Taking a Health History
How do nurses gather information and assess a patient’s health? Consider the importance of conducting an in-depth health assessment interview and the strategies you might use as you watch. (16m)
play a critical role in gathering information and
assessing a patient’s health.
MARIANNE SHAUGHNESSY: The health assessment is one of the most
critically important pieces of our patient interaction.
NARRATOR: With more demands on their time, this critical step can suffer.
MARIANNE SHAUGHNESSY: Certainly, practicing nurses are extremely busy people. But if you rush through
a health interview or a patient
interview, chances are good there’s going
to be information you’re going to miss. And if that
information is missed, the consequences could
be dire for the patient.
Marianne Shaughnessy shares her expertise on how
to conduct an in-depth health assessment interview, and
provides a demonstration of effective strategies. [music playing]
MARIANNE SHAUGHNESSY: Capturing
all health-related information in a systematic way,
documenting that information, creates a foundation, a
database, for us to build upon. In fact, all members
of the healthcare team can utilize the nursing database
if it’s well-constructed and contains the information
necessary to then build a plan for managing a
patient’s health in conjunction with the patient over
the course of time. [knock knock]
MS. HUDGENS: Come in.
MS. HUDGENS: Yes.
MARIANNE SHAUGHNESSY: Good morning. My name is Marianne Shaugnessy. I’m a nurser practitioner, and I’ll be doing your history and physical this morning.
MS. HUDGENS: Good, thank you.
It’s nice to meet to you.
MS. HUDGENS: Nice meeting you.
MARIANNE SHAUGHNESSY: When
I walked into the room, I was able to immediately
established a rapport with the patient by
speaking with her cordially but professionally. When starting an
interview with a patient, it’s very important to try and
establish an environment that is conducive to communication. We’ve all been in
doctors’ offices with exam rooms that have
paper thin walls where you can hear noise on either side.
We’d like to try and
avoid that as much as possible by providing an
environment in which a patient feels safe to open
up and talk, and has a reasonable expectation
that it’ll be private. Good morning. You walk into a room, sit down,
calmly relax and establish eye contact. That sends a
message to a patient that you have all the time
in the world for them, and as nurses that’s
rarely actually the case.
It’s also important,
if you can, to make sure to be on eye-level
with the patient, and to try and avoid
the superior position, where you are looking
down on a patient. We started with some very
global, open-ended questions. So what brings you in today?
MS. HUDGENS: Well, we haven’t
had insurance for awhile. My husband was laid off,
but we have insurance now, so I just wanted to kind of
cover a couple of things, get a physical.
MARIANNE SHAUGHNESSY: Great. OK. Have you been feeling well? Find out first what’s
on the patient’s mind, because that’s
why they’re there, and it’s critical to address
the issues of importance in the patient’s mind, whether
or not those issues actually may be the most
life-threatening issues. We move the interview
from open-ended questions to closed-ended
questions, and by that I mean asking the patient
to embellish or talk more about a particular concern.
OK, then I need to ask
you about some exposure in your early years. The reason that the
history was so in-depth is because it’s important
to capture not only what the patient is telling you they
want to address when they come in for an appointment, but also
to do some routine surveillance and screening to capture issues
that patients may not even be aware of. Do you have any history
of anemia in the past?
MS. HUDGENS: No, I haven’t.
MARIANNE SHAUGHNESSY: OK. OK. Have you been having any problems with fatigue?
MS. HUDGENS: No, there’s been stress, but other than the stress, really, no fatigue.
MARIANNE SHAUGHNESSY: Weakness?
MS. HUDGENS: No, I’ve been OK.
MARIANNE SHAUGHNESSY: So your energy levels are normal?
MS. HUDGENS: Yes.
MARIANNE SHAUGHNESSY: All right. Have you noticed any problems with unusual bruising?
MS. HUDGENS: Bruising? No.
MARIANNE SHAUGHNESSY: No? OK. And your periods are regular?
