Istinye University and health story collection

• İstinye University was established in 2015 by the 21st Century Anatolian Foundation.
• It builds on 25 years of knowledge from the MLPCare Group, uniting "Liv Hospital", "Medical Park", and "VM Medical Park".
• The goal is to be among Turkey's and the world's distinguished universities.
• It aims to contribute to the production of new information through education and research performance.
• Istinye University is student-focused, has a vision of being a science and research center, and aims to expand the boundaries of science.
• The faculty aims to implement scientific developments for the welfare of society, while providing quality and accessible health services.
• A learning and development environment is provided with universal standards in teaching, research and community services, covering technology and art.

Health Story Collection

• Health story collection is the first step for patient assessment
• The lecturer is Asst. Prof. Gizem Yağmur Yalçın, and can be reached at [email protected].
• NUR111-Health Assessment

Phases of the Interview Process

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

Pre-interaction Phase

• Before meeting with the patient, the nurse collects data from the medical record
• Reviews the patient's history of medical illnesses or surgeries, current medication and problem list

Beginning Phase

• The nurse introduces themself by name
• States the purpose of the interview
• Asks the patient what their preferred name is
• Privacy is ensured in the healthcare setting by pulling drapes or closing doors, considering confidentiality guidelines.
• The beginning phase may continue with neutral topics if the patient seems anxious.

Working Phase

• The nurse asks specific questions, each with a purpose to elicit appropriate responses.
• Closed-ended questions have "yes" or "no" answers.
  • An example is: “Do you have a family history of heart disease?".
• Open-ended questions are broad, prompt the patient's own words, and are key to understanding symptoms and health practices.
  • Examples are: "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 and stating the two to three most important patterns or problems.
• Patients are asked if they would like to mention or need anything else.
• The nurse also thanks the patient and family for their time and information.

Summary: The Interview Process

• Have appropriate time
• Have a Suitable interview environment including privacy, seating arrangement, lighting, and room temperature
• The nurse should introduce themself
• Explain the purpose of the interview
• Ensure good communication
• Obtain an accurate and sufficient amount of history
• Keep records after the interview, if possible

Health History Collection

• During history taking and interviewing, the nurse establishes trust with patients.
• Through therapeutic communication, the patient and the nurse work together to resolve problems through collaborative solutions.
• Conversation with patients becomes more comfortable, with smooth transitions between questions as the nurse develops interviewing capabilities.

Therapeutic Communication Techniques

• Therapeutic techniques make it easier for the individual to talk about their feelings and thoughts, and keep communication open.
• Active listening means focusing on patients and their perspectives.
• Encouraging elaboration (facilitation) helps patients describe problems more completely, encouraging them to continue the conversation.
• Empathy is the ability to perceive understanding of another person's feelings without criticism.
• It is important to see and feel the situation from the patient's perspective, not the nurse's.
• Other Techniques: Facilitation-Support, Using silence, Confirm, Clarification, Summarizing

Question Types

• Open-ended questions
• Closed-ended questions

Considerations When Asking Questions

• Be understandable
• Be aimed at clarifying the situation
• Questions should be asked in a way that reveals all details
• Not be intended to satisfy curiosity
• Do not ask more than one question at a time
• The answer should not be in the question

General Principles of Story Taking

• Start with open-ended questions.
• Ask specific and narrow questions that will 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 and show openness with body posture
• Show approval with head gestures
• Silence gives patients the opportunity to express themselves
• Summarize what they saying while actively listening to ensure accuracy
• Generate a list by extracting complaints
• If there is confusion, talk about the topic again for clarification
• If the patient's feelings are obvious, indicate understanding with phrases showing empathy
• Ask about other complaints
• Communicate and address that all of the patient's problem's will be addressed and supported

Nonverbal Communication

• The tone of voice, facial expressions, hand gestures, eye contact, body posture and physical appearance are important
• Nonverbal behaviors send real messages
• Facial expressions and tone of voice account for 93% of communication, while words account for 7%.

