Health Story Collection & Interview Phases

• İstinye University was founded in 2015 by the 21st Century Anatolian Foundation.
• It is backed by the 25-year knowledge and experience of the MLPCare Group, which includes "Liv Hospital," "Medical Park," and "VM Medical Park."
• The university aims to be among the leading universities in Türkiye and the world, contributing to the creation of new knowledge.
• It focuses on education and research with a successful academic staff.
• İstinye University aims to broaden the boundaries of science, implement scientific developments for the welfare of society, and provide quality and accessible healthcare services.
• It offers a learning and advancement environment that incorporates technology and art.

Health Story Collection

• A health story collection is the first step for patient assessment.

Phases of the Interview Process

• Pre-interaction Phase
• Beginning Phase
• Working Phase
• Closing Phase

Pre-Interaction Phase

• Prior to meeting the patient, nurses gather data from medical records.
• They will review the patient's history of medical illnesses or surgeries.
• Nurses should review current medication lists and problem lists.

Beginning Phase

• The nurse introduces themself by name.
• The nurse states the purpose of the interview to the patient.
• The nurse asks the patient their preferred name.
• The beginning phase may involve neutral topics to ease anxious patients.
• Ensuring privacy by pulling drapes or closing doors is essential.
• This ensures confidentiality guidelines.

Working Phase

• The nurse asks specific questions to elicit appropriate responses,
• Closed-ended questions elicit "yes" or "no" answers, such as "Do you have a family history of heart disease?"
• Open-ended questions are broad and provide responses in the patient's own words.
• Open-ended questions are key to understanding symptoms, health practices, and areas requiring intervention.
• Examples of open-ended questions include: "What is the reason to continue using cigarette?" and "What do you think about your ... problems?"

Closing Phase

• The nurse ends the interview by summarizing the most important patterns or problems.
• The nurse asks patients if they need anything else or would like to mention additional information.
• The nurse thanks patients and family members for providing their time and information.

Summary: The Interview Process

• Appropriate time management
• Interview environment should be suitable with consideration for privacy, seating arrangement, and lighting.
• Temperature of the room should be considered
• The nurse should introduce themself
• The nurse should explain the purpose of the interview
• Have good communication
• Gather an accurate and sufficient amount of history
• Keep records after the interview

Health Story Collection

• During history taking and interviewing, nurses should establish trust to the patients.
• Therapeutic communication enable the patient and the nurse to work together to resolve problems through collaborative solutions.
• Capability development and well refined interviews, conversations with patients become more comfortable.

Therapeutic Communication Techniques

• Makes it easier for the patient to talk: Keep communication open.
• Essential qualities include empathy, active listening, and focus on the patient's perspective.
• If it makes it easier for the individual to talk about their feelings and thoughts, they are called or therapeutic techniques that keep communication open or therapeutic techniques.
• Active listening means focusing on your patients and their perspectives
• Encouraging elaboration assists the patient to more completely describe the problems
• Active listening includes providing appropriate responses encouraging patients to say more, continue the conversation, and show the patient the nurse is interested.
• Empathy helps understand what the patient is feeling without criticize them.
• See and feel the situation from the patient's perspective, not the nurse's.

Question Types

• Open-ended questions
• Closed-ended questions

Considerations When Asking Questions

• Understandable
• Aimed at clarifying the situation
• Ask in a way that reveals all the details
• Do not intend to satisfy curiosity
• Do not ask more than one question at a time
• The answer to the question should not be in it

General Principles of Story Taking

• Start with open-ended questions.
• Ask specific and narrow questions that will eventually lead to a differential diagnosis
• Take your time
• When an individual stops talking, ask questions that will keep them talking, such as ‘’what else do you have’’
• Maintain eye contact.
• Show your openness to her/him, with your body posture.
• Show approval of it with a head gesture (at the appropriate time).
• Give the patient the opportunity to express themself, by staying silent
• When the patient takes a break, briefly summarize what they are saying.
• Extract all the complaints together.
• If there is confusion of the sequence of events, talk about it again to clarify.

Communicating with the patient:

• If the patient's feelings are obvious say, "you look sad, I understand that, it's annoying..." Indicate that you understand with phrases such as empathy
• If there is confusion of the sequence of events, talk about what happened again to clarify
• If they have other complaints, ask them about them
• Communicate that all of the patient's problems will be addressed and support her/him

Nonverbal Communication:

• It’s not what you say but how you say it
• Look at facial expressions, tone of voice, posture, and body language
• Consider non verbal behavior or context when evaluating

Subjective Data Collection includes:

• Take health histories and collect data
• Assess the patient’s health status and provide communication
• Interview
• Observation
• Biographical information
• Client's perception of the health

Subjective Data:

• Patient
• Charts and family members are secondary data sources

Components

• Demographical Data
• Reason for Seeking Care
• History of Present Illness
• Past Health History
• Current Medications and Indications
• Family History
• Functional Health Assessment
• Review of Systems

Demographical Data

• Includes name, age, gender
• Include educational status, and martial status (who they live with).
• Also includes address, employment, income , and insurance details.

Reason for Seeking Care

• A brief statement, usually in the patient’s own words, that establishes why they are seeking medical assistance.
• “Tell me why you came to the clinic today?" or "What happened that brought you to the hospital?"

History of Present Illness

• The nurse begins with questions and has patients explain symptoms.
• A complete and essential description of the illness.
• Use PQRST: Provokes, Quality, Radiates, Severity, Time The nurse will question the symptoms, the nurse will be specific in order to be complete.

Past Health History

• This includes what their medical and surgical problems were and what treatments with outcomes.
• Some problems will be chronic or acute.

Current Medications and Indications

• It's vital for the patients safety.
• This includes name (drug), dose, route and frequency.
• The nurse will verify allergies and findings of legal records
• The nurse notes type of allergic response (Eg, Rash, throat swelling).

Family History

• Health of family can help prevent disease Important familial conditions include diseases like high blood pressure, stroke cancer, diabetes mellitus obesity, alcohol or drug addiction, and mental illness.

Functional Health Assessment

• Inquires about disturbances and relationships.
• Assess health and focus on effects of health or illness on quality of life.
• Asses the strengths of patient

Functional Health Patterns

• Health perception/health management
• Nutrition/metabolic
• Elimination
• Activity/exercise
• Cognition/perception
• Sleep/rest
• Self perception/self-concept
• Role/relationship
• Sexuality/reproductive
• Coping/stress tolerance
• Values/beliefs

Review of Systems

• A series of questions about all body systems that help to reveal concerns or problems.
• Ask all the questions related to each body system (eg, cough in the respiratory system).
• Systematically before proceeding to the physical assessment.
• Integrate questions while physically examining each region (eg, chest pain when assessing the heart).
• The sequence and format may vary.
• Ask about general health state.
• Skin, hair, and nails should be tested
• There should be questions about the head and neck, regional lymph nodes, the eyes, and the ears.
• Review the Thorax and Lungs, the cardiovascular system, heart and neck vessels.
• Inquire about the peripheral vascular and Abdominal-Gastrointestinal.
• The sequence and format varies with nurse.
• Include general state symptoms related to heart, throat, and lungs

Sample Questions for the Cardiovascular System

• Have any sensations in your chest, neck, or arm.
• Shortness of breath during exercise and if there were irregularities.
• Have you ever had high or low blood pressure?
• Have you ever had rheumatic fever or heart attack?
• Have you had sudden blackout?