MS. HUDGENS: Well, I’m 48 so they’re becoming irregular a little bit,
and I’m a little bit heavier. I have a family history
of uterine fibroids, and I think that might be
coming up with me, too.
MARIANNE SHAUGHNESSY: OK. In terms of this
particular interview, the patient brought up a
number of significant points, primarily concerns about
anemia, which ordinarily could be caused by
any number of things, and it wasn’t until I began to
question her about her aspirin use that I became very
suspicious that her anemia may actually be caused by
a GI bleed as opposed to iron deficiency anemia, which
is so very common in women. Are you taking any medication?
MS. HUDGENS: No, not at this time.
MARIANNE SHAUGHNESSY: None whatsoever?
MS. HUDGENS: No.
MARIANNE SHAUGHNESSY: How about over the counter?
MS. HUDGENS: Over the counter
[inaudible] aspirins or Tylenol when I get a headache
or leg aches, or–
MARIANNE SHAUGHNESSY: You’re
not simply asking a question, and accepting a
yes or no answer, and moving on to
the next question because it’s very
important to follow up with probing questions
when a patient reports a positive finding. Do you take aspirin or
do you take Tylenol?
MS. HUDGENS: Usually just aspirin.
MARIANNE SHAUGHNESSY: OK. How many times a week are you taking it?
MS. HUDGENS: About two time– a couple of times a week.
MARIANNE SHAUGHNESSY: And how much do you take?
MS. HUDGENS: Just the
two that the label says. If I need–
MARIANNE SHAUGHNESSY: Regular
adult strength, right?
MS. HUDGENS: Yes.
MARIANNE SHAUGHNESSY: OK. So you’re taking
probably 650 milligrams, two 325 milligram tabs.
MS. HUDGENS: OK. MARIANNE SHAUGHNESSY:
OK, twice a week. OK. We’re going to need
talk a little bit more about that aspirin, especially
in light of your anemia. The most common
mistake that’s made is rushing through
it, because we all have multiple demands on our
time at any given moment.
Certainly practicing nurses
are extremely busy people, but if you rush through
a health interview, or a patient
interview, chances are good there’s going
to be information you’re going to miss, and if
that information is missed, the consequences could
be dire for the patient. If you take your time,
use a systematic approach, and probe the positive responses
for additional information, nine times out of 10 you’ll
capture all the information you need in order
to help complete a comprehensive
database and have a structure, then, for advancing
management and treatment strategies.
Please forgive my
note taking, I’m just trying to organize the
information as it’s coming in. When you’re performing
a health assessment, there’s going to be a certain
degree of note taking. You have to. Patients are divulging
a lot of information. Once you get into the habit
of taking a health assessment, you can actually reduce your
note taking to a minimum. However, a little bit
of note taking is fine. You want to make sure not
to lose the eye contact that you’ve established
with the patient, because that goes a long
way toward building rapport. It’s perfectly fine, as
you get to know a person, to relax a little bit and
have a cordial and friendly interchange.
MS. HUDGENS: My younger
sister had the melanoma when she was in her 30s. She worked at the lake
with me several years.
MARIANNE SHAUGHNESSY: Ah. Lifeguards, were you?
MS. HUDGENS: Well, close to it, yes.
MARIANNE SHAUGHNESSY: However, it’s very important for
the professional nurse to maintain a professional
demeanor, and make sure that the questions
that she’s asking patients, the responses
that she’s recording, and additional questions
that she’s asking stay within the realm of
professional nursing practice.
MS. HUDGENS: My husband said
that there’s a spot on my back that looks a little funny. I’ve had other moles
taken off before and they were never
cancerous, but I just wanted to have that checked out.
The baccalaureate prepared nurse has advanced
skills in terms of capturing depth of information. For example, when this
morning’s patient told me that she had a history
of sun exposure, and now had a lesion
of concern on her back, that led to probing
questions about the history of early sun exposure
and prior mole identification and removal. Also looking for
pathologies of lesions that had been
removed in the past. Let’s talk a little bit
about the mole on your back. Do you have– you
mentioned that you had some moles removed previously.
