Note: ROS may be conducted with the physical exam. When the patient has few symptoms, this can be very efficient.

As you learn a patient’s symptoms and their attributes, you should start to think critically about what bodily system might be involved by a pathological process. Leg pain, for example, may suggest a problem with peripheral vascular, musculoskeletal, or nervous system. Direct questions may be used to gather specific information, but direct questions should not be leading questions (“did your stools look like tar? – what color were your stools?”) May offer multiple choice answers with your questions (ie: was your pain sharp, pressing, burning, shooting, or what?) Only ask one question at a time, multiple questions may lead to confusion (ie: any TB, asthma, bronchitis, pneumonia?)

Health History RNRS 210 Fall 2008

Objectives

The Health History and Patient Physical A “Partnership with the Patient” – taking the history usually begins your relationship with the patient Begin with history (interview) Move into physical examination The patient health history followed by the physical examination are the heart of the diagnostic and treatment

Goals of the patient health history Discover information leading to diagnosis and management Provide information about diagnosis Assess wellness and usual health practices Negotiate and share in health care management Counsel about disease prevention

Formats of the Health History

5 Steps of Patient Centered History University of Florida, College of Medicine, Essentials of Patient Care, 5-Steps of Patient Centered Interviewing Checklist

What is subjective data? Symptoms Feelings Perceptions Desires Preferences Beliefs Ideas Values Personal Information Collection of subjective Data

Where does subjective data come from? The patient interview. . . . . It is information obtained by the nurse during the health history. All data obtained during the health history is considered subjective data.

Effective Interview Skills are Essential Establish a trusting relationship Systematic method of obtaining and recording data is necessary Provide privacy Provide comfort Provide a quiet environment Assure and maintain confidentiality Remove any physical barriers Maintain a professional demeanor Maintain a non-judgemental attitude Be aware of verbal and nonverbal communication

Essentials of Non-Verbal Communication Ensure a professional appearance Display poise and a professional demeanor Keep a close check on facial expressions Maintain a professional and nonjudgmental attitude Utilize and be comfortable with periods of silence Listening is the most important skill

Avoid Non-Verbal Communication Traps Distraction or inappropriate distance Standing Facial expression revealing personal opinion or fear Excessive or insufficient eye contact

Use Good Verbal Communication Use open ended questions “How have you been feeling lately?” Use close ended questions to obtain facts “When did your neck pain start?” Laundry List—Provide options to the patient for describing symptoms. “Is the pain intermittent, dull, constant, stabbing, or sharp?” Rephrasing—use this to clarify information “Do you think that your weight is a problem in your ability to do your job?”

Verbal Communication Traps Biased or Leading Questions Rushing Through the Interview Reading the Questions

Cultural Alert!!! Be aware of Potential Cultural Issues in Communication! Reluctance to reveal personal information Variation in ability to understand or communicate in English Variation in use or meaning of non-verbal communication Differences in personal space needs Differences in eye contact Variations in the family’s role in decision making

Specific Professional Format for Health History/Patient Interview Biographical Data Chief Complaint Present illness/Problem Past Medical History Family History Personal and Social History Review of Systems Summary

Forms For Conducting a Health History For this course, located on the Blackboard Site Real World? Agency Specific

Where do we begin? Introduce yourself---be the poised, warm, caring nursing you might want taking care of your family member Provide privacy, comfort, confidentiality and make the time to ask the questions the right way Take minimal notes—this means you will need to practice and memorize the questions

Biographical Data Begin history by recording patient’s name, address, age, gender, birth date May include race, religion, occupation, marital status May require name, address, telephone number of person to contact in an emergency Identify physician or other usual health care providers Indicate source & reliability of information

Biographical Data Could be in narrative style. . . . .or fill in the blanks on a form. Sample Narrative: Mr. Gere is a married caucasian male, age 58 from Los Angeles, California. He was born in Philadelphia, PA, attended University of Massachusetts, majoring in Philosophy, and has worked most of his life as an actor in films. He practices Buddhism. This is his first admission. Mr. Gere was referred by Dr. Gage.

