Interviewing my patient

  1. When I go back to clinical next week I have to do a physical assessment on my patient and my teacher did not tell us what to ask them when we interview them. I have a sample interview in the back of one of my books but seems like it would take a long long time and my patient is very old and I don't want her to get restless. Can anyone give me any suggestions or resources?

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    About Carla25

    Joined: Feb '06; Posts: 112; Likes: 2


  3. by   Imafloat
    What kind of info do you need? Does it have to come from her or can you get it out of her chart? I would get as much as possible out of her chart and ask her about the rest. When we were in geriatrics we had to write a case study and I got all medical info out of the chart and asked my client about her social history.
  4. by   Daytonite
    think about what it is that you are doing. you are doing data gathering as part of the nursing process. part of your data collection includes obtaining a history and physical examination, much like physicians do, except i am sure that in your nursing school you must have been given some guidance as to how you are to conduct a nursing assessment of the patients activities of daily living. perhaps according to gordon's 11 functional health patterns, maslow's hierarch of needs, or some other system. your interview of the patient is where you are going to collect your history and review of systems information. this would be the patient's subjective information. your actual physical exam is going to give you the objective information. so, if you have already been given some kind of guideline as to how to approach this, then that is how you want to tailor your conversation with the patient. keep a list or outline in front of you so you won't skip any subject areas you are suppose to be collecting this subjective data on.

    as an example, let's say you are to be using gordon's functional health patterns to assess your patient and you have your guideline with the 11 functional health patterns listed on it in front of you. you are at elimination, or the patient suddenly starts to talk about having bowel problems. that's where the conversation goes for the moment. you ask, "what kind of bowel problems do you have?" and listen. remember, you are looking for the unusual or abnormal things. or, you ask, "do you have a bowel movement every day?", "can you describe it for me?", "do you have a problem with hemorrhoids?", "do you have to use any laxatives?", "do you have any problems urinating?" are you getting the idea? if you later proceed to a physical examination, your objective exam would include actually looking at a stool sample, or doing a guaic of a stool sample, or even doing a manual digital exam of the rectum.

    so, you see, you need to do a little prep work before this interview. make a list of all the areas you need to assess so you don't forget them. check them off as you go along with your conversation with the patient. i'm sure that somewhere in your lecture notes or in your program syllabus you were told how your data collection was to be organized. when you say in your post, conversation, i am taking that to mean questioning of the patient rather than actually doing a physical examination of their body. however, if you are doing both things what you do is ask questions to get the patient talking about the body area you are examining or the activity you are observing them perform as you are doing the hands on physical exam.
  5. by   Carla25
    Thanks for your tips. I got a lot of information from her chart, but I still feel like I need to do an interview, and my patient is an older adult in her 90's and she is alert but not oriented so thats why I am worried.
  6. by   Daytonite
    ok. if you've already been through her chart then you have a very good idea why she is admitted and what she is primarily being treated for, or what her primary medical diagnoses are. you get all that from her medications and the physician's h&p, labwork, x-rays, etc. you should also have been able to see another nurses assessment of her ability to perform her own adls, so you will also have a good idea going in what her capabilities are with regard to ambulating, toileting, personal care and hygiene, eating, dressing, sleeping. you also know she may have some problems with orientation. so, what you want to do is to confirm some of this information for yourself. assessing the patient's mental state is also part of the assessment process. you might want to look up some information on assessing orientation and confusion. nursing homes and doctors office nurses use a very simple assessment tool (list of questions) for assessing confusion that takes only about 5 to 10 minutes. you might want to consider doing that. here is a link to where you can find geriatric assessment tools. - geriatric assessment tools from the university of iowa. you can view and download a variety of different dementia assessment tools from this university of iowa site by clicking on "dementia and delirium". (or linking here ) i have most commonly seen the mini-mental state examination (mmse) done which you can print out from this site. it only takes about 5 or 10 minutes to do. the 10 or 11 questions are listed on the first page of the download which you can print out and the second and third pages tell you how to score the results. i looked at the clock drawing test which is two pages you can down load. very simple. first page has a circle on it that you ask the patient to draw numbers in the circle to make it look like the face of a clock. then draw hands of the clock to read "10 after 11". the second page tells you how to score the results. very simple test.
    if you decide to include one or more of these assessment tools with your interview, defend them with your instructor by telling him/her that you were concerned about assessing the patients orientation so you did a little research and found these assessment tools and thought it would be interesting to see how they worked on the patient. doing one or two of these little tests will give you a much better idea of just how advanced her disorientation is. and, that is a very scientific way to do it!

    you also want to ask burning questions first if you are concerned that the patient may not be able to remain focused very long for an interview. get them out of the way first. think of ways to ask the same question two different ways and at two different times during the interview. if you get two very different answers, you are possibly confirming the confusion. that is a piece of data that is going to affect her care. if you spend an hour asking this patient all the questions on your lists and all you come away with is that she's confused, you have still learned something about her and about how the confused mind works. you always want to meet the patient face to face though. don't ever be afraid of talking with patients and try not to pre-judge them before you meet them. the chart doesn't tell the entire story. you want to see the person with your own eyes and talk to them. you may find that her disorientation is not as bad as the chart lead you to believe. on the other hand, if she's really "three sheets to the wind", a very technical term for confused (ha! ha!), you'll get some practice putting on a straight professional face. unless i'm very wrong, your worry is that you won't learn anything from this patient during this interview. what i'm trying to give you an elbow in your ribs about is that there are things you can learn that you just haven't considered beyond the list of questions at the back of your book.

    i also wanted to point out to you that restlessness, if your patient exhibits that during your interview, is a symptom and you should note it because it is an abnormal finding. it differs from anxiety in that it is almost constant physical movement of the arms and legs.

    a look ahead. . .this assessment data would normally be used to develop nursing diagnoses as part of planning care for the patient. that is the next step in the nursing process.

    i've bored you enough and probably written more than you ever wanted to read. hopefully, i've helped to set you off on a good direction. i expect to hear that your interview was successful and that you learned something about the patient that wasn't in the chart. carry on, nurse!