Health Story Collection: Istinye University

• İstinye University was founded by the 21st Century Anadolu Foundation in 2015, building upon the 25-year knowledge and experience of the MLPCare Group.
• The university aims to be among the distinguished universities in Turkey and worldwide, contributing to the production of new knowledge.
• Istinye University seeks to expand the boundaries of science and implement scientific findings for the welfare of society by providing quality and accessible healthcare services.

Health Story Collection

• Gathering a patient's health history is the first step in patient assessment.

Phases of the Interview Process

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

Pre-interaction Phase

• Prior to meeting, the nurse gathers data from the medical record.
• The medical record provides the patient's history of medical illnesses or surgeries.
• The medical record provides the patient's current medication list
• The medical record provides the patient's problem list

Beginning Phase

• The healthcare professional introduces themselves by name.
• The healthcare professional states the purpose of the interview.
• The healthcare professional asks the patient for preferred name.

Interview Best Practices: Beginning Phase

• The beginning phase may continue with discussion of neutral topics if the patient is anxious.
• Should ensure privacy within the specific healthcare setting.

Working Phase

• Specific questions are valuable to elicit appropriate patient responses.
• Each question should serve a purpose.
• Closed-ended questions can be answered with "yes" or "no."
  • An example of a closed-ended question is "Do you have a family history of heart disease?"
• Open-ended questions gives a patient a broader opportunity to respond in their own words
  • Should be applied to encourage understanding of symptoms, health practices, and areas needing intervention.
  • Examples of open-ended questions include:
    • "What is the reason to continue using cigarette?"
    • "What do you think about your ... problems?"

Closing Phase

• Summarize the interview.
• The nurse presents the 2 to 3 most important information or problems that have arisen.
• Ask patients if they would like to mention or need anything else.
• Thank patients and family members for their participation.

Interview Process Summary

• Allot appropriate time
• Provide a suitable interview environment
  • Privacy is important
  • Seating arrangement
  • Lighting
  • Room temperature
• Nurse Responsibilities:
  • Introduce themselves
  • Explain the purpose of the interview.
  • Practice good communication.
  • Gather accurate information.
  • Keep records after the interview if possible.

Building Trust

• Establish trust with patients during history taking.
• Achieve collaborative solutions through therapeutic communication
• Develop and refine interviewing capabilities with smooth transitions between questions.

Therapeutic Communication Techniques

• Therapeutic techniques make it easier to discuss feelings and thoughts and fosters open communication.
• Practicing active listening helps a healthcare worker focus on the patient's perspectives.
• Encouraging elaboration assists patients to describe problems more completely.
  • Responses should encourage patients to say more
  • Responses should continue the conversation
  • Responses show a patient that the nurse is interested.
• Empathy means to perceive and understand another person’s feelings without criticism.
• Perceive and feel the situation from the patient’s perspective, not from the nurse’s.
• Therapeutic communication
  • Facilitation/Support
  • Using silence
  • Confirm
  • Clarification
  • Explanation

Question Types

• Open-ended questions
• Closed-ended questions

Considerations when Asking Questions

• Must be understandable
• Should clarifies the situation
• The nurse should ask questions that reveal all the details
• Should not satisfy curiosity.
• Do not ask more than one question at a time.

Principles of Story Taking

• Start with open-ended questions.
• Eventually lead to a differential diagnosis by asking more specific questions
• Take your time.
• When an individual stops talking, ask questions that will keep them talking.
  • A good follow-up questions is : "What else do you have?"
• Maintain eye contact and show openness through body posture.
• Approve patient’s input with head gestures and body language
• Allow to self-express
• As they are talking carefully listen to and summarize
• Extract information by listening and summarizing.
• Review patient history/story and identify sequence of events
• If the patient's feelings are obvious:
  • Acknowledged statements such as: "you look sad,....I understand that, it's annoying..."
  • Use empathetic phrases
  • Ask about other complaints
  • Communicate a through investigation and support

Communication Cues

• Nonverbal skills impact the communications process
• Facial expressions and tone of voice make up most of the communication by volume

Health History Details

• Health histories collect subjective data.
• Focus upon the patients health perception
• Thorough communication of the nurses observations

Health Data Sources

• The patient is is the primary data source.
• Charts and family members are secondary data sources.

Components of a Complete Health History

• 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

• Name
• Age
• Gender
• Educational status
• Marital status
• Address
• Employment details
• Income
• Insurance details

Reason for Seeking Care

• Record a brief statement, in the patient’s own words
• Reason for seeking care establishes why he or she is visiting the hospital
• What happened that brought you to the hospital?

History of Present Illness

• The nurse should start with open-ended questions
• Enquire about the explain current symptoms.
• A complete description of the illness is essential.
• The question should be directed to symptoms

Past Health History

• A full background of data
• Record the patient’s history of medical and surgical problems along with treatments and outcomes
• Ascertain which problems are acute, or chronic, and when resolved

Current Medications and Indications

• The nurse should review current medications
• If there is confusion with the medications the patient or relatives should bring in pill bottles for review
• In addition, it can be beneficial for the patient to reconcile all medications to remove redundant medication

Allergy Review

• Allergies should be recorded, verified and updated
• Record the type of allergic response
• Distinguishes side effects or adverse reactions from allergies to medications Review family health history
• Review the health history of parents, grandparents, siblings and offspring
• Review of systems to help identify potential issues that need treatment

Functional Health Assessment

• Functional health patterns focus on health or illness impact on quality of life.
• Using this approach the health worker can utilize a strength based approached for improving areas of needed importance

Cardio Vascular System

• Consider blood pressure readings
• Review any irregularities or stutters of heartbeats
• Ask the patient about recent occurrences of;
• Chest pain
• Neck pain
• Arm pain
• Shortness of breath
• Review with the patient the use of hypertension medication
• The nurse must verify the specific reaction.
• A patient is suffering from a side effect vs allergic reaction

Functional Health Patterns

• Health perception/health management
• Nutrition/metabolic
• Elimination patterns (bowel, bladder, and skin)
• Activity level
• Recreation opportunities
• Sensations
• Cognition perceptions
• Rest patterns
• Sleep patterns
• Assess self-perception
• Assess self-concept
• Review patients role in relationships
• Review sexuality
• Review reproductive health goals and methods
• Find out what is the patient's general coping pattern
• Assess effectiveness in handling stress
• What are the patient's goals and beliefs
• Spiritual needs
• The nurse should ascertain the values that guide their patient's behavior

Comprehensive Review of Systems

• The nurse should ascertain concerns in the health history through questions
• Questions should relate to each body system
• The heart, lungs, and neurological indicators should be reviewed
• Be sure to integrate questions while physically examining each region the body