NURSING GUIDELINES

OF AN EFFECTIVE
INTERVIEW AND
HEALTH HISTORY

MERCYDINA ABDONA M. CAPONPON, MD, DPPS, MPH

OBJECTIVES:

 Learn Components of a Nursing Health History

 Able To learn Types of Communications
 Able To learn Phases of Communications
 Learn Special Considerations
 Age
 Cultural
 Psychosocial/Emotional Variations
 COMPONENTS OF A NURSING
HISTORY

 BIOGRAPHIC DATA
 CLIENT’S NAME
 ADDRESS
 AGE
 SEX
 MARITAL STATUS
 OCCUPATION
 RELIGION
 HEALTH CARE FINANCING
 SOURCE OF MEDICAL CARE
CHIEF COMPLAINT OR REASON FOR
VISIT

 The Answer given to the question “What is Troubling

you ?” or “Can you tell me the Reason you came to the
Hospital or Clinic Today?” .

 The Chief Complaint Should be recorded in the client’s

own words.
 HISTORY OF PRESENT ILLNESS
 Childhood Illness, such as Chickenpox, mumps, measles, rubella
(German Measles), rubeola (red measles), Streptococcal
infections, Scarlet fever, rheumatic fever, and other significant
illnesses.
 Childhood immunizations and the date to the last tetanus shot
 Allergies to Medications, Animals, Insects or Environmental
agents, The type of reaction that occurs, and how the reaction
is treated
 Accidental and Injuries: How, When, and Where the incident
occurred, type of injury, treatment received, and any
complications.
 Hospitalization for serious illness: reason for hospitalization,
dates, surgery performed, course of recovery, and
complications.
 Medications: All Current used prescription and over-the-counter
medications, such as aspirin, nasal spray, vitamins, or laxatives
 PAST HISTORY

 When the symptoms started

 Whether the onset of symptoms was sudden or gradual
 How often the problems occurs
 Exact location of the distress
 Character of the complaint (e.g., intensity of pain or quality of
sputum, emesis, or discharged)
 Activity in which the client was involved when the problem
occurred
 Phenomena or symptoms associated with the chief complaint
 Factors that aggravate or alleviate the problem
 FAMILY HISTORY OF ILLNESS
 Risk Factors for certain diseases, the ages of siblings, parents, and
grandparents and their current state of health
 If they are deceased , the cause of death are obtained
 Particular attention should be given to disorders such as
 Heart disease
 Cancer
 Diabetes
 Hypertension
 Obesity
 Allergies
 Arthritis
 Tuberculosis
 Bleeding disorder
 Alcoholism
 And any mental health disorders
 LIFE STYLE
 Personal Habits: Amount, Frequency and duration of substance use
(tobacco, alcohol , coffee, cola, tea and illicit or recreational drugs)
 Diet: Description of typical diet on a normal day or any special diet,
number of meals and snacks per day , ethnically distinct food patterns,
and allergies.
 Sleep/rest Patterns: Usual daily sleep/wake times, difficulties sleeping
and remedies used for difficulties.
 Activities of Daily Living: any difficulties experienced in the basic
activities of eating, grooming, dressing, elimination, and locomotion
 Instrumental activities of daily living: any difficulties experienced in
food preparation, shopping, transportation , housekeeping, laundry, and
ability to use telephone, handle finances , and manage medications.
 Recreation/hobbies: Exercise activity and tolerance, hobbies and other
interests, and vacations.
 SOCIAL DATA
 Family relationships/Friendships: Client support system in time of
stress.
 Ethnic affiliation : Health Customs and beliefs; Cultural practices
that may affect health and recovery.
 Educational History: Data about the clients highest level of
education attained and any past difficulties with learning.
 Occupational History: Current employment status, the number of
days missed from work because of illness, any history of
accidents on the job, any occupational hazards with potential for
future disease and accident.
 Economic Status: Information about how the client is paying for
medical care.
 Home and Neighborhood Conditions: Home Safety measures and
adjustments in Physical facilities that may be required to help
the client manage a physical disability, activity intolerance, and
activities of daily living.
 PSYCHOLOGICAL DATA
 Major Stressors Experienced and the clients perception of the
 Usual coping pattern with a serious problem or high level of
stress
 Communication style: Ability to verbalize appropriate emotion;
non-verbal communication- such as
 Eye movements
 Gestures
 Use of touch
 Posture
 Interaction with support persons
 Congruence of nonverbal behavior and verbal expression.
COMMUNICATING/COMMUNICATION

 Any Means of Exchanging information or

Feelings Between two or more people.

