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Advice on Health History Assessments

Posted

Hi everyone,

This is my first semester in my BSN program and we just did a simulation (real people not the mannequins) health history assessment. (it was eight pages.)

I didn't feel satisfied with how I did. I did try to do as much as I could to keep the patient engaged, and I did say that some of the material might be a little bit personal and/or sensitive and that everything that we collect is confidential, that they don't have to answer until we build a more trusting relationship, (you know what I mean). I did try to open up some of the closed ended answers that I was getting. Some of my issues had a little bit to do with the patient's personality, but I know that I can do better next time.

I was wondering if any more experienced nurses/nursing students could give me some tips on how to keep the patient engaged, become more confident with the procedure itself, and any other tips that you think would be helpful. I would appreciate it so much! I'm always open to learning from those who are experienced beyond my level (which, let's be honest here, I'm on the bottom level with it being my first semester!)

Thank you!

I will leave the more experienced nurses to answer your question in regards to the real world.

However, for nursing school, when you get a health history on patient's in the hospital setting...break up the questions. I found that all of our questions were a lot to have the patient answer at once and they probably already answered most of theses questions when the RN did their admission assessment.

So, I would ask as many questions as I could and when I felt the patient was becoming dis-engaged or overwhelmed, I would say something like, "Okay, Mr. Pickle (made up name and person), I will give you some time to rest, but, if it is okay with you I will be back in x amount of time with a few more questions for you regarding xyz."

Hope this helps!

firstinfamily, RN

Has 33 years experience.

It has been a long time since my BSN days, but I do remember these health assessments, some did ask very personable questions. In the real world of nursing very few questions are asked on the nursing assessment about sexual habits, income, etc. Mostly we concentrated on prior health issues like what medical diagnosis they had and medications they were taking, what prior surgeries had been done etc. Unless you are working on an OB floor or Aides unit, there really is no reason to ask about someones sexual habits. None of the nursing assessments I have done over the years working in ICU, PCU and IMC, telemetry ever asked about sexual habits. I also was intimidated by the health assessment we had to do with the BSN. They are trying to teach you how to take a complete health history. I would break it down into the medical versus social areas and work on it that way. Are you getting ready for community health?? I don't remember using anything like the college was teaching us until I did my rotation of community health. I guess my physical assessment class may have had one. I believe telling the pt up front that this will take so many minutes, it may have some personal questions etc. would help with completion. It is hard to keep pts attention when they are not warned in advance. I think with practice you will be more comfortable and the process will be less painful. Hang in there!! Most nursing assessments in the hospital or home health setting are approximately 4-6 pages.

Most of us, when confronted with lengthy assessments become so familiar with the outline that we begin to become "conversational" in our engagement of the patient. We ask the questions as we complete some of the other hands on assessment and make mental note of the answers which we will then populate in the EMR or on the form.

I find that this style suits me well and that often patients are more relaxed and forthcoming if the interview style is more relaxed and informal. As well, when encountered with a clinical urgency or emergency that style allows you to gather vital information at the same time you are engaging in physical care of the patient.

Good question. You will get more comfortable with the processes and will develop your own approach to each position you hold going forward.

Good luck!

I am getting ready for community health! (bi-weekly... We go to long term care every other week)

We also do this thing called Longitudinal Elder Initiative where we visit a senior citizen about three times a semester, each, and we will be doing this assessment for them as well.

Thank you so much :)