Health History

HEALTH  Past medical history

ASSESSMENT (N024-  Past physical issues

25)  Past psychological issues

 Social history
Chapter 1
 Cultural history
Introduction to Health
 Spiritual beliefs
Assessment
 Environmental influences
HEALTH
 Developmental level
 Relative state in which a person is
able to live to his or her potential. Physical Examination
 Includes the “7 Facets”  Structured head-to-toe examination
 Is not solely the absence of disease
or eating right  Identify changes in patient’s body
systems

The “7 Facets” of Health  Unusual or abnormal findings may

support history data or trigger new
questions
 Document all findings in a clear,
concise manner
 Collate all information with medical
records
The Nursing Process
 The overall goals:
o Extrapolate the findings

o Prioritize the findings

o Formulate the plan of care

o Implement the plan of care

Health Assessment #1 Purpose of Health Assessment
 Definition: The processes used to  Determine a patient’s health status
evaluate the health status of a person
 Determine the patient’s risk factors
 Asking pertinent questions to gather
data  Determine the need for health education

 Consists of:  Develop a nursing plan of care

o Comprehensive health history

o Complete physical examination

Health Assessment #2 Health Assessment #3
 Every person needs to have a complete  Nurse detects areas of concern
assessment requiring immediate attention
 Ideally done on admission  Nurse uses findings to decide the areas
that take precedence
 Circumstances may delay the
completion; should be completed once  Health promotion and disease
situation allows prevention are essential areas of patient
education
o A critically ill patient coming into
the ER—wait until patient is Additional Components
stable to complete
 Individual’s personality and attitude
o A patient with a professional
 Resilience
relationship with the nurse—just
need updates  Family dynamics
o A patient with dementia may  Access to healthcare and resources
require supplementation from  Nutrition
family
 Exercise
Nursing vs. Medical Assessments
 Culture
 Nursing
 Beliefs
o Focus on diagnoses and
treatment of the actual or Healthy People 2020
potential human responses  Framework that identifies risk factors,
o Identifies many contributing health issues, and diseases of concern
factors to the individual’s health in the United States
and wellness  Goals and objectives serve to improve
 Medical the health of individuals and
communities
o Focus is on the diagnoses and
treatments of the disease  Overall goal is to increase quality of life
by creating guidelines for healthy
Health Care Team lifestyle
 Nurse  Promotes health and disease prevention
 Physician as it impacts the quality and length of a
person’s life
 Nutritionist
 Data provided by U.S. Department of
 Social worker Health and Human Services
(www.healthypeople.gov)
 Physical therapist
 Occupational therapist
 Speech therapist
 Dentist
The Role of the Nurse #1  Learn to detect a change in patient to
enable providing best care
 Take advantage of teaching
opportunities that present with the
patient and family
 Continually reassess the patient for
changes in order to achieve the best
results
Role of the Nurse #2
Chapter 2
 Use findings and decide in which areas
patient needs the most care Critical Thinking in
 Deliver care across the lifespan Health Assessment
 Promote health and prevent disease The Nursing Process
 Set a goal
 Educate and counsel individuals,
 Develop an action plan
families, groups, and communities
 Implement the plan
 Determine what affects the patient’s  Evaluate the outcome
health
Types of Patient Data
 Focus on health and goals of the patient
 Subjective—Symptoms
Role of the Nurse #3 o What patient tells you
o History
 Oversee the holistic care of each patient
o Chief complaint
 Collect data o Review of systems
 Make judgments that will impact patient  Objective—Signs
safety and quality of care o What you see
o Physical examination
 Identify what is important on a daily o Laboratory reports
basis for each patient o Radiologic findings
 Carefully watch and listen to the patient Examples of Patient Data
to determine what additional questions  Mrs. G is a 54-year-old hairdresser who
to ask reports pressure over her left chest “like
an elephant sitting there” which radiates
 Watch for subtle changes in the patient to her left neck and arm.
Role of the Nurse #4  Mrs. G is an older, overweight white
 Rely on assessment skills female, who is pleasant and
cooperative. Height 5’4”, weight 150 lb.
 Use the “7 Facets” to assess the BMI 26, BP 160/80 right arm, sitting, HR
patient 96 and regular, respiratory rate 24 and
 Use information detected in assessment regular, temperature 97.5˚F oral.
to work with the patient to enhance
quality of life
Subjective Data #1
  OLD CART o Any interventions the patient has
previously tried
o Onset
Nursing Process #1
o Location
 Broad systematic framework
o Duration
 Provides methodical base
o Characteristic symptoms
 Problem-solving approach addresses
o Associated manifestations human response, needs of patient,
o Relieving factors family, and community
Nursing Process #2
o Treatment
 ADPIE
Subjective Data #2
o Assessment
 Onset
o Diagnosis
o When did the sign or symptom
begin? o Planning
 Location o Implementation
o Where is the sign or symptom o Evaluation
located?
Assessment
 Duration
 Gathering subjective and objective data
o How long has the sign or
symptom been going on?  Instrumental in devising a care plan