 TWO MAIN PURPOSES OF NURSING

COMMUNICATIONS
 To Influence Others
 To Obtain Information
MODES OF COMMUNICATION

 NON-VERBAL
 VERBAL

COMMUNICATION PROCESS
> Face to Face Communication involves a
SENDER, a MESSAGE, RECIEVER and
RESPONSE/FEEDBACK.
 I. SENDER (Source Encoder) –A Person or Group Who
Wishes to Convey Message To Another
 Encoding-Transmit Message, Such as Language
words to use, tone of Voice and Gestures to use.
 II. MESSAGE (Requires Response/Feedback)- What is
Actually Said or Written, Body Language That
Accompanies the words.
 Talking Face to Face with a person may be more
effective in some instances than using telephones
or writing message. Ex. Facial expressions,
Gestures and Body movements.
 III. RECIEVER (Decoder)- Listener, Who must Listen
Observe and Attend.
 IV. RESPONSE (Feedback)- Is the Message That the
Receiver returns to the sender.
MODES OF COMMUNICATION

 VERBAL COMMUNICATION- is a type of

communication where we use spoken and
written words to get our message and
information across to the other person..
 NON VERBAL COMMUNICATION-Uses Other
forms, Such as Gestures or Facial Expression
and Touch.
 ELECTRONIC COMMUNICATION-
Communication has involved with technology.
Verbal communication
 Words used vary among individuals. According to CULTURE,
SOCIO-ECONOMIC BACKGROUND,AGE, AND EDUCATION,
 When Choosing words to say or write, Nurses need to Consider:
I. PACE AND INTONATION- Manner Of Speech, Speak Slowly and Softly to an
excited Client may help calm client.
II. SIMPLICITY- Use of commonly understood words, brevity and
Completeness. Nurses Need to Learn Select Appropriate, Understandable
terms. Based on Age, Knowledge, Culture And Education of Client.
III. CLARITY AND BREVITY- CLARITY-Saying Precisely What is Meant And
BREVITY- Using The fewest words Necessary.
IV. ADAPTIVIBILITY- Adjustment of What Client Situations
V. CREDIBILITY- Worthiness of Belief, Trust worthiness and Reliability
VI. HUMOR-Positive and Powerful Tool in Nurse-Client Relationship
*Timing is Also Important to Consider
*Humor and Laughter can Help Reduce Stress and Anxiety in EARLY And
RECOVERY STAGE OF CRISIS.
*Peak of Crisis-May be Consider Offensive or Distracting at Peace.
Non-Verbal communication
 Involves Body Language, Gestures, use of Touch and
Physical Appearance.
 I. Personal Appearance- How a Person dresses is often an
indicator of how person feels. Clothing and Adornments can be
sources of information about a person.
II. Posture and Gait- The way people walk and carry themselves
are often reliable indicators of self concept, current mood and
health.
*Erect Posture and an Active- Purposeful strides suggest a
feeling of well-being.
*Slouched Posture and Slow- Shuffling gait suggest Depression
or Physical Discomfort
*Tense Posture and Rapid- Determined gait anxiety or Anger.
III. Facial Expression- No Body part is as expressive as the Face.
*Eye Contact- Is another essential element of Facial
Communication-eye contact acknowledges recognition of other
person willing to maintain communication.
IV. Gestures-For people with Special Communication problems,
such as the deaf, the hands are invaluable in communication.
Electronic Communication

 Email- most common form of Electronic

Communication

 ADVANTAGES- It is Fast Efficient Way to

Communicate and it is Legible.