MS. HUDGENS: Yes.
MARIANNE SHAUGHNESSY: And how long ago are we talking?
MS. HUDGENS: I had one removed off of my leg just about four years ago.
MARIANNE SHAUGHNESSY: Mmhm. And the pathology on that, do you–?
MS. HUDGENS: They said it was fine. There was no problems with it.
MARIANNE SHAUGHNESSY: OK.
MS. HUDGENS: But my sister does have– did have a history of
melanoma, and so I’m always worried about it.
MARIANNE SHAUGHNESSY: OK. Let’s talk a little bit about your sun exposure.
MS. HUDGENS: I grew up in Phoenix.
MARIANNE SHAUGHNESSY: You did?
MS. HUDGENS: Yes, and lots of time on the water, lot of sunburns. I spent a couple of summers
working at the lake, and didn’t take care of it very well.
MARIANNE SHAUGHNESSY: And
you only apply sunscreen if you’re going to
be going outside?
MS. HUDGENS: Yes.
MARIANNE SHAUGHNESSY: OK. What number do you use?
MS. HUDGENS: 15.
MARIANNE SHAUGHNESSY: OK. Well, for somebody
like you we would recommend that
you actually go up to 30 or above and every day.
MS. HUDGENS: OK.
It’s very important to take every opportunity
to pull in health promotion strategies. In this interview,
we utilized not only the opportunity to educate
the patient about SPF, but also weight
loss, diet, exercise. I take every opportunity to
work health promotion strategies into every interaction with
a patient whenever I can. Would you like to try
and lose some weight?
MS. HUDGENS: Yes.
MARIANNE SHAUGHNESSY: OK. Well, we can talk more about
that, because I can provide you with some– a recommended diet
for you to follow if you’re interested in doing that. When you’re dealing with
sensitive issues in general, the communication strategies
really do come into play. It’s very important to
watch the tone of your voice so that you’re not in any
way conveying a judgment, but allowing them to openly
communicate and share with you what
sensitive issues they feel comfortable disclosing. OK, and your fourth pregnancy?
MS. HUDGENS: The
fourth pregnancy I was 23, and that did
end in a termination. My husband was laid
off at the time, so we chose to
terminate the pregnancy.
MARIANNE SHAUGHNESSY: OK. I think one thing that I
would caution RNs about is you know that the time
you need to set aside to do an interview
with a younger person is going to be significantly
different from the time you need to set aside to do
with an older person. In the world of
gerontology, it wouldn’t be unusual at all for
an interview like that to go upwards of 45
minutes, and would include a lot more questions
about functional assessment, day to day activities,
cognitive status, and things like that that can
impact the life of a senior.
If you work in a setting
where you have patients from a number of
different cultures, you learn very quickly what
the issues are surrounding health care, patient
interviewing, physical exams, how someone is either willing or
unwilling to disrobe for a man or woman in the room,
about their comfort level with making eye contact.
All of those things are
very setting-dependent, but the nurse who’s working, no
matter where, has to be aware that some of these influences
can come into play at any time and keep the radar up for
when those issues may come into play, because the
most important thing is making sure that the
patient is comfortable. We’re going to go back
to the review of systems. I’m going to go
from head to toe.
MS. HUDGENS: OK.
MARIANNE SHAUGHNESSY: All right? And we’re going to start with
your general, overall health. Have you noticed in
the last six months any changes in your weight?
MS. HUDGENS: No. MARIANNE SHAUGHNESSY:
The review of systems is the close of the interview. It’s a final
opportunity to capture any issues that may
have been missed to that point in the interview. The laws vary according
to state in terms of mandatory reporting
for domestic violence, but it’s critically important
to make sure and ask that screening
question, which I asked at the end of the interview.