Subjective Data #3  Key points and relevant pieces of

information are clustered together
 Characteristic symptoms
 Preliminary problem list is formulated
o What the symptom feels like; how
it is described; what is the  Assessment phase continues
severity? throughout entire patient encounter

 Associated manifestations Diagnosis

o What else is happening when the  Based on real or potential health

problems or human responses to health
patient experiences these sign(s)
problems
or symptom(s)?
 Based on assessment data and patient
Subjective Data #4
problem list
 Relieving factors
 Sets stage for remainder of care plan
o Anything the patient has tried to
Planning
relieve the symptom
 Devise the best course of action to
address patient’s diagnoses
 Nurse and patient select goals for each
 Treatments diagnosis
  Set short-term goals (STG) and long-  Test the hypotheses and establish a
term goals (LTG) working nursing diagnosis
 Be realistic Develop a plan agreeable to the patient
 Work with patient’s goals, economic Identify Abnormal or Positive Findings
means, competing responsibilities, and
 Make a list
family structure and dynamics
o Patient’s symptoms
Implementation
 Can be completed by patient, family, or o Observed signs
health care team  Identify the positive responses
 Clearly relate to nursing diagnosis and Cluster the Findings
planned goals
 Group complaints with area in body
 Individualized for each patient
 Include information on stress level
 Modified as changes occur
 Be specific
 Support positive outcomes
 Localize symptoms and signs, if
Evaluation possible
 Continuing process to determine if goals  Include any psychosocial issues
have been attained
Interpret the Findings
 Based on patient’s condition
 Patient problems can stem from different
 Goals are realistic or appropriate causes:
 Ongoing process o Disease processes
 Confirms that nursing care is relevant o Relationships
Assessment and Diagnosis: o Nutritional
The Process of Clinical Reasoning
o Immunologic
 Three types of reasoning for clinical
problem solving: o Infectious
o Pattern recognition o Congenital
o Development of schemas o Many more
o Application of relevant basic and Make Hypotheses
clinical science
 Nature of the patient’s problem
Steps in Clinical Reasoning
 Continue learning about patterns of
 Identify abnormal or positive findings abnormal diseases and issues
 Cluster the findings  Consult clinical literature
 Interpret the findings  Evidence-based decision making
 Make hypotheses about the nature of
the patient’s problem
  As broader knowledge and experience o Order of priority
are gained, you will begin to develop
highly specific hypotheses o Separate lists for active and
inactive problems
Nursing Diagnoses
o Assign each problem a number to
 Based primarily on: be referenced in health record
o Changes in person’s life  Use list to check status of problems in
o Altered processes future visits
 Allows other health care team members
o Specific causes
to review patient status
 Complaints may not fall neatly into these
Sample Problem List
categories
Date Problem Problem
 May be related to stressful events
Entered No.
Health Maintenance 1/12/16 1 Headaches
2 Evaluated blood
 Immunizations pressure
 Screening measures 3 Overweight
4 Family stress
 Nutrition instruction 5 Tobacco use
since age 18
 Self-screening examinations 6 Low back pain
 Exercise 7 Health
maintenance
 Seat belt use 8 Occasional
incontinence
 Responding to important life event
9 History of right
Develop a Plan pyelonephritis
10 Varicose veins
 Must be agreeable to patient
 Develop and record plan for each The Challenges of Clinical Data #1
problem
 Cluster data into single versus multiple
 Specify what steps are needed problems
 Share assessment with patient o Age
 Ask the patient for his or her opinion o Timing
 Patient should always be an active o Different body systems
participant of plan
o Multisystem conditions
 Adapt and change as problems change
The Challenges of Clinical Data #2
Generating Problem List
 Sifting through an extensive array of
 List the most active and serious problem
data
first and record date of onset
 No specific method
 o Pull out separate clusters of o When the specificity is high, a
observations and analyze one positive test result rules in the
cluster at a time target disorder.
o Ask a series of key questions to o “SpPin”
guide in a specific direction
Lifelong Learning: Integrating Clinical
The Challenges of Clinical Data #3 Reasoning, Assessment
 Assessing the quality of the data
o Subject to error