 DISAVANTAGES- Risk of Confidentiality

PHASES OF COMMUNICATION
I. PRE-INTERACTION PHASE
 Similar to the planning stage before interview,
 The Nurse has information about the Client
before Face to Face Meeting such as:
 NAME

 ADDRESS

 AGE

 MEDICAL HISTORY
 SOCIAL HISTORY
II. INTRODUCTORY PHASE/
ORIENTATION PHASE
 Or known Pre-helping Phase, The orientation phase is the
period when the nurse and patients first meet and goals
are set. The goal of the orientation phase is to build trust
and respect.
 Client Also may display Some Resistive Behavior
 RESISTIVE BEHAVIOR- Are those that inhibit
involvement cooperation or change. Due to difficulty in
acknowledge the need for help and fear of exposing
facing feelings, anxiety behavior patterns.
 BY OVER COME BY RESISTIVE BEHAVIOR, convey a
caring, attitude, genuine interest in the client and
competence may foster development of trust in the
relationship.
STAGES OF INTRODUCTORY PHASE
 I. OPENING THE RELATIONSHIP-
 Tasks-Both Client and Nurse identify each other by NAME.
 Skills-A relaxed, Attending attitude to put the client at ease. It is not
easy for all Clients to receive Help.
 II. CLARIFYING THE PROBLEMS-
 Task-Because the client initially may not see the problem Clearly, the NURSE’S
major Task is to help Clarify the Problem
 Skills- Attentive Listening, Paraphrasing, Clarifying and other Effective
Communication Techniques
 III. STRUCTURING AND FORMULATING-
 Task-Nurse and Client Develop Degree of Trust and Verbally Agree about
(a)Location, Frequency and Length of Meetings
(b)Overall purpose of the relationship
(c)How Confidential Material will be Handled
(d)Task to be accomplished
(e)Duration and indications for termination of relationship
Skills-Communication skill and ability to overcome resistive behavior
 By the end of the INTRODUCTORY PHASE client should begin to

 Develop Trust in the Nurse

 View the Nurse as a Competent Professional Capable of Helping
 View the Nurse as Honest, Open and concerned about their Welfare
 Believe the Nurse will try to Understand and Respect their Cultural
Values and Beliefs
 Believe the Nurse will Respect Client Confidentiality
 Feel Comfortable Talking About Feelings and Other Sensitive Issues.
 Understand the purpose of the relationship and roles
 Feel that they are Active Participants in Developing Mutually
Agreeable Plan of Care
III.WORKING PHASE
Client Begin to View each other as Unique Individuals.
III.WORKING PHASE

 STAGES OF WORKING PHASE

 I. Exploring and Understanding thoughts and Feelings-Nurse Assist
the Client to Explore Thoughts and Feelings and Acquires an
Understanding of the Client.
 II. Facilitating and Taking Action- The Nurse Plans Programs within
the Clients Capabilities and Consider long or Short term Goals.

