideally, a health history interview should be conducted in an area which is private, quiet, gratuitous from distractions and comfy.
Privacy is crucial in facilitating a patient's ease in discussing personal information. Patients may be unwilling to share sensitive information in an open and honest style if they are fearful of being overheard by others (including their family / friends, members of the public and / or health care providers). Ideally, health history interviews are conducted in private test rooms; even so, depending on the clinical context in which a nurse works, this may not always be possible, and a nurse may accept to instead draw curtains around a cubicle or pull chairs to a quieter part of a larger treatment room, etc. The nurse should advisedly consider whether the presence of the patient's family or meaning others is appropriate during the interview. If the nurse judges that the presence of these people may impede the patient sharing sensitive data, these people should be invited to wait in a visitors' room or other location whilst the interview and physical test are being conducted.
The location in which an interview is conducted should be quiet and costless from distractions. Interruptions should be avoided to the greatest possible extent - for instance, a nurse should avoid an surface area which must exist frequently accessed by other staff or an area which is adjacent to a thoroughfare. Any unnecessary equipment in the interview space - including telephones and pagers, etc. - should be turned off, and removed if possible. Nurses may consider placing an 'Interview / Test in Progress' sign on the door or curtain to discourage interruptions.
To facilitate a patient's ease in discussing personal information, they must besides be physically comfortable throughout the interview. Wherever possible, the nurse should let patients to remain in their own clothes for the interview (and alter into a hospital gown immediately prior to the physical examination). The nurse should sit at a distance and angle from the patient which respects their personal space, whilst all the same promoting the flow of conversation. When planning for the patient's comfort, the nurse should also consider the seating provided, the temperature and lighting of the room, and the patient's access to water and toilets (if required).
- The professional behaviour of the nurse conducting the interview. Again, this tin can take a significant touch on on the quality of the exchange of information between a patient and a nurse. The nurse's demeanour should exist professional yet warm, and they should practice a multifariousness of interpersonal skills to develop rapport (discussed in detail in a later on section of this chapter). The nurse should focus on the patient, and on agreement the patient'due south experiences and perspectives, without interruption, sentence or interpretation. The nurse must demonstrate a 18-carat interest in the patient, treat the patient with credence and respect, and focus on the patient'southward private health-related issues and needs.
- The private variables of the patient participating in the interview. This is another factor which tin can have a pregnant impact on the quality of the substitution of information between a patient and a nurse. Patients who are very physically or psychologically unwell, who are experiencing extremes of emotion (e.g. sadness, acrimony, feet, etc.), or who are otherwise uncomfortable (e.thousand. cold, thirsty, hungry, in pain, etc.) may non be able to participate finer in a wellness history interview. In these situations, nurses should focus on collecting only the data required to provide firsthand care, and render to complete a more comprehensive health history interview when the patient is more prepared to participate. Over again, barriers to advice when collecting a wellness history interview will be described in particular in a later section of this unit of measurement.
Questioning, interpersonal skills and other communication techniques
Questioning is a key advice skill used by nurses during the health history interview. Questioning occurs in 2 equally-important parts: (1) asking the patient for information, and (2) listening carefully to the patient's response. There are 2 cardinal types of questions a nurse may ask during a health history interview:
- Open-ended questions. These are broadly-stated questions which encourage a detailed multi-word response. Consider the following example:
Instance
| Nurse: | "How have yous been feeling these past few weeks?" |
| Patient: | "Well, I'thou quite fatigued. I've been having a lot of trouble sleeping. I wake upwardly in the morning and yet feel tired." |
| Nurse: | "Okay. Can you tell me more than about what this fatigue is like?" |
| Patient: | "Well, information technology's worse in the mornings. I feel exhausted from the moment I wake up. My head, joints and muscles ache…" |
Open-ended questions are useful when a nurse wishes to collect full general information about a patient's symptoms, their wellness-related values, beliefs and attitudes, their current health-related practices, the socioeconomic, cultural and other factors impacting on their wellness, and their willingness and capacity to make wellness-related changes. However, a nurse should be careful to ask open-ended questions in a style which facilitates the drove of the information required. For example, a question such equally: "Tell me a fiddling near yourself" is likewise wide for a health history interview; it will likely result in the patient providing the nurse with information which is irrelevant to their health care.