Chief Complaint Seek answer to the question “What underlying problems or symptoms brought you here?” Note all significant patient complaints Brief quote from patient Concrete complaint of single symptom (two at the most) Determine the duration of the current illness by asking “How long has this problem been present?” or “When did these symptoms begin?” Record patient’s exact words in quotation marks (avoid paraphrasing with medical terminology) Example cc: “My right knee gives out.”

Present Problem or Illness—Or History of Chief Complaint Immediate reason for visit Chronology of events: determine when S/S appeared Health state before present problem Stability of problem Exposure to others with illness First symptoms, COLDSPA Pneumonic or PQRST Chronology review of onset of each S/S Review of involved systems Typical “attack”

COLDSPA Use it every time, for every symptom!!! Character—Describe the sign or symptom. How does it feel, look, sound, smell, and so forth? Onset—When did it begin? Location—Where is it? Does it radiate? Duration—How long does it last? Does it recur? Severity—how bad is it? Pattern—What makes it better? What makes it worse? Associated Factors—What other symptoms occur with it?

Past Medical History Ask patient about previous illnesses, injuries, immunizations and health care practices. Note dates of significant treatments and surgeries Note when and why patient sought medical attention Describe specifically, in an organized manner General health Childhood diseases Major adult illnesses Immunizations Surgeries Previous hospitalizations Serious injuries/disabilities Allergies Habits Current medications Transfusion Psychological/emotional Sociological

Family History Ask the patient about health of his/her family Investigate any S/S similar to pt Investigate any major illnesses or hereditary diseases, such as heart disease, diabetes, cancer Ask if family members have unusual limitations from illness

Pedigree ---Visually displays major family hx

Pedigrees are also called Genograms Pedigree. . .Include a Legend

Personal & Social History Habits – alcohol, tobacco, drugs, eating, exercise, sleep Sexual history – monogamous, bisexual, protected, Home conditions – safe in home? Apt? city or well water Occupation – office secretary, sits at desk for work day Environment – city, rural, pollution Personal status - Married, divorced, single, relationship with others with others? Military record Religious preference – medical concerns Finances: concerns re: cost of care, health insurance Have these activities changed in response to cc? Investigate any changes in lifestyle, personality or behavior

Review of Systems (ROS): Explore the following to review common symptoms in each body system Overall general health/ usual health or symptoms Diet Skin, hair, and nails Head and neck Nose Ears Eyes Mouth and Throat Respiratory/Chest and lungs Cardiovascular/Heart and blood vessels Breasts Endocrine/metabolic Neurological Gastrointestinal Renal/Genitourinary Musculoskeletal Hematologic Psychiatric mental health/emotional

Review of Systems (ROS) Overall general health/ usual health Weight changes: i.e.: Do clothes, shoes, rings fit more tightly/loosely? Fever Chills Fatigue Malaise Fatigability Night sweats Tolerance of daily activities?

ROS---Skin Changes in skin Pigmentation Temperature moisture texture Rash, eruption, itching, scaling Excessive sweating Abnormal nail or hair growth Changes in warts, moles or nevi

Review of Systems (ROS) cont. Head Head trauma Head injuries Headaches Dizziness Syncope Loss of consciousness

Review of Systems (ROS) cont. Neck Neck pain Radiating pain Swelling Stiffness Lumps Swollen glands Goiter Limited movement

Review of Systems (ROS) cont. Nose Sense of smell Colds Sinusitis Obstruction Epistaxis Postnasal discharge Sinus pain

Review of Systems (ROS) cont. Ears Hearing loss Hearing aid Pain or tenderness Discharge Ear infection Tinnitus Vertigo Last hearing test

Review of Systems (ROS) cont. Eyes Acuity Corrective lenses Blurring Diplopia Photophobia Burning, Pain Vision changes Cataracts Glaucoma Eye medications Trauma Excessive tearing Last eye exam

Review of Systems (ROS) cont. Mouth and throat Hoarseness or change in voice Sore throats Bleeding gums Tooth aches, abscesses, extractions Soreness or ulcers of tongue/mucosa Taste changes Difficulty swallowing Last dental exam