GOALS MUST BE
S-Smart
M-Measurable
A-Attainable
R-Realistic
T-Time Oriented
IV. TERMINATION PHASE
 Nurse and Client Accept Feelings of Loss, The Client Accepts the
end of Relationships without Feeling of Anxiety or Dependence
 The Nurse Must Summarizing Skill of the Client Ability to Handle
Problems Independently.
 Consideration of grieving/loss
 STAGES
 D-Denial
 A-Anger
 B-Bargaining
 D-Depression
 A-Acceptance
 SPECIAL CONSIDERATION OF
COMMUNICATION
 AGE/LIFE SPAN CONSIDERATION- Communicate Directly
Related to the Development of thought Process, Presence of
intact sensory and Motor Systems.
INFANTS- AGE (Birth-1 year old)
 Infants Communicate Non verbally, Often in Response to Body
Feelings
 Infants perceptions are related to Sensory Stimuli.
 Gentle Voice is Soothing.
TODDLERS & PRESCHOOLERS
(1-3 YEARS OLD) (4-5 YEARS OLD)
 Toddlers and Young Children gain skills in Both Expressive
 Allow time for them to Complete Verbalizing their Thoughts
without Interruption
 Provide a Simple Response to questions because they have
Short Attention Spans.
 Drawing and Picture Can Provide Another way for the Child to
Communicate, They are Attentive to Bright Colors
 SCHOOL AGE
(6-12 YEARS OLD)
 Talk to the Child at his or Her eye Level to Help Decrease
Intimidation
 Include The Child in the Conversation when Communication
with Parents.
 ADOLESCENTS
(12-18 YEARS OLD)
 Take Time to Build Rapport with the Adolescent
 Use Active Listening Skills
 Project A Non-Judgemental Attitude and Non-Reactive
Behaviors, Even when the Adolescents says Disturbing
Remarks.
COMMUNICATION WITH ELDERS
 Older Adults may have Physical or Cognitive Problems that
Necessitate Nursing Intervention for Improvement of
Communication Skills
 Sensory Deficits, Visions and Hearing
 Cognitive Impairment as in Dementia
 Neurological Deficits from Strokes or Other Neurological Conditions
 Psychosocial Problems such as Depression
 Include Family and Friends in Conversations.
 SPECIAL CONSIDERATION OF
COMMUNICATION
 CULTURE- Set of Beliefs, Values, Artistic, Historical and
Religious Characteristics.
 CULTURE SHOCK-A Form of Stress associated with the
beginning of a person’s Assimilation into a new ghastly
Different Culture.
 CULTURAL COMPETENCE-Nursing Knowledge and
Understanding of Another Person’s Culture; Adapting
Interventions and approaches to health care, adjusted to the
specific culture of the patient, family and social group.
 CULTURALLY SENSITIVE-Implies that nurses possess some
basic knowledge of and constructive attitudes towards health
traditions.
 CULTURALLY APPROPRIATE-Implies that nurses apply the
underlying Background Knowledge.
 CULTURALLY COMPETENT-Implies that within the delivered care,
Nurses Understand and Attend to the Total Context of Client Situations:
 Nurse’s Must Possessed Skill, Knowledge And Attitude.
 TRANSCULTURAL NURSING-Focuses on Providing Care within the
Difference and Similarities of the Beliefs, values and Patterns of
Cultures.
 SUBCULTURE- is Usually Composed of People who have a distinct
Identity and yet Larger Cultural group. Ex. Societal Groups (feminist),
Ethnic Groups
 BICLTURAL-Is used to Described a person who has dual Patterns of
Identifications and Crosses two culture, life styles and sets of Values.
 DIVERSITY- Refers to the Factor or state of being different many factor
account for; Race, Gender, Sexual Orientation, Culture, Ethnicity, Socio-
economic Status , Educational Attainment and Religion.
 ACCULTURATION-Occurs when people adapt to or borrow traits from
another culture
 ASSIMILATION- Is the process by which an individual develops a new
cultural identity.
 RACE-is the classification of people according to share biologic
characteristics genetic matters or features.
 PREJUDICE-Is a Negative Belief or Preference that is
generalized about a group and that leads to prejudgment.
Associated with XENOPHOBIA-Fear on Dislike of people
different from one’s self.
 STEREOTYPHING-Making a judgement about an individual that
is influenced by an mental state.
 ETHNOCENTRISM-is the belief that one’s own culture or way of
life is better than that of others.
 DISCRIMINATION-Differential treatment of individuals on groups
based on; RACE,ETHNICITY,GENDER and SOCIAL CLASS.
 SPECIAL CONSIDERATION OF
COMMUNICATION
 Psychosocial/Emotional Variations

 THERAPEUTIC COMMUNICATION
 Promotes Understanding and can help establish a constructive
relationship between the nurse and client.
 Therapeutic Communication
Techniques
 ACTIVE LISTENING
 Is an active process that requires energy and concentration. It
involves paying attention total message, both verbal and nonverbal.