o Ask open-ended questions

o Listen carefully

o Follow “yes” answers with “OLD

CART”
o Keep an open mind Chapter 3
o Always include worse-case
scenario
Interviewing and
o Confer with colleagues to clarify Communication
uncertainties
Introduction
Evaluating Clinical Findings #1
 Primary goal: improve the well-being of
 Reliability the patient
o Do repeat measurements of the  Threefold purpose:
same relatively stable
o Establish a trusting and
phenomenon give the same
results? supportive relationship

 Validity o Gather information

o Does the given observation agree o Offer information

with “the true state of affairs”? Process of Interviewing
Evaluating Clinical Findings #2  Health history format
 Sensitivity o Structured framework for
o When the sensitivity of a organizing patient information in
symptom or sign is high, a written or verbal form
negative response rules out the o Focuses on specific kinds of
target disorder. information
o “SnNout”  Interviewing process
 Specificity o Demands effective
communication and relation skills
 o Need ability to elicit accurate o Remain calm and unhurried
information
o Keep the patient’s perspective in
o Need interpersonal skills to mind to build trust
respond to patient’s feelings and
Phase 1: Pre-interview #3
concerns
 Adjust the environment
Phases of the Interview
o Private and comfortable
 Pre-interview: set the stage
 Introduction: put patient at ease, o Part of the nurse’s job is to make
establish trust adjustment.

 Working: obtain patient information  Take notes

 Termination o Jot down short phrases, specific

dates, and words
Phase 1: Pre-interview #1
o Maintain good eye contact
 Take time for self-reflection
o Do not let note-taking, or written
o Be consistently respectful and or electronic forms distract you
open from the patient
o Continual part of professional Phase 2: Introduction #1
development
 Greet the patient and establish rapport
 Review the medical and nursing records
o First impressions
o Helps gather information and
make plans o Greet patient by name and
introduce self
o Provides valuable information of
past history o Use formal title to address patient

o Be careful to avoid bias or o Acknowledge any visitors in room

preventing new treatments or o If visitors are in the room, you are
approaches
obligated to maintain patient
Phase 1: Pre-interview #2 confidentiality; ask patient’s
permission to continue with
 Set goals for the interview visitors present
o Before meeting patient, clarify o Cultural differences
goals
Phase 2: Introduction #2
o Must balance these provider-
centered goals with patient-  Establish agenda
centered goals o Presenting problem/chief
 Review clinical behavior and complaint
appearance
o Open-ended questions
o Nurse sends messages to patient
o First problem may not be the
through words and behavior
most important one
 o Identify all concerns at beginning  Expand and clarify the patient’s story
of interview
o Use the patient’s words

o Use plain English words, not

medical jargon
Phase 3: Working Phase #1 o Establish the sequence and time
 Invite the patient’s story course

o Use a non-focusing approach to o Move back and forth from open-

tell story ended questions to increasingly
focused questions, back to open-
o Do not inject new information ended question
o Do not interrupt o Cover the seven attributes of a
symptom
o Use active listening skills
Seven Attributes of a Symptom
o Follow the patient’s leads
 OLD CART
o Use a focusing approach to
explore patient’s story in more o Onset
depth o Location
Phase 3: Working Phase #2
o Duration
 Identify and respond to the patient’s
o Characteristic symptoms
emotional cues
 Offer clues of concerns o Associated manifestations

