Interviewing and History Taking

The material set forth in tis document is only a general overview of the subject matter and is provided for information purposes only. It is based upon the research that we have conducted and is current to the date of publication. Readers are cautioned against making any decisions based on this material alone. Rather, it is strongly encouraged that a qualified professional be consulted prior to making any decision whatsoever.

LEARNING OBJECTIVES

Proper assessment interview process

Different interviewing techniques

Information gathering

Non-verbal skills

Proper review of systems

The Assessment Interview

Some factors that may affect the ability of the client/patient/resident to fully participate are:

1. Internal Factors• Unsure how information will be used

2. External Factors• Intimidating setting

Gaining trust is essential to a successful Gaining trust is essential to a successful assessmentassessment

The Assessment Interview

Stages of the assessment interview process are:

Stage 1: Introduction PhaseClient/patient/resident needs to understand the purpose of the interview

Stage 2: Working PhaseInformation gathering

Stage 3: Closing PhaseSummarize info in a positive and “hopeful” manner

Interviewing Techniques

1. Open-Ended Questions• Require explanation

2. Closed Questions• “Yes” or “No” response

3. Directive Questions• Often using scenarios as examples

4. Use of Silence• Allowing person time to respond

5. Facilitation• Presenting choices

6. Use of examples• Sense of inclusion

Interviewing Techniques Con’t

7. Restatement• Ensures understanding

8. Reflection• Allows emotional connection

9. Clarification• Reviews intent

10. Summary• Consent to intent• Content to assessment findings

11. Confrontation• Avoid, use only with unresponsive• Assertively encourages participation

Non Verbal Communication

Your body might be contradicting what your voice or words are saying

This is called your “Unware Self”

• Practice interviewing yourself in a mirror to become “aware” of your

“unaware self”• You will see what someone receiving your message may

be seeingPosture

Facial ExpressionEye Contact

Tone of Voice

Non Verbal Communication Examples

Physical Appearance

Components of a Health History

Biographic Data

Chief Complaint

Current Health status

Past Health History

Family History

Personal Health History

Family History

Personal and Social Status

Review of Systems

Summary of Findings

A combination of the following provide an inclusive portrait of an individual:

A General Review of Systems

• Overall State of Health• Usual Weight• Weight Changes• Fever• Chill• Fatigue

• Night Sweats• History of Anemia• Bleeding Tendencies• Blood Reactions • Radiation• Pain• Discharge• Redness Infections• Injuries

The following explore the basics of the health history and guage theclient/patient/resident’s comfort level with interviewing. Start with:

Review of Systems: The Skin

Commonly used tools will include a rating system for wounds• The Braden Tool

Skin is considered a risk indicator in healthcare and requires:• Constant Support• Quality Improvement Approaches

This will encourage proactive and/or reactive remedies to

Suspected or actual skin conditions and trauma

It is important you check for or review:

History of Skin DiseaseRashes

ItchingMoles

LumpsBruises Easily

Change in Skin ColorChange in Hair Texture

Change in Nail Texture

Review of Systems: The Ear

• Change in hearing acuity is a common effect of aging

• An ear assessment takes into consideration all possible reasons for hearing changes

• The ear assessment will include:• Hearing Impairment• Use of hearing Aid• Earaches• Infections• Discharge• Pain• Ringing in Ears

Review of Systems: The Nose

The Assessment of the Nose includes obtaining histiry of pre-existing nasal conditions

The Assessment of the Nose will cover:

• Discharge• Nosebleeds• Sinus Pain/Infections• Nasal Obstruction• History of Injury• Allergies/Hay Fever• Frequency of Colds

Review of Systems: The Eyes

The condition of the eyes are key to sake maneuvering for any Individual, but especially the aging person

• Important information when reviewing he eyes:• Use of Glasses• Changes in Vision• Double Vision• Excessive Tearing• Dryness• Glaucoma• Cataracts

Review of Systems: Mouth and Throat

• Problems with teeth and/or the mouth can result in serious infections

• This is especially true with persons living with cognitive impairments as these individuals often avoid or neglect oral care