 PHYSICAL ATTENDING
 Which defines as the manner of being present to another or being
with another
 TECHNIQUE DESCRIPTION EXAMPLES

Accepting pauses or Sitting quietly (or

silences that may walking the client)
USING SILENCE extend for several and waiting
seconds or minutes attentively until the
without interjecting client is able to put
any verbal response. thoughts and
feelings into words.
Using Statements or “Can you tell me how
Questions that it is for you?”
PROVIDING (a)Encourage the “perhaps you would
GENERAL LEADS client to verbalize, like to talk about..”
(b) Choose a topic of “Would it Help to
conversation, and discuss your
(c) Facilitate feeling?’
continued “Where would you
verbalization. like to begin?”.
 TECHNIQUE DESCRIPTION EXAMPLES

“Rate your pain on a

scale of 0-10”
(specific Statement)
BEING SPECIFIC Making statements “Are you in Pain?”
AND TENTATIVE that are specific (general Statement)
rather than general “You Seem
tentative rather than unconcerned about
absolute. your Diabetes”
(tentative Statement)
“You don’t care about
your diabetes and
you never will”
(absolute Statement)
 TECHNIQUE DESCRIPTION EXAMPLES

Asking broad “Id like to hear more

questions that lead about that”
USING OPEN-ENDED or invite the client to “Tell me about. . .”
QUESTIONS explore(Elaborate, “How have you been
Clarify, Describe, feeling lately?’
Compare, or “What brought you to
Illustrate) thoughts the Hospital?”
or feelings.
Providing Putting an arm over
appropriate forms of the client’s Shoulder.
USING TOUCH touch to reinforce Placing your hand
caring feelings. over the client’s
hand.
 TECHNIQUE DESCRIPTION EXAMPLES

Client: “I couldn’t
manage to eat any
dinner last night- not
even the dessert”
RESTATING OR Actively listening for Nurse: “You had
PARAPHASING the client’s basic difficulty eating
message and then yesterday”
repeating those Client: “Yes, I was
thoughts and/ or very upset after my
feelings in similar family left”.
words. Client: “I have
Trouble talking to
strangers”
Nurse:” You find it
difficult talking to
people you do not
 TECHNIQUE DESCRIPTION EXAMPLES

A Method of Making “I'm not sure I

the Clients board understand that.”
SEEKING overall meaning of “Would you please
CLARIFICTION the message more say that again?”
understandable. “would you tell me
more?”
A Method similar to Client: “My Husband
clarifying that never gives me any
presents”.
PERCEPTION verifies the meaning
Nurse: “You mean he
CHECKING OR of specific words
has never given you a
SEEKING rather than overall present for your
CONSENSUAL meaning of a birthday or Christmas?”
VALIDATION message. Client:” Well-not never.
He does get me
something for my
birthday and Christmas,
but he never thinks of
 TECHNIQUE DESCRIPTION EXAMPLES
Suggesting one’s “I’ll Stay with you until
presence, interest, or your daughter arrives”
wish to understand the “We can sit here quietly
OFFERING SELF
client without making for a while; we don’t
any demands or need to talk unless you
attaching conditions would like to.”
that the client must “ill help you to dress to
comply with to receive go home, if you like.”
the nurse attention.
Providing in a simple “your surgery is
and direct manner, schedule for 11 am
specific factual tomorrow.”
GIVING
information the client “you will feel a pulling
INFORMATION
may or may not sensation when the
request. When tube is removed from
information is not your abdomen”
known, the nurse states “I do not know the
this and indicates who answer to that, but I
has it or when the will find out from Mrs.
nurse will obtain it. Park, the nurse in
 TECHNIQUE DESCRIPTION EXAMPLES
Giving Recognition, in “you trimmed your
nonjudgmental way, of beard and mustache
a change behavior, an and wash your hair”
ACKNOWLEDGING
effort the client has “I notice you keep
made, or a contribution squinting your eyes, are
to communication. you having difficulty in
seeing?”
“you walked twice as
far today with your
walker”
Helping the client Client:” I Vomited this
clarify an event, morning.”
situation, or happening Nurse: ” Was that after
CLARIFYING TIME
in relationship to time. breakfast”.
OR SEQUENCE
Client: “ I feel that I
have been asleep for
weeks.”
Nurse: “you had your
operation Monday, and
today is Tuesday.”
TECHNIQUE DESCRIPTION EXAMPLES
Helping the Client to “That telephone ring
differentiate the real came from the program
from the unreal. on television.”
PRESENTING
“I see shadows from
REALITY
the window coverings.”
“your magazine is here
in the drawer, it has not
been stolen.”
Helping the client Client : ” My wife says
expand on and develop she will look after me ,
a topic of importance. but I don’t think she
FOCUSING
It is important for the can, what with the
nurse to wait until the children to take care of,
client finishes stating and they’re always
the main concerns after about something-
before attempting to Clothes ,homework ,
focus. What’s is dinner that
night.”
Nurse: “ Sounds like
you are worried about
 TECHNIQUE DESCRIPTION EXAMPLES

