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Health History

Georgela Rasadu Faculty of Health Disciplines, Athabasca University NURS 326: Health Assessment Tutor Shona Hommy March 16, 2021

2 Health History Knowing the patient in nursing practice is “an essential precursor to the delivery of highquality patient care” (Luker et al., 2000, as cited in Kelly et al., 2013, p. 2), and this is achieved through a general survey and by collecting the patient’s health history. As the accuracy and completeness of the information contained in a patient’s health history is essential for designing an individualized patient care plan, being proficient in health history taking is a must for nurses. Thus, the purpose of this paper is to become proficient in collecting patient’s data as part of their health history. This is achieved by discussing the components of the general survey and the interview, using a patient of choice as example. Next, the paper discusses the purpose and the components of the health history, using the same patient as example. Finally, health promotion priorities and health promotion activities are identified for this patient.

The Description of a Client and the General Survey

The general survey is a study of the whole person, and its purpose is to gather objective data, by performing general observations of the patient, such as: physical appearance, body structure, mobility and behavior (Jarvis, 2019, p. 153). In fact, the client’ data being collected are: weight, height, body build, posture and gait, obvious signs of distress, level of hygiene, skin integrity, and the patient's actual age compared to the age that he/she appears like.

The client chosen for this paper is Mrs. L. Smith, a 73-year-old female, admitted to hospital on March 10, 2021, after a follow-up appointment for a failed femoral-tibial aneurysm repair of the left leg. I first met this lady on March 13, 2021, while working as a bedside nurse in a surgical unit in Edmonton. Thus, I found an old, Caucasian, slim, tall lady, who was showing

3 her stated chronological age. She was awake, alert and orientedx3, sitting up quietly in bed, her facial features were symmetric with movement, and her facial expression appeared sad. Although her skin appeared intact and very light-beige pink in color, her hands were bright red, with fingers swollen. Her hair was short, frizzy, reddish blond in color. She was wearing a hospital gown, while her lower body was covered by two blankets. As I introduced myself, the patient established good eye contact and her hearing was good. Her teeth were yellow, her front teeth appeared crooked and the gums receding on lower incisors and canines. Her breathing was effortless with a respiratory rate of 16 breaths/minute. No abnormalities in her breathing pattern and no breath odor from smoking or from drinking alcoholic beverages were noted. Her body movements appeared rigid, when she tried to move in bed. As she had a leg amputated, she could not walk, so I could not see her gait. All these objective data were collected based on what I saw while I observed her. The next data, also objective, were collected using my hearing. The patient was using complete sentences, however, she showed a very strong Newfoundland English accent, difficult to understand at times. She looked like a sad individual, and she was tearful when I asked first questions about her condition. Working with many patients who lost a limb, I knew that sadness is a common finding in this population group, as people go through distinct stages of grieving, while adjusting to a limb loss.

Therefore, acknowledging her feelings, I advised her to meet with the spiritual team, which she did next. Performing a general survey of a client is like going through “an introduction for the physical examination that will follow” (Jarvis, 2019, p. 153). Thus, the next step in collecting further data about Mrs. Smith was interviewing her.

4 The Data Collected through Interviewing the Patient

The most important part of data collection is the interview, and its goal is to obtain the client’s health history (Jarvis, 2019, p. 153). The data can be obtained from the client (primary source), or/and from client’s family or individuals involved in client’s care (secondary source), when the client is admitted to hospital (Lapum et al., 2020, p. 63). Some data may be taken in other clinical settings, whether there is a need for new information. Mrs. Smith's interview was conducted on March 10, 2021, when she was admitted to the surgical floor. However, on March 12, 2021, while I was her bedside nurse, I conducted a second interview to gather some missing data, which helped me learn about her and her individual needs.