Review of systems Cont. Respiratory Pain Dyspnea Cyanosis Wheezing Cough Sputum Hemoptysis Night sweats Exposure to tuberculosis, TB skin test Last chest x-ray History asthma, bronchitis, pneumonia

Review of Systems (ROS) cont. Mouth and throat Hoarseness or change in voice Sore throats Bleeding gums Tooth aches, abscesses, extractions Soreness or ulcers of tongue/mucosa Taste changes Difficulty swallowing Last dental exam

Review of Systems (ROS) cont. Respiratory System Pain Dyspnea Cyanosis Wheezing Cough Sputum Hemoptysis Night sweats Exposure to tuberculosis, TB skin test Last chest x-ray History asthma, bronchitis, pneumonia

Review of Systems (ROS) cont. Cardiovascular Chest pain Palpitations Dyspnea Orthopnea Edema Hypertension Previous myocardial infarction Exercise tolerance Date of last EKG Other cardiac tests Cyanosis Edema Cold extremities Thrombophlebitis Claudication Postural hypotension Varicose veins Peripheral vascular disease

Review of Systems (ROS) cont. Respiratory System Pain Dyspnea Cyanosis Wheezing Cough Sputum Hemoptysis Night sweats Exposure to tuberculosis, TB skin test Last chest x-ray History asthma, bronchitis, pneumonia

Review of Systems (ROS) cont. Breast Changes in breast Tenderness Lumps Nipple discharge History of breast cancer Self breast exam Mammogram

Review of Systems (ROS) cont. Endocrine and metabolic Thyroid enlargement or tenderness Heat/cold intolerance Weight change Nervousness Diabetes Polydipsia Polyuria Changes in facial or body hair Increased hat or glove size Skin striae

Review of Systems (ROS) cont. Endocrine: Female and Male Female: Menses Intercourse Birth control Pregnancy Menopause Breasts Male: Puberty onset Erections Emissions Testicular pain Libido Infertility

Review of Systems (ROS) cont. Neurological Headache Syncope Seizures Weakness or paralysis Abnormalities of sensation or coordination Tremors Loss of memory

Review of Systems (ROS) cont. Gastrointestinal Changes in appetite Changes in weight Bowel elimination pattern Characteristic of Stool Flatulence Hemorrhoids Jaundice Previous x-rays Food intolerances Dysphagia Heartburn Nausea/vomiting Hematemesis Abdominal pain Rectal bleeding Hernias Gallbladder disease Liver disease

Review of Systems (ROS) cont. Renal & Genitourinary Sexually transmitted infections Dysuria Pain Urgency Frequency Nocturia Hematuria Polyuria Hesitancy Dribbling Loss in force of stream Passage of stone Edema of face Stress incontinence

Review of Systems (ROS) cont. Musculoskeletal Muscle pain Joint stiffness, pain Restriction of motion Swelling, redness, heat Bony deformity Back problems Changes in gait Arthritis

Review of Systems (ROS) cont. Hematologic Anemia Tendency to bruise/bleed easily Thromboses Thrombophlebitis Blood cell abnormalities Past transfusions

Summary Statement Summarize the findings of the health history interview in several narrative paragraphs

Documentation Document your findings in a head to toe fashion. . . . . Various formats are used in multiple healthcare settings Use appropriate documentation methods—Black Pen, Correct spelling, Correct and Standardized Abbreviations, phrased language instead of complete sentences, etc. Refer to the Do’s and Don’ts of Documentation

References Anderson, D. M., Keith, J., Novak, P. A., & Elliot, M. A. (2002). Mosby's Medical, Nursing, & Allied Health Dictionary (6th ed.). St. Louis, MO: Mosby. (Potter P A Perry A G 2009 Fundamentals of Nursing)Potter, P. A., & Perry, A. G. (2009). Fundamentals of Nursing (7th ed.). St. Louis, MO: MOSBY Elsevier. Seidel H., Ball J., Dains J., Benedict G. ( 2006). Mosby's Guide to Physical Examination (6th ed.). St. Louis, MO: MOSBY Elsevier.