 Respond immediately when you hear o Relieving/exacerbating factors

emotional cues o Treatment
o N – naming  OPQRST
o U – understanding o Onset
o ReS – respecting o Palliating/Provoking factors
Clues to the Patient’s Perspective on Illness o Quality
 Direct statement(s) o Radiation
 Expression of feelings about the illness
o Site
 Attempts to explain or understand
o Timing
symptoms
Phase 3: Working Phase #4
 Speech clues
 Sharing a personal story
 Generating and Testing Diagnostic
Hypotheses
 Behavior clues
Phase 3: Working Phase #3
 o Develop nursing care plan

Phase 4: Termination
 Summarize important points
o Let patient know end of interview
is approaching
o Allow time for final questions

Phase 3: Working Phase #5  Discuss plan

 Create a shared understanding of the o Review plan of care
problem
o Review follow-up
o Explore deeper meanings
patients attach to their symptoms Therapeutic Communication Techniques #1
o Disease/Illness distinction model  Active listening

 Disease: explanation the  Guided questioning

nurse brings to the
 Nonverbal communication
symptoms
 Empathic response
 Illness: how the patient
experiences the disease  Validation
Explore the Patient’s Perspective  Reassurance
 FIFE  Summarization
o Feelings: including fears or  Transitions
concerns about the problem
 Empowering the patient
o Ideas: about the nature and
Therapeutic Communication Techniques #2
cause of the problem
 Active listening
o Function: the effect on the
patient’s life o Close attention to what the
patient is communicating
o Expectations: of the disease,
health care team, or health care, o Be aware of patient’s emotional
based on prior experiences state
Phase 3: Working Phase #6 o Avoid drifting to next question
 Negotiate a plan Therapeutic Communication Techniques #3
o Create a complete picture of the  Guided questioning
problem
o Facilitate patient’s fullest
o Basis for planning further communication
evaluation
o Moving from open-ended to
o Building rapport with patient focused questions
 o Using questions to elicit a graded o Convey information in a
response competent manner
o Asking a series of questions, one Therapeutic Communication Techniques #7
at a time
 Summarization
o Offering multiple choices for
o Give a capsule summary of
answers
patient’s story
o Clarifying what patient means
o Give the patient a chance to
o Encouraging with continuers clarify any misunderstandings

o Using reflection  Transitions

Therapeutic Communication Techniques #4 o Tell patient when changing

directions during interview
 Nonverbal communication
o Orient patient with brief
o Pay close attention to eye transitional phrases
contact, facial expression,
posture, head position,
movement, interpersonal Therapeutic Communication Techniques #8
distance, placement of arms and
legs  Empowering the patient
o Match your position with the o Evoke the patient’s perspective
patient’s
o Convey interest in the person, not
o Be sensitive to patient’s culture just the problem

Therapeutic Communication Techniques #5 o Follow the patient’s lead

 Empathic responses o Elicit and validate emotional

content
o Identify the patient’s feelings
o Share information with patient
o Do not assume you know how the
patient is feeling; ask them o Make your clinical reasoning
transparent to the patient
o Once you identify the feelings,
respond with understanding and o Reveal the limits of your
acceptance knowledge
Therapeutic Communication Techniques #6 Adapting the Interview for Special
Patients #1
 Validation
 The silent patient
o Acknowledge the legitimacy of
the emotional experience o Silence has many meanings and
purposes
 Reassurance
o Patient may be collecting
o Do not provide false reassurance
thoughts, remembering details,
o Identify and acknowledge the deciding whether to trust you
patient’s feelings
 o Nurse should appear attentive o Always seek best-informed
and give brief encouragement source
o Watch patient for nonverbal cues Adapting the Interview for Special Patients
#4
o Patient’s culture
 The talkative patient
o Depression or dementia
o Give patient free reign for first 5
to 10 minutes
o Note patient’s culture

o Focus on what is important to the

Adapting the Interview for Special Patients patient
#2
o Set limits where needed
 The confusing patient
o Do not show impatience; if time
o Confusing array of multiple runs out, explain need for second
symptoms meeting
o Guide interview into psychosocial o Set time limit for next
assessment appointment
o If you suspect a psychiatric or Adapting the Interview for Special Patients
neurologic disorder, shift to a #5
mental status examination
 The crying patient
o Check responses against chart or
o Crying signals strong emotions
seek permission to speak with
family members o Offer the patient a tissue, and
allow patient to recover
Adapting the Interview for Special Patients
#3 o Be supportive
 The patient with altered capacity o Learn to accept displays of
o Determine “decision-making emotions so you can support your
capacity” patients