Conducting an interview is not an easy task, as every patient is a a complex, unique human being, with different personality traits, expectations and perceptions. In addition, people seen in clinical settings are suffering individuals. According to Younas (2020), “patient suffering is a personalized and variable experience […] affected by hidden factors” (p. 942). As example, Mrs. Smith's sadness was related to the loss of her daughter, as I later found, and this was a hidden factor. In addition, people seeking care can be at their highest state of vulnerability, which can be enhanced by race, ethnicity, age, sex, disability, culture or social and economic status. Due to her recent BKA surgery, Mrs’ Smith’s was a disabled individual. Her older age, also, could impact her ability to learn new skills which are required for people after a limb amputation. Moreover, she was born in Canada, but she had only a "childhood friend" in Edmonton, which makes her prone to isolation. Her very strong Newfoundland English accent, which makes others difficult to understand her, can be seen as a communication obstacle. She

5 might not need a translator, but this can affect her self-esteem, as well as the length of the interview, which can impact the completeness of the information she provides.

The quality of patient’s data are not only affected by the patient’s characteristics, but also by “nurses’ personal factors [which] can interfere with their ability to develop a comprehensive understanding of patient suffering” (Zamanzadeh et al., 2018, as cited in Younas, 2020, p. 937). Obviously, interviewing a patient requires nurses "a high degree of self-reflectivity"(Jarvis, 2019, p. 154), and a relational inquiry approach, through which nurses become capable of using "five ontological capacities such as compassion, curiosity, commitment, competence, and correspondence during each nurse-patient interaction" (Younas, 2020, p. 938).

Overall, "therapeutic communication and relationships are the foundation of an effective client interview" (Lapum et al., 2020, p. 63). Therefore, establishing rapports with the patients can be easy if nurses' focus is “on the unique nature of human as an interactive whole of needs, knowledge, wills, emotions and feelings” (Rovithis, 2003, para. 8). I did so with Mrs. Smith, and the fact that she shared her information with me is a proof that I was able to connect with her.

The Interview Phases

The interview is divided into three phases which are: “the introductory phase, the working phase, and the termination phase” (Dilon, 2007, p. 19). During the introductory phase, I asked Mrs. Smith "How are you doing this morning?" followed by introducing myself. Next, I asked her for permission to ask questions, while explaining my goal, to get to know her, so that I can better assist her. I assured that her information would be kept confidential (Dillon, 2007, p. 19). Moving on to the working phase, “the data-gathering phase” (Jarvis, 2019, p. 155), I asked

6 her closed questions, such as "are you in pain?" Open-ended questions were also used, such as: "I heard you've been through a lot recently, can you tell me what happened to you?" She told me about her daughter as well as what else she had been going through since she lost her. While listening to the patient, I used a few communication techniques, such as facilitation (ex. “go on”), reflection, empathy, clarification and silence. As “the session should end gracefully”(Jarvis, 2019, p. 162) to preserve our therapeutic relationship, I asked her: “Is there anything you would need right now?” This question signaled the end of the session and was addressed after discussing a plan about how to respond to her immediate needs for that day.

The Health History The purpose of the health history is “to source important and intimate knowledge about the patient, their lifestyle, social support, medical history and health concerns, with the history of presenting illness as the focus" (Ingram, 2017, p. 1033). Thus, data collected about Mrs. Smith came from the primary source. Her biographical data showed that she is 73-year-old widow, born in Newfoundland, who retired at 65, after working in a grocery store. She used to live with her daughter, in an apartment on the third floor of a building with elevator. Her chief complaint was: "My left foot turned black and was very painful, I could not walk on it for a month." The present illness was left leg ischemia and the leg was amputated a day before I met her. Her past medical history showed: atrial fibrillation, peripheral artery disease and Raynaud’s disease. She had no known allergies. Her past surgical surgery showed left femoral tibial bypass surgery in January 2021. Discussing about her family history, she said that: mother died at the age of 55 from kidney failure, father died at the age of 71 from stroke, husband died 7 years ago of pneumonia, daughter died two months ago, at the age of 42 from colon cancer.