- Closed-concluded questions. These are specific questions which encourage a i- or ii-word reply. Consider the post-obit example:
Example
| Nurse: | "Practise you always experience pain?" |
| Patient: | "Yep, sometimes." |
| Nurse: | "Would you describe it every bit sharp, irksome or agonized pain?" |
| Patient: | "Generally agonized." |
Closed-ended questions are useful in collecting data nearly a specific topic, to analyze data gathered during open up-concluded questioning and in urgent situations where data is required quickly. Nonetheless, a nurse should exist careful to avoid drawing inaccurate conclusions from the short answers a patient provides to closed-concluded questions.
In improver to questioning, there are a variety of other communication strategies a nurse should use when collecting information from a patient during a health history interview. These skills include:
- Acknowledgement and encouragement. A nurse may admit what a patient has said by using intonations that demonstrate interest and understanding (e.g. "Okay", "Mmm", etc.). A nurse may encourage a patient to go on discussing a topic by using phrases such as: "Could y'all tell me more about that?", "Please go on", etc.
- Active listening. This involves listening fully to the patient with the aim of identifying, understanding and acknowledging the (ofttimes subtle) message/south they are communicating.
- Clarifying. This involves using a question to prompt a patient to further explain something they have mentioned. It is typically used when the information a patient provides is unclear or ambiguous.
- Empathy. This involves attempting to empathise how the patient may be feeling, and to convey this understanding to the patient. It is important to recollect that a nurse can never completely understand how another person is feeling, fifty-fifty if they have experienced a similar state of affairs themselves or have cared for other patients in similar situations. Nurses tin can, even so, communicate what they sympathise nearly the patient's experience - for example: "I can see this is very hard for you".
- Restatement. This involves repeating what a patient has said, using different words. Oftentimes, restatement is used to confirm or analyze the information provided by a patient. It is used to validate that the patient has been heard and understood.
- Summarising. This involves stopping a conversation with a patient to review the fundamental points covered. Information technology is particularly useful when patients provide a 'rambling' response to a question, or do not provide information in a sequential order. Summarising is also useful in ensuring the nurse understands the information the patient has provided, and in confirming to the patient that they have been heard and understood.
When communicating with patients, including when conducting health history interviews, it is important for nurses to realise that people are non ever directly in saying what they mean. Nurses must exist conscious of picking upwards on 'cues', or subtle hints which suggest the patient may take an underlying business organization they are finding hard to talk over. There are a number of cues seen commonly in wellness care settings:
- A patient may use indeterminate statements (e.grand. "I manage", etc.).
- A patient may use neutral statements (due east.grand. "I had surgery", etc.).
- A patient describes psychological symptoms, such equally 'worry' or 'stress'.
- A patient is unclear or evasive about the symptoms or concerns they feel.
- A patient may exist vague or indirect when answering a nurse'due south questions.
If a nurse identifies ane of these cues, they should question the patient in a respectful and sensitive style to further explore the topic - if information technology is appropriate and relevant to do so.
There are also a number of general strategies nurses should use when questioning patients during a health history interview:
- Questions must be clearly spoken, so that they are understood past patients.
- Avoid medical linguistic communication / jargon, and define words the patient does non empathise.
- Utilise terms and phrases familiar to the patient, wherever possible.
- Accommodate questions to the patient'south own level of knowledge and understanding.
- Encourage patients to be specific / detailed in their responses to questions.
- Enquire ane question at a fourth dimension, and wait for a respond earlier moving to the next question.
- Exist attentive to the patient's reactions / feelings in relation to the questions asked.
- Explicate the need for asking about sensitive topics (due east.1000. sexuality, violence, drugs, etc.).
Barriers to effective communication
It is of import for nurses to recognise that at that place are a variety of barriers that diminish the quality of the information nerveless during a health history interview - for example, by interrupting the menses of the interview or impairing the rapport between the nurse and the patient, etc. The key barriers - which nurses conducting wellness history interviews must take care to avoid - are described in the post-obit section:
- Utilize of medical terminology / jargon. This tin be confusing to a patient; nevertheless, many patients feel too embarrassed to ask for clarification. This tin can lead to the collection of inaccurate data.
- Expressing value judgements. If a patient feels judged past a nurse during the interview, they are likely to reply in an angry, guilty or defensive style. In doing so, they may provide the nurse with incorrect information.
- Interrupting the patient. Although they are ofttimes pressured for time, nurses should avoid finishing the patient's sentences, completing the patient's thoughts and changing the topic before a patient has finished giving data, etc. This may result in the data being provided by the patient being interpreted inaccurately.