o Obtain patient permission to talk Adapting the Interview for Special Patients
#6
to family member
 The angry or disruptive patient
o May need to find surrogate
informant or decision maker to o May have a reason to be angry
assist with history
o May direct this anger toward
o Check for durable power of nurse
attorney for health care or a
health care proxy o Accept angry feelings

o Apply same principles of o Do not get angry in return

interviewing
 o Validate their feelings without o Family members may not
agreeing with their reasons understand and give incomplete
information
o If overtly disruptive, alert security
staff o Make your questions clear, short,
and simple
o Move to a more private location
o Speak directly to the patient
Adapting the Interview for Special Patients
#7 Working With an Interpreter:
Interpret Tool #1
 The Dying Patient
 Introduction: Introduce all individuals
o Can be extremely challenging
patients  Note Goals: Note goals of the interview
o Important to work through own  Transparency: Everything said will be
feelings concerning death interpreted

o Give patients opportunities to talk  Ethics: Use qualified interpreters, not

about their illness if they want to family members

o Respect patient’s preference to  Respect Beliefs: Interpreter can help

remain on social level serve as cultural broker and help explain
cultural beliefs
o Understand patient’s wishes
about treatment at end of life  Patient Focus: Interact with patient not
interpreter
Adapting the Interview for Special Patients
#8 Working With an Interpreter:
Interpret Tool #2
 The Dying Patient (cont.)
 Retain Control: Do not allow interpreter
o Ask patient about Advance and patient to take over conversation
Directives, A Durable Power of
 Explain: Use simple language and short
Attorney for Healthcare, or Do
sentences
Not resuscitate (DNR) status if
information is not found in  Thanks: Thank the interpreter and the
patient’s record patient for their time; note in chart the
interpreter’s name
o Assist the patient in connecting
with local hospice care, if Adapting the Interview for Special Patients
applicable to the situation #10
Adapting the Interview for Special Patients  The patient with low literacy
#9
o Assess the patient’s ability to
 The interview across a language barrier read before asking them to sign
anything
o Learn to work with qualified
interpreters o Some patients are uncomfortable
disclosing their reading deficit
o Ensure interpreter understands
you need everything translated, o Ask the patient to read
not condensed or summarized instructions you have written
 o Respond sensitively  The patient with cognitive disabilities
Adapting the Interview for Special Patients o If you suspect problems, pay
#11 special attention to patient’s
schooling and ability to function
 The patient with impaired hearing
independently
o Deaf
o Assess sexual history
 Find out the patient’s
o If you are unsure about the
preferred method of
patient’s level of disability, make
communicating
a smooth transition to mental
 Find an interpreter or use status examination
a written questionnaire
o You may have to elicit history
from family members or
caregiver, show interest in patient
first
o Hard of hearing
o Alternative or Augmentative
 If patient uses a hearing Communication (AAC)
aid, ensure it is on and
Adapting the Interview for Special Patients
working
#14
 Eliminate background
 The patient with personal problems
noise
o Patient may ask you for advice
 Speak at normal volume
outside the range of your clinical
and rate
expertise
Adapting the Interview for Special Patients
o Ask patient what approaches they
#12
have considered
 The patient with impaired vision
o Related pros and cons
o Blind
o What supports are available for
 Shake hands and establish different choices
contact
o Let patient talk through the
 Orient patient to problem
surroundings
Adapting the Interview for Special Patients
o Poor vision #15
 Encourage patient to wear  Sexuality in the nurse–patient
glasses whenever possible relationship
 Use words because o Attraction is a normal human
posture and gestures may response
not be seen
o Recognize them and bring them
Adapting the Interview for Special Patients to conscious level
#13
 o Any sexual contact or romantic o Focused on emergent problem
relationship with a patient is
Comprehensive or Focused?
unethical
 Comprehensive
o If patient makes advances, calmly
but firmly make it clear your o New patients in all settings
relationship is professional, not
personal o Provides fundamental and
personalized knowledge
o If behavior continues, leave room
and return with a chaperone o Strengthens nurse–patient
relationship
Ethics of Interviewing
o Provides baseline
 Ethics
o Creates platform for health
o A set of principles crafted through promotion\
reflection and discussion to
define what is right and wrong  Focused