Health History: Subjective Data Collection

• Includes the patient's perspective
• Comprised of Sources and Components
• It assess the patient's health status and provide therapeutic communication
• Health histories are taken while collecting subjective data

Sources

• The individual patient is considered the primary data source
• Charts and family members are considered secondary 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
• Educational status, marital status (whom live with?)
• Address, employment, income and insurance details.

Reason for Seeking Care

• This brief statement is usually in the patient's own words, establishing why he or she is making the visit (coming hospital).
  • Common questions are
    • “Tell me why you came to the clinic today."
    • "What happened that brought you to the hospital?"

History of Present Illness

• The nurse starts with with open-ended questions and asks patients to explain symptoms.
• Questions about symptoms (subjective sensations or feelings of patients) in six to eight categories assist patients to be more specific and complete.
• A complete description of the present illness is essential.

History of Present Illness details include

• location
• intensity
• duration
• description
• aggravating factors
• pain goal
• alleviating factors
• functional impairment
• Includes Onset, Location, Duration, Character, Aggravating/Relieving Factors, Timing and Severity

Past Health History

• The past health history includes the patient's history of medical and surgical problems along with treatments and outcomes.
• Some problems are acute, others resolve, and others are chronic.

Current Medications and Indications

• The nurse asks about current medications including names, purposes, doses and routes
• Confusions should be clarified with patients of family and pill bottles
• For hospitalized patients, the nurse must reconcile all medication lists with medications taken regularly at home
• allergies should be verified, and findings compared against legal records
• The nurse notes the type of allergic response and differentiates allergies from and side effects

Family History

• Questions include the health of parents, grandparents, siblings, and children
• It is important to identify diseases for which patients may be at risk and help enable nurses to provide health teaching.
• Important familial conditions include high blood pressure, coronary artery disease, high cholesterol, stroke, cancer, diabetes mellitus, obesity, alcohol or drug addiction, and mental illness

Functional Health Assessment

• Focuses on the effects of health or illness on quality of life.
• Assesses the strengths of patients as well as areas needing improvement.

1. Health perception/health management: Perceived health and well-being and how health is managed.
2. Nutrition/metabolic: Includes food, metabolic need and indicators of local nutrient supply
3. Elimination: Excretory function of the bowel, bladder and skin are assessed
4. Activity/exercise: Exercise, activity, leisure and recreation
5. Cognition/perception: AssessesSensory perceptions and thought patterns
6. Sleep/rest: Assesses sleep, rest, and relaxation
7. Self perception/self-concept: AssessesSelf-concept, body comfort, body image and feeling state
8. Role/relationship: Assesses Role engagements and relationships
9. Sexuality/reproductive: Assesses Satisfaction and dissatisfaction with sexuality and reproductive patterns.
10. Coping/stress tolerance: Assesses General coping pattern and effectiveness in terms of handling stress.
11. Values/beliefs: Identifies Values, beliefs (including spiritual), or goals that guide choices or decisions.

Review of Systems

• A series of questions about all body systems that helps to reveal concerns or problems.
• Inquire about:
  • General Health State
  • Skin, Hair, and Nails
  • Head and Neck, regional lymph nodes
  • Eyes
  • Ear, nose, mouth and throat
  • Thorax and Lungs
  • Cardiovascular system (Heart and Neck Vessels, Peripheral Vascular)
  • Abdominal-Gastrointestinal
  • Neurological
• Sequence and format vary with setting, urgency of the problem, and style of the nurse.

Sample Questions for the Cardiovascular System

1. Have you ever had any pain or pressure sensations in your chest, neck or arm? (myocardial ischemia)
2. Do you have shortness of breath during exercise??
3. Have you ever woken up at night with shortness of breath? (heart failure)
4. Can you lie flat without shortness of breath?
5. Do you have swelling in your ankles?
6. Have you ever felt irregularities or stuttering in your heartbeat?
7. Have you had a sudden blackout without any complaints?
8. Have you felt tired in your legs during exercise?
9. Have you had coldness and blueness in your hands or feet?
10. Have you had a rheumatic fever or heart attack?
11. Do you have high blood pressure (hypertension)?