7 Collecting Mrs. Smith's health history, I was seeking to find out whether she had social support, which was needed to help her cope with her recent loses. Answering to the questions: "Do you live alone?", "Do you have children?" and "How about your friends?"I learned that she had no one in Edmonton, except a "childhood friend" who visits her often. Next question: "Are you religious?" was addressed to see if she can receive her church-peers support. She said "I am a Jehovah's Witnesses. I do not attend church services here." This revealed that she might refuse blood transfusions, which could impact her recovery, in case blood is needed. Next, I asked "Are you a smoker?" as she had atrial fibrillation and poor peripheral circulation, which already led to one limb being amputated. She was heavy tobacco smoker but she quit a month ago. This was important to know, as smoking is affects the peripheral circulation. In fact, as a smoker she would be supported while dealing with cravings in hospital.

Health Promotion Activity Being an individual with lower-limb amputation, Mrs. Smith is at high risk of getting injure and/or depressed (Sahu et al., 2016, para 3), due to the “difficulty in coping up with the impairment" (Sahu et al., 2016, para 3). Studies show that “independence in self-care activities is significantly associated with higher rates of survival after six months of rehabilitation and prosthetic use, and predicts a good walking ability”(Celeiro et al., 2017, p. 1780) in people with her condition. Thus, starting her rehabilitation immediately is the best approach (Celeiro et al., 2017, p. 1780). As she used to take care of herself, she can be a good candidate for prosthetic rehabilitation, which is “aimed at range of motion and strength, […] transfers and wheelchair mobility [and] independence in basic activities of daily living ” (Celeiro et al., 2017, p. 1780). As a nurse, my role is to offer her physical and emotional support, while she works through mastering the skills taught by the rehabilitation team. What I am seeking for her is to get her

8 prepared for a specialized rehabilitation program, so that she can later get a prosthetics, which could significantly improve her life.

Conclusion Delivering high-quality patient care is not possible without knowing the patient. Thus, nurses gather data about each patient, by using either a primary source or secondary source. While data are collected through the general survey and by interviewing the patient, nurses must know how to build therapeutic relationships with each patient, so that the patient can trust them and share their sensitive information with the nurse. These will ensure the integrity of data being collected, which in turn, assist nurses to identify each patient’s individual needs and provide whether preventive care, or diagnosis of an illness care accordingly.

9 References Dilon, P. M. (2007). Nursing health assessment. A critical thinking, case studies approach (2nd Ed.). F.A. Davis Company

Ingram, S. (2017). Taking a comprehensive health history: learning through practice and reflection. British journal of nursing, 26(18), 1033–1037. https://doi.org/10.12968/bjon.2017.26.18.1033

Jarvis, C. (2019). Physical examination & health assessment (3rd Canadian ed.). (A.J. Brown, J. MacDonald-Jenkins, & M. Luctkar-Flude, Eds.). Elsevier.

Kelley, T., Docherty, S., & Brandon, D. (2013). Information needed to support knowing the patient. ANS. Advances in nursing science, 36(4), 351–363. https://doi.org/10.1097/ANS.0000000000000006

Lapum, J., St-Amant, O., Hughes, M. & Garmaise-Yee, J. (2020). Introduction to communication in nursing. Pressbooks. https://pressbooks.library.ryerson.ca/communicationnursing/

Luker, K. A., Austin, L., Caress, A., & Hallett, C. E. (2000). The importance of 'knowing the patient': community nurses' constructions of quality in providing palliative care. Journal of advanced nursing, 31(4), 775–782. https://doi.org/10.1046/j.1365-2648.2000.01364.x

Rovithis, M. (2003). [Nursing as an art] Professioni infermieristiche. 57. 194-201. https://www.researchgate.net/publication/8072662_Nursing_as_an_art/link/5f0560f7458 51550509478ac/download

10 Sahu, A., Sagar, R., Sarkar, S., & Sagar, S. (2016). Psychological effects of amputation: A review

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Zamanzadeh, V., Valizadeh, L., Rahmani, A. et al. (2018). Factors facilitating nurses to deliver compassionate care: a qualitative study. Scand J Caring Sci. 32(1), 92-97. https://doi.org/10.1111/scs.12434

Younas, A. (2020). Relational inquiry approach for developing deeper awareness of patient suffering. Nursing Ethics, 27(4), 935....