Interview and history taking

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 assessment

The Assessment Interview Stages of the assessment interview process are: Stage 1: Introduction Phase Client/patient/resident needs to understand the purpose of the interview Stage 2: Working Phase Information gathering Stage 3: Closing Phase Summarize 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 seeing Posture Facial Expression Eye 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 the client/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 Disease Rashes Itching Moles Lumps Bruises Easily Change in Skin Color Change 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

Interview and history taking

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