Directing ideas, Client: “What can I

feelings, questions, do?”
REFLECTING or content back to Nurse: “What do you
clients to enable think would be
them to explore their helpful?”
own ideas and Client: “Do you think
feelings about a I should tell my
situation. husband?”
Nurse: “you seem
unsure about telling
your husband?”
Stating the main “in a few days I’ll
points of a review what you
SUMMARIZING AND discussion to clarify have learned about
PLANNING the relevant points the actions and
discussed. This effects of your
technique is useful insulin.”
at end of interview
Barriers to Communication
Techniques
 TECHNIQUE DESCRIPTION EXAMPLES

Offering generalized “ Two year-Old

and oversimplified Brats.”
STEREOTYPING beliefs about groups “Women are
of people that are Complainers.”
based on “Men don’t Cry.”
experiences too
limited to be valid.
Akin to judgmental Client: “I don’t think
responses, agreeing Dr. Kim is a very
AGREEING AND and disagreeing Good Doctor. He
DISAGREEING imply that the client doesn’t Seem
is either right or interested in his
wrong and that the patients”.
nurse is in a position Nurse: “Dr. Kim is
to judge this. head of department
of surgery and is an
excellent surgeon.”
 TECHNIQUE DESCRIPTION EXAMPLES

Attempting to Client: “Those night

protect a person or nurses must just sit
BEING DEFENSIVE health care services around and talk all
from negative night. They didn’t
comments. answer my light for
over an hour.”
Nurse: “I’ll have
know we literally run
around on nights.
You’re not the only
client you know”.

Giving a response Client: “I felt

that makes clients nauseated after that
CHALLENGING prove their red pill.”
statements or point Nurse: “Surely you
of view. don’t think I gave you
the wrong pill.?”
TECHNIQUE DESCRIPTION EXAMPLES

Asking for Client: “I was

information chiefly speeding along the
PROBING out of curiosity street and didn’t see
rather than with the the stop sign.”
intent to assist the Nurse: “Why are you
client. speeding?”

Asking questions “Who do you think

that make the client you are?”(forces the
TESTING admit to something. client to admit their
status is only that of
client)
“Do you think I am
not busy?”(forces the
client to admit that
the nurse really is
busy).
 TECHNIQUE DESCRIPTION EXAMPLES

Refusing to discuss “I don’t want to

certain topics with discuss that. Let’s
REJECTING the client. talk about
something.”

Directing the Client: “I’m

communication into separated from my
CHANGING TOPICS areas of self-interest wife. Do you think I
AND SUBJECTS rather than should have sexual
considering the relations with
clients concerns. another women?”
Nurse:” I see you’re
36 and that you like
gardening.”
 TECHNIQUE DESCRIPTION EXAMPLES
Using cliches or “You’ll feel better soon”
comforting statements “I'm sure everything
of advice as a means to will turn out all right”
UNWARRANTED
reassure the client.
REASURRANCE

Giving opinions and “That’s good(Bad)”

approving or “you shouldn’t do that”.
disapproving “that’s not good
PASSING
responses, moralizing, enough”
JUDGEMENT
or implying one’s own “What you did was
values. wrong(right)”
Telling the Client what Client: “Should I move
GIVING COMMON to do. These responses from my home to a
deny the client’s right nursing home.?”
ADVICE
to be an equal partner. Nurse: ” If I were you,
I’d go to nursing home,
where you’ll get your
meals cooked for you.”
THANK YOU