And the last question
is are there any times that you don’t
feel safe at home? That’s a very globally
worded question, but it allows the
door to be opened. OK, you’re afraid of falling. OK. OK, I have to– I ask
that question of everyone only because you never know.
I always conclude an
interview by asking a patient, is there anything else
you wanted to discuss that we have not yet discussed? The reason for
this is I’m trying to avoid what we typically refer
to as a doorknob agenda item, meaning when you’ve
completed the interview, given the patient a
gown, and asked them to undress for
the physical exam, as you’re moving
toward the door, as you place your
hand on the doorknob, a patient will
sometimes say, oh, yes, there’s one more thing.
Now, before we wrap
up the interview, are there any other issues
that you want to talk about that we have not yet discussed?
MS. HUDGENS: No, I think that’s all.
MARIANNE SHAUGHNESSY: OK. All right, then. Well, we’re going to
go ahead and proceed to your physical exam, then.
MS. HUDGENS: OK, great. Thank you.
MARIANNE SHAUGHNESSY: So once
the interview is complete, it guides your
physical examination. By talking to a patient,
you can identify 90% of what your physical
exam is going to need to be. Students are very, very
focused on learning techniques that are involved
in physical exam, and they sometimes tend
to ignore the interview. But the interview is probably
the most critical component. That’s where you start– with
what the patient tells you.
Somewhat ironic, I think, that
most of the physical assessment textbooks really do emphasize
the physical assessment aspect much more so
than the interview, when the interview actually
plays such a critical role in establishing where
things go moving forward in terms of physical
exam techniques that are chosen from
that point forward, and from specific systems
that a provider may need to pay special attention to.
That information is
captured in the interview, and in the health history. There’s always a great deal
of professional satisfaction derived from
capturing information, from making someone
feel at home, and for establishing yourself as
a partner in their healthcare. [music playing]
Assessment Tool, Diagnostics, Growth, Measurements, and Nutrition in Adults and Children – Week 3 (11m)
LACHANDA BROWN: Hello,
everyone and welcome to 6512: Advance Health Assessment. I’m Dr. LaChanda Brown, and I’m
one of the contributing faculty members in the Advance
Health Assessment course. In this week, week
3, we will focus on assessment tools, diagnostics
and growth, measurements, and nutrition, in
adults and children.
One of the major issues in
health care today is obesity. Obesity is an
ever-growing problem. It has increased the mortality
rate, morbidity, and increases in health care costs
as well as utilization. We have also seen an
increase in obesity in children over
the past 30 years. When we are looking
at all of this, we want to make sure that we
get an overall health overview.
We want to look at nutritional
status, as well as body measurements, as
well as other factors like socioeconomic,
culture, religion. There are several ways that
we can look at our patients as far as providing care. One such way is
cultural competency. As mentioned previously,
cultural competency is very important. We want to make sure that
we are culturally sensitive, being sensitive to the
needs of our patients, as well as being
aware of diversity.
We know that not
everyone is the same. We want to be aware of a
patient’s religion, how it may affect their
health care, as well as socioeconomic status, as
well as any other thing that can affect the patient’s care. We want to be sensitive
to that, and we want to assess the
needs of that patient. By being culturally
competent, we can help to define
the culture broadly. We can look at a client’s
Again, how does that
affect their patient care? How does that affect how
they take care of themselves, if they’re taking
their medication, how they interact with you? We also want to
recognize the complexity in language and interpretation. We also want to facilitate
learning between providers and communities. So you may be in
a community that may be poor socioeconomic or
possible language barriers.
You want to try
to figure out ways to be able to interact
with your patients. And you also want to
be able to collaborate with other agencies, if
possible, for your patient. And also provide
training, making sure that you have that you are
trained in cultural sensitivity and diversity, as well as staff. So when we look at assessment
tools with our patients, we want to make
sure that we have tools that will accurately
test the patients and assess their needs.
