Conducting a Patient Interview
When interviewing a patient, the goal is always to obtain as much information as
possible. The information collected is used to make a diagnosis. In addition, a
therapeutic relationship is established between the nurse and the patient during the
interview process. It is important to document all information obtained not only for
diagnostic purposes but also to identify possible outcomes, continuance of care, and for
teaching purposes. Information given during a patient interview is also the key to being
able to provide patient-centered care.
The components of a patient interview include Chief Complaint, History of
Present Illness, Medical history, Surgical History, Current use of Medications, Allergies,
Social History, Family History, a Review of Systems, and of course an assessment to
establish a baseline. The chief complaint is the reason for the visit of which the patient
will express when asked. History of Present Illness refers to whether the patient has had
the current issue before and how it has been managed. If the patient has never had the
issue before it will be document as a new onset illness. “Obtaining a medical history can
reveal the relevant chronic illnesses and other prior disease states for which the patient
may not be under treatment but may have had lasting effects on the patient’s health”
(Nichol, 2020). Surgical history refers to any surgeries minor or major that has occurred
in the patient’s past. Current use of medication is extremely important information to
gather as it can be the cause of the patient’s visit. This includes over the counter and
prescription medication. Allergies ranks high on the list of vital information to be
collected. There are different types of allergies such as food, drug, and skin and should
all be listed.
“Social history is a broad category of the patient’s medical history but may include
the patients smoking or other tobacco use, alcohol and drug history and should also
include other aspects of the patient’s health including spiritual, mental, relationship
status, occupation, hobbies, and sexual activity or pertinent sexual habits” (Nichol,
2020). Family history provides an overview of what your patient may be genetically
predisposed to. For example, if the patient presents with a lump in her right breast,
complains of weight fluctuations, and has a family history of breast cancer more than
likely the unfortunate cause of the chief complaint is due to the family history. Last is a
review of systems which covers the eyes and any vision irregularities, ears and hearing
impairments, nose and sense of smell or sinus issues. Review of systems also covers
the mouth and throat which goes into any issues in that area, chest and pulmonary
issues, breast and tenderness, lumps etc., cardiac status, gastrointestinal and
genitourinary function. The last few items addressed in the review of systems are
musculoskeletal, hematology, vascular, neurological, endocrine, and psychiatric issues.
An assessment is usually done to establish a baseline by obtaining a set of vitals
such as temperature, oxygen saturation, blood pressure, heart rate, blood sugar, and
respiration rate. To ensure you gather accurate vital signs you must ensure you have
the right equipment with knowledge of proper use. For example, when checking a
patient’s blood pressure, it is important to secure the right size cuff. “The most common
error when using indirect blood pressure measuring equipment is using an incorrectly
sized cuff. A BP cuff that is too large will give falsely low readings, while an overly small
cuff will provide readings that are falsely high” (McEvoy, 2018). I remember the first time
I committed this error. The patient kept telling me that they never had an issue with their
blood pressure and when I asked for help a fellow nurse told me I was getting an
inaccurate reading because I was using the wrong size cuff.
In order to get as much information as possible from your patient and to be able
to complete an assessment, you must practice cultural competence. It is important to
understand that in some cultures their family represents them and so the family must be
directly involved, in some cultures you must avoid looking at them directly in the eye,
and while some cultures welcome touch others do not. Creating a therapeutic
relationship requires cultural competence and luckily, I have not had an issue with this.
What Are The Goals Of Patient Interview?
When a patient visits a clinic, the health professionals usually interrogate the individual
to information on the person’s wellbeing. The main aim of the patient interview is to help
in identifying the sickness, thus enabling appropriate medications. The patients must
give clinicians to all the questions asked during the interview since it plays a crucial role
in the treatment plan (Allen & Becker, 2019). The correct information captured during an
interview is critical for prescribing an accurate treatment plan (Gilliland & Wainwright,
2017). Thus the interview plays a crucial role in allowing a patient to tell the clinician
how they are feeling as well as allowing the nurse to evaluate an individual’s condition
The main aim of the patient interview is to assess an individual’s medical history.
Furthermore, the clinician will also seek to know if an individual has ever experienced
such a condition before – and what kind of treatment was used in case, the patient had
the same disease in the past (Gilliland & Wainwright, 2017). The patient’s medical
history assist medical practitioners in administering the right treatment. The patient
interview also helps in ensuring a there is the right emotional environment that will
facilitate the quick recovery of the individual. In addition to that, patient interview fosters
the right communication environment between an individual and the patient, thus
promoting a good relationship that encourages the best treatment plan (Allen & Becker,
An effective interview promotes good communication that will quickly make the patient
open up in sharing all the necessary information. Consequently, the clinicians have a
better chance of applying the correct decision-making technique that gives the best
outcome. The nurse also gets an excellent opportunity to identify the future field of
specialization since the patient interview will enable health professionals to identify the
area of interest. Also, the interview will allow the clinicians to determine if the patient’s
family will be supportive during the treatment period – hence the health professionals
will be able to make necessary adjustments where possible.
Components of Patient’s History
The main components of the patient’s history that the interview seek to establish is the
name and the address of the individual. Furthermore, the clinicians ask questions about
medical history to identify any underlying medical condition that the patient has
experienced in the past. On the other hand, family medical history is a crucial
component used in determining any genetic disease that the patient might have
acquired (Stojan, Clay & Lypson, 2016). The clinicians also assess the mental condition
to identify elements of stress and past illness. Nurses use the components of the
patient’s history together with the diagnostic tests and physical examination to come up
with an ideal treatment plan.
An Incident Where I Used Improper Technique on Measuring Blood Pressure
There was an incident where a patient arrived in the hospital complaining of some chest
pain. After doing a physical examination, I used a BP cuff that was too small, resulting in
an overly high reading. At first, I panicked because the readings seemed to show the
patient is in great danger. However, I decided to call the nurse next to me to confirm the
readings, but the lady told me I should first use the proper cuff since the patient seemed
big. That incident taught me to assess the patient’s history before any diagnostic tests
and the importance of teamwork.
Different Culture Barriers
Diverse cultural background usually hampers proper patient interviews and hence an
appropriate treatment plan (Van Rosse et al., 2016). For instance, patients coming from
a different cultural background from that of a clinician might have a language barrier,
thus necessitating the need for a translator. Furthermore, individuals from a strong
religious experience such as Muslims, might have a problem when answering questions
asked by male clinicians, therefore, opting to hold back crucial information that will
enable proper treatment.
The post Conducting a Patient Interview appeared first on Versed Writers.
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