- Beingness authoritarian or paternalistic - that is, where a nurse takes the approach of 'knowing what is best' for the patient. Nurses in all wellness care settings must retrieve that a person's health is their own responsibility. Acting in an disciplinarian or paternalistic mode risks disengaging the patient, which will result in the collection of poorer-quality data.
- Using 'why' questions. Many patients feel threatened when asked these types of questions, and they are likely to answer in an angry, guilty or defensive way. In doing so, they may provide the nurse with incorrect information.
It is important to note that at that place are a variety of other challenges a nurse may encounter when completing a health history interview. These challenges, and how a nurse may finer manage them, are described following:
- The patient asks the nurse a personal question. In some situations, information technology may exist appropriate for a nurse to briefly share a personal experience; indeed, this may help to build rapport with the patient. However, the focus of the interview should be rapidly directed dorsum to the patient.
- The patient is silent in response to a question. This can be awkward for nurses. However, allowing the patient to be silent for a short period can be useful, as information technology allows them time to gather their thoughts and program a response.
- The patient displays emotion - for case, anger or sadness. The nurse should acknowledge the patient'southward emotion, and allow the patient to feel it. It is oftentimes advisable to discontinue the interview to allow the patient to recover, before recommencing and exploring the reason for the emotion (if appropriate).
- The patient is overly-talkative. This is problematic because information technology can result in the collection of large amounts of irrelevant data, whilst important data may be overlooked. Nurses should tactfully redirect the conversation, and utilise closed-ended questions to focus the chat.
- The patient speaks a language other than English. In this situation, nurses have a responsibility to access the services of a qualified health interpreter. Nurses should familiarise themselves with their organisation's policies and procedures for doing so. Recollect: using a patient's family unit / friends to interpret may violate the patient's correct to privacy and confidentiality, and should be avoided.
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Decision
As you take seen in this chapter, the collection of a health history from a patient - that is, subjective data, which focuses on the patient'southward symptoms - is the get-go step in wellness observation and assessment, and a fundamental skill for nurses working in all clinical areas. This chapter has introduced the noesis and skills required by nurses to collect a comprehensive health history from a patient. Information technology began with an explanation of the identify of health history in the health observation and assessment procedure, a description of the different types of wellness histories and their uses, and a detailed overview of the components of a comprehensive health history. This chapter went on to explain the importance of therapeutic advice and rapport in the health history interview, and the use of questioning, interpersonal skills and other advice techniques to facilitate data collection. Finally, this affiliate considered the variety of barriers and challenges to constructive communication in the health history interview, and how nurses tin respond finer to these. In completing this chapter, you take equipped yourself with the noesis and skills necessary to collect a comprehensive wellness history from a patient.
Reflection
Now nosotros have reached the end of this chapter, yous should be able:
- To explain the place of the wellness history in the wellness observation and assessment process.
- To discuss the different types of health histories, and their uses in unlike clinical contexts.
- To listing the components of a comprehensive health history.
- To explicate the use of therapeutic communication and rapport in the health history interview.
- To describe the importance of effective questioning, and the utilize of a variety of interpersonal skills and communication techniques, in the health history interview.
- To depict the various barriers and challenges to constructive communication in the health history interview, and constructive responses to these to facilitate data drove.
Reference list
Cox, C. (2009). Physical Assessment for Nurses (2nd edn.). West Sussex, U.k.: Blackwell Publishing, Ltd.
Fawcett, T. & Rhynas, S. (2012). Taking a patient history: The role of the nurse. Nursing Standard, 26(24), 41-46.
Jensen, Due south. (2014). Nursing Wellness Assessment: A Best Practice Arroyo. London, UK: Wolters Kluwer Publishing.
Kaufman, G. (2008). Patient assessment: Effective consultation and history taking. Nursing Standard, 23(4), 50-56.
Kourkouta, Fifty. & Papathanasiou, I.V. (2014). Communication in nursing exercise. Materia Sociomedica, 26(i), 65-67.
Royal College of Nursing. (2016). Activity on Advice. Retrieved from: https://www2.rcn.org.britain/development/do/patient_safety/human_factors_communication/action_on_communication
Wilson, S.F. & Giddens, J.F. (2005). Health Assessment for Nursing Practice (4th edn.). St Louis, MI: Mosby Elsevier.
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