For example, if a patient comes
in with issues of sore throat, most likely, you will
do a rapid strep test. But you also want to
make sure that you are aware that that strep
test may be invalid. You want to look at the
patient’s overall symptoms. Another example is
looking at BMIs. You want to look at
the BMI of a patient. A patient’s BMI may be higher. You may have one ethnicity
that may have a higher BMI, but not necessarily
be obese by looking. But if you calculate
the height and weight, it will automatically
But by looking at the patient,
they may not look obese. So you want to be aware
of your assessment tools. You want to look
at your reliability and validity of your tools. And then you want to
look at diagnostic costs. We never want to order
tests that are unnecessary, but we also want to
order tests that will be effective for the patient.
So being aware of that, one of
the main issues that we have seen in health care [AUDIO OUT] One of the issues that
we look at is treatment. Is it effective? When we order tests,
will it make a difference in the morbidity or
mortality of the condition, if it’s caught early or
if it’s detected late. So you want to be aware of that. Another issue is
that more than 50% of orders that
have been made will be a big eye-opener to
policyholders to your patient. They may not know why
this test is ordered. So you want to make
sure that you explain the tests that you’re
ordering and why, and making sure that the
patient is aware of it, and that they’re OK with
the diagnostic test.
So this week, you will
have a case study, and you will use week 3. You will apply, from
your reading material, diagnostic tools,
growth, and measurements. Your case study will be posted
by day 1 by your instructor. Your next assignment
is your Shadow Health. I’ve been discussing
Shadow Health since week 1, but this is the first week
that your orientation is due. Please remember, if you haven’t
purchased Shadow Health, please purchase Shadow Health. You can purchase shadow health
through your Walden U book store.
And once you purchase
Shadow Health, you will receive a
confirmation email. You do not need a PIN
number from your instructor. If you have any issues
regarding Shadow Health– uploading or accessing–
please contact Shadow Health IT or your instructor. And again, please go through
your Shadow Health orientation. I did point on here
links for you guys, also, note the IT, as well as Shadow
Health tips for success.
And please note the
documentation tutorial, it is very important. In the documentation
tutorial, it will give you a
clear, concise way of how to look at the patient. You want to make sure that you
look at the subjective data. Subjective is what the
patient is telling you. What is going on
with the patient– the chief complaint, the
history of present illness, the review system– those are all subjective data. And then your
objective data is what you see– your vital signs,
assessing heart and lungs. So you want to make
sure that the difference of the subjective and
the objective data.
And then once you complete your
assignment in Shadow Health, there is a student
acknowledgment form that you will manually
sign and upload on Blackboard. That needs to be uploaded
every time you turn in a Shadow Health assessment. So, again, for week 3,
your second assignment is your Digital Clinical
Experience Health History Assessment, your DCE. You want to make sure you
review the learning resources, as well as take a Health
History media program. You want to download and
review the student checklists on the subjective data, as
well as the learning resources. Your DCE orientation in
Shadow Health is 15 minutes.
Your Conversion Concept
Lab is 50 minutes. That does not need to be
uploaded in Blackboard. That is practice. Your Health History
of Tina Jones is what you’re going to be
uploading in Blackboard. Again, I repeat– Tina Jones Health
History is what you will be submitting in Blackboard. Do not submit the
Conversion Concept Lab. You should be submitting
your DCE score. Your DCE score will have
a number at the bottom and it will say whatever
percentage that you have. And also, just remember, in
each Shadow Health assessment, it may be opened as
many times as you like.
But on the last day,
it’s the deadline, day 7. And you must have
at least the 80%. So again, your DCE score– it is a combination of your
Digital Clinical Experience, as well as your
documentation notes. Tina health does not have to
be turned in until week 4, and please note week 4.
This week is more of a practice. So if you haven’t already
started practicing, you can begin to practice
in Shadow Health. I do recommend that you
start as soon as possible. And if you have any
questions or concerns, please reach out
to your instructor. Thank you.