o Medical ethics guide professional o Established patients, especially

behavior routine or urgent care visits
o Focused concerns or symptoms

 Confidentiality o Assesses symptoms restricted to

specific body system
o Paramount importance in the
nurse–patient relationship Comprehensive Adult Health History #1

o Information may only be shared  Identifying data and source of the history
with appropriate health care team  Chief complaint(s)
members
 History of Present Illness (HPI)
Chapter 4  Past history
 Family history
THE HEALTH HISTORY
 Review of systems
Types of Health History
 Health patterns
Types of Health Histories
Comprehensive Adult Health History #2
 Comprehensive Health Assessment
 Initial information
o Admission of new patient
o Date and time of history
 Focused or Problem-Oriented Assessment
o Identifying data: age, gender,
o Returning patient birth date, marital or relationship
 Follow-up History status, occupation, other as
appropriate
o Problem or treatment evaluation
 Source of history
 Emergency History
o Reliability
Comprehensive Adult Health History #3  Prescription
 Chief complaint(s)  Over-the-counter
o Make every attempt to quote the  Herbal supplements
patient’s own words.
 Vitamins/Mineral
o If there are no complaints, report supplements
goals.  Oral contraceptives
 History of present illness (HPI)  Medications borrowed
o Chronologic account of from family members or
problem(s) friends

o Onset of problem(s) Comprehensive Adult Health History #7

o The setting in which it developed  Past history: key elements (cont.)

o Any treatments o Childhood illnesses

Comprehensive Adult Health History #4  Measles, rubella, mumps,

whooping cough,
 HPI: Key elements chickenpox, rheumatic
fever, scarlet fever, polio
o Seven attributes of each principle
symptom (OLD CART or  Chronic conditions (e.g.,
OPQRST) asthma)
o Self-treatment by patient or family o Adult illnesses
o Past occurrences of the  Medical
symptom(s)
 Surgical
o Pertinent positives and/or
 Accidents
negatives from the review of
systems  Psychiatric
o Risk factors or other pertinent Comprehensive Adult Health History #8
information related to the
 Past history: key elements (cont.)
symptom
o Health maintenance
Comprehensive Adult Health History #5
 Immunizations
 Past history: key elements
 Screening tests
o Allergies
 Safety measures
 Include specific reaction
 Risk factors
 Medication, food, insects,
environmental factors  Tobacco
Comprehensive Adult Health History #6  Environmental
Hazards
 Past history: key elements (cont.)
 Substance abuse
o Medications
  Alcohol  Focus questions to distinguish use from
misuse
Alcohol and Drugs
 Adapt CAGE questions by adding “or
 Misuse of alcohol or drugs often
drugs”
contributes to symptoms.
 Ask about patterns of use
 Should routinely ask about current
and past use of alcohol or drugs,  Ask about modes of consumption
patterns of use, and family history.
 Include adolescents and older adults
in questioning.
Alcohol #1
Comprehensive Adult Health History #9
 Assess what patient considers alcohol.
 Family History
 Screening tool: CAGE
o Have you ever felt the need to
Cut down on drinking?
o Have you ever felt Annoyed by
criticism of your drinking?
o Have you ever felt Guilty about
drinking?
o Have you ever taken a drink first
thing in the morning (Eye-
opener) to steady your nerves or
get rid of a hangover?
Alcohol #2
 Positive CAGE results: 2 or more Comprehensive Adult Health History #10
affirmative answers
 Review of Systems
 If detect misuse, ask about:
o Address each body system, from
o Blackouts head to toe
o Seizures o Most questions pertain to
symptoms
o Accidents
o May uncover problems patient
o Injuries while drinking
has overlooked
o Job problems
o Do not use medical terms
o Conflicts
Review of Systems
o Legal problems  General
Illicit Drugs  Skin
  HEENT  Consciously acknowledge whatever
discomfort you are feeling. Denying
 Neck
your discomfort may lead you to
 Breasts avoid the topic altogether.