• When reviewing Mouth and Throat, check for:• Mouth pain• Frequent Sore Throat• Bleeding Gums• Toothache• Lesions in Mouth• Hoarseness• Aletered Taste• Tonsilectomy• Postnasal Drip

Review of Systems: The Neck

The neck is relatively easy to asses for malformation and conditions

Conditions to look for in the neck are:

• Pain• Limitation of Motion

• Often muscle stain, but can indicate meningitis• Lumps• Goiter• Tenderness• History of Swollen Glands• Thyroid Problem

Review of Systems: Cardiac

Accurate assessment of the cardiac systems is of the gratest importance

Without a health cardiac cystem, the rest of te systems are at risk

Appropriate checks for the Cardiac System are as follows:

Chest Pain High BP Palpitations Coronary Artery Disease SOB on Exertion SOB Lying Flat History of MI Rheumati Fever Last ECG Heart Murmur

Review of Systems: Respiratory

The Respiratory System is the most affected system through an individuals life cycle

Assessments should include”

• Past Hx• Pneumonia• Bronchitis• Emphysema• Cough• Sputum (Colour and Amour)• Pain• Hemoptysis• Last CXR• Shortness of Breath• Asthma• Last TB Skin Test• TB• Istort of TB Vaccination

Review of Systems: Vascular

Vascular Assessments refer to systems that support blood flow to all areas of the body

Common vascular conditions include:• Thrombophlebitis• Varicose Veins• Numbness or Tingling of Legs• Leg Pain• Edema• Coolness of Extremeties• Discoloration of hands and feet• Ulcers

Review of Systems: Urinary

The urinary systems can be reflective of many common conditions familiar to the aging resident

• Decreased urinary output:• Kidney impairment• Congestive heart failure• Dehydration

Increased urinary output: Acute bladder infection Diabetes Prostate conditions Ongoing assessment of aging residents is important

Review of Systems: Urinary

Urinary assessment should include:

• Frequency• Urgency• Burning on Urination• Incontinence• Infections• Stones• Bed-wetting• Blood in Urine• Nocturia• Dysuria• Pain in Urination• Flank Pain• Urine Colour/Odour• Paiin in Lower Back

Review of Systems: Musculoskeletal

Falls are the number one leading cause of hospitalization for older adults

• These often result in ongoing rehabilitation and medical support

• Musculoskeletal assessments should reviiew:• History of Arthritis or Gout• Weakness• Paralysis• Stiffness• Limitation of Movement• Joint Pain• Back Problems• Deformities

Review of Systems: Neurological

As a starting point, the nuerological assessment will review the following:

• Psychiatric Disorders• Fainting• Strokes• Tingling• Nervousness• Tremors• Disorientation• Hx of Seizure Disorder• Dizziness• Numbness• Loss of Memory• Mood Changes• Speech Disorders• Undteady Gait

Review of Systems: Gastrointestinal

The gastrointestinal system demonstrates how well the body is managing food intake and waste excretion.

The assessment should take into consideration:

• Appetite

• Excessive Hunger/Thirst

• Nausea

• Vomiting

• Difficulty Swallowing

• Constipation

• Diarrhea

• Heartburn

• Laxative Use

• Abdominal Pain

• Changes in Stool Colour

• Changes in Stiool Consistency

• Frequency of BM’s

• Hemorrhoids

• Vomiting of Blood

• Jaundice

• Food Intolerance

Analysis of a Symptom

Recording a symptom is only one part of an assessment

For further investigation of the symptom reviw the PQRSTAAA Mnemonic

• P Provoke/Prevent• Q Quality• R Region/radiation• S Severity• T Timing• A Aggravating factors• A Alleviating factors• A Associated factors

Assessment Techniques

• The health history provides subjective data based on:• The perceptions of the resident• The perceptions of the interviewer

• Signs percieved by assessor through physical exam are objective data.• Actual findings through physical examination of an assessment• When gathering data during the physical assessment you will

use: Sight Touch Smell Hearing

A combination of subjective and objective information result in the initial information of the assessment