 Respiratory The Sexual History

 Cardiovascular  Determine risks for pregnancy

 Gastrointestinal  Determine risks for sexually

transmitted diseases (STDs)
 Peripheral vascular
 Sexual practices may be related to
 Urinary patient’s symptoms
 Reproductive  Sexual dysfunction may result from
 Musculoskeletal use of medication or misinformation

 Psychiatric  Be matter-of-fact in questioning

 Neurologic  Use specific language

 Hematologic  Make no assumptions about the

patient
 Endocrine
The Mental Health History
Comprehensive Adult Health History #11
 Be aware of cultural constructs
 Health Patterns
 Be sensitive to reports of mood changes
o Self-perception/self-concept or symptoms of possible depression
o Value-belief  Ask open-ended questions initially, then
o Activity-exercise move to more specific
 Ask about using psychotropic
o Sleep-rest
medications
o Nutrition
 If patient seems depressed, ask about
o Role-relationship thoughts of suicide

o Coping-stress-tolerance Family Violence #1

Guidelines for Sensitive Topics  Many authorities recommend routine

screening for domestic violence.
 The single most important rule is to
be nonjudgmental.  Start with general questions and move
to more specific.
 Explain why you need to know
certain information.  If abuse is suspected, it is important to
spend part of encounter alone with the
 Find opening questions for sensitive patient.
topics and learn the specific kinds of
information needed for your  Do not force the situation.
assessments.  Ask parents how they cope with their
crying baby.
  Be alert to nonverbal communication. o What is considered to be a health
problem
Family Violence #2
o How symptoms and concerns
 Physical abuse should be considered in
the following situations: about the problem are expressed

o If injuries are unexplained, o Who should provide treatment for

inconsistent with story, the problem
concealed, or cause o What type of treatment should be
embarrassment given
o If patient has delayed getting Cultural Assessment #1
treatment for trauma
 Refers to systematic, comprehensive
o If a past history of repeated examination of individuals, families,
injuries or “accidents” groups, and communities regarding their
health-related cultural beliefs, values,
o If patient or person close to
and practices.
patient has history of alcohol or
drug abuse  Form foundation for the clients’ plan of
care, providing valuable data for setting
o If partner tries to dominate the
mutual goals, planning care, intervening,
interview, will not leave the room, and evaluating the care.
or seems unusually anxious or
solicitous Healthy People 2020
Documenting the Health History  Goal: reduce health disparities among
ethnic or cultural groups in the United
 Form of documentation is frequently States
computerized
 OMH created National Standards for
 Must be accurate and thorough Culturally and Linguistically Appropriate
Chapter 5 Services in Health and Health Care (the
National CLAS Standards)
Cultural and Spiritual Assessment Principle Standard
Culture #1 Provide effective, equitable, understandable,
The system of shared ideas, rules, and and respectful quality care and services that
meanings that influences how we view the are responsive to diverse cultural health beliefs
world, experience it emotionally, and behave in and practices, preferred languages, health
relation to other people. literacy, and other communication needs.

Culture #2 Governance, Leadership, & Workforce

 Is not limited to ethnic or minority groups  Advance and sustain governance and
leadership through policy, practices, and
 Defines: allocated resources
o How health care information is  Recruit, promote, and support diverse
received governance, leadership, and workforce
o How rights and protections are that are responsive to service area
exercised
 Educate and train governance,  Cultural competence: recognizes the
leadership, and workforce on an need for a set of skills necessary to care
ongoing basis for people of different cultures
Communication and Language  The nurse needs to see herself or
Assistance himself becoming culturally competent,
not being culturally competent.
 Offer language assistance to individual
with communication needs at no cost to  Cultural sensibility: a deliberative pro-
them or facilitate timely access to all active behavior by health care providers
health care and services who examine cultural situations through
thoughtful reasoning, responsiveness
 Inform all individuals of availability of
and discreet (attentive, considerate and
language assistance services
observant) interactions
 Ensure the competence of individuals
 Cultural humility: process that requires
providing language assistance
humility as individuals continually
 Provide easy-to-understand print and engage in self-reflection and self-critique
multimedia materials in common as lifelong learners and reflective
languages of local populations practitioners.

Engagement, Continuous Improvement, Self-Reflection

and Accountability #1
 Am I aware of my biases? Prejudices?
 Establish culturally and linguistically Stereotypes?
appropriate goals, policies, and
 Am I comfortable interacting with people
management accountability and infuse
from different cultures?
throughout organization
 Do I seek out experiences with other
 Conduct ongoing assessments and
cultures?
integrate CLAS-related measures
 Do I seek out opportunities to learn
 Collect and maintain accurate and
about other cultures?
reliable demographic data to monitor
and evaluate impact  Do I respect the beliefs of individuals
from other cultures?
Engagement, Continuous Improvement,
and Accountability #2  Do I know how to access language
interpreter services for patient?
 Partner with community to design,
implement and evaluate policies, Dimensions of Cultural Humility #1
practices and services
 Self-awareness
 Create conflict- and grievance-resolution
o Learn own biases
processes
 Communicate the organization’s o Explore own cultural identity
progress to all stakeholders,  Describe yourself
constituents, and general public
 What aspects of your
Cultural Assessment #2 family do you identify with?
How are you different?
  How do these identities o Modesty
influence your beliefs and
behaviors? o Use of touch

Dimensions of Cultural Humility #2 Health Assessment #1

 Respectful Communication  Communication and language

o Work to eliminate assumptions  Family structure

o Learn directly from patients  Family roles and organization

 Social networks
o RESPECT model
 Educational background and learning
 Rapport, Empathy,
style
Support, Partnership,
Explanations, Cultural  Nutrition
competence, Trust
Health Assessment #2
 Child-bearing and child-rearing
Dimensions of Cultural Humility #3 practices
 Collaborative Partnerships  High-risk behaviors
o Build patient relationship on  Health care beliefs and practices
respect and mutually acceptable
 Health care practitioners
plans
 Spirituality and religion
o Listen to and validate feelings of
anger or shame Health Assessment #2
o Reexamine own beliefs about  Child-bearing and child-rearing practices
what is the “right approach” to  High-risk behaviors
clinical care
 Health care beliefs and practices
o Be flexible and creative as shared
plans are developed  Health care practitioners

Transcultural Perspectives on the Health  Spirituality and religion

History Reason for Seeking Care
 Knowledge of cultural or minority groups  Patients may interpret symptoms per
will help you better understand and their cultural view.
interpret the patient’s needs.
 Cultural-bound syndromes
 General precepts
o “Illnesses” defined by a particular
o Nonverbal communication
culture, but no corresponding
o Silence illness in Western medicine

o Distance between patient and  Symptoms may be attributed to actions

interviewer of another individual.

o Eye contact o Referral to healer of the patient’s

culture
Spiritual Assessment #1 Stoll’s Guidelines for Spiritual Assessment
#2
 Spirituality: “all behaviors that give
meaning to life and provide strength to  Sources of Hope and Strength
the individual”
o Who is the most important person
 Religion: a system of beliefs or a to you?
practice of worship
o To whom do you turn when you
 Spiritual distress may be a response need help? Are they available?
to illness or health issues.
o In what ways do they help?
 Must be able to recognize that a
patient has spiritual needs o What is your source of strength
and hope?
 Listening is an important part of being
present with a patient. o What helps the most when you
are afraid or need special help?
Spiritual Assessment #2
Stoll’s Guidelines for Spiritual Assessment
 Nursing presence is often what patients #3
value most.
 Religious Practices
 Observe nonverbal cues.
o Do you feel your faith (or
 Key nursing action is to listen, not talk.
religion) is helpful to you? If
 Encourage the patient to express yes, would you tell me how?
feelings and concerns.
o Are there any religious
 The nurse should not offer solutions. practices that are important to
you?
 Help the patient identify the problem and
resources used in the past to cope with o Has being sick (or what has
problems. happened to you) made any
difference in your practice of
Stoll’s Guidelines for Spiritual
praying or religious practices?
Assessment #1
o What religious books or
 Concept of God or Deity
symbols are helpful for you?
o Is religion or God significant to
Stoll’s Guidelines for Spiritual Assessment
you? If yes, can you describe
#4
how?
 Relation Between Spiritual Beliefs and
o Is prayer helpful to you? What
Health
happens when you pray?
o What has bothered you most
o Does a God or deity function in
about being sick (or what is
your personal life? If yes, can you
happening to you)?
describe how?
o What do you think is going to
o How would you describe your
happen to you?
God or what you worship?
o Has being sick (or what has
happened to you) made any
 difference in your feelings about
God or the practice of your faith?
o Is there anything that is especially
frightening or meaningful to you
now?