Health interview is a meeting between a client and health personnel at which the health worker asked questions in order to find out a suitable solution or solving problems. It also involves in gathering health history of a client. Cox (2019) said that patient’s history is the major subjective source of data about their health status. She also mentioned that physiological, psychological and psychosocial information that is obtaining will helped in knowing the patients perception on presented health status and lifestyle. Jarvis (2016) explained that health history is important in beginning to identify the person’s health strengths and problems and as a bridge to the next step in data collection, the physical examination.
The professional nursing assessments you make on a client determine nursing interventions that directly or indirectly influence their health status. (Webber, 2013, p.1). Physical assessment allows the nurse to obtain a complete assessment of client through inspection, palpation, percussion and auscultation to gather information. Physical examination helps to determine the general status of one’s health. Estes (2013) states that health assessments form the foundation of all nursing care. The interview begins with the introduction of self and explained my role in the provision of her health care. Explanation was done on why the interview was being conducted and also the processes involves. This is to prepare the client and to enhance her comfort in sharing health related information.
The interview was conducted to a one BL of Naitutu village in Tailevu. Phone number of 9465423. A 40 years old I taukei, married with 3 children, she belongs to a Methodist church and works as a registered midwife under the Ministry of Health and Medical services. The history was provided by the client herself.
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Client presented today with sudden onset of severe headache. She describes the pain as throbbing and mostly on the frontal region. She has been experience this headache for 4 days now. The pain radiates to the back of her neck and relieves only with Panadol and a short nap. The pain aggravated when staying awake in the night for long hours and also when growling at her children. The pain sometimes relieve when she is away from the children. She is worried about this headache getting worse and it might end up to a long term illness like her aunt who is having a mild stroke.
For her past health history, she denies any High blood pressure, diabetics, heart disease, and cancer and seizure disorder. Nil childhood illness like measles, chicken pox, strep throat, rheumatic fever and poliomyelitis. No involvement in any accidents or injuries. No hospitalization and operations at any time. She is a gravida 3, para 3, Ab- nil, living -3. She is fully immunised, her last dose of tetanus and flu injections was November last year. No known food and drugs allergies and reactions. The only current medication she is taking is her contraceptive pills and panadol when she is in pain.
A family medical history can identify people with a higher than usual chances of having common disorders such as heart disease and diabetic. Knowing ones family medical history allows people to take steps to reduce her risk. According to the interview, father’s brother and mother’s brother both died of heart disease and mother’s sister is a dual case and died at the age of 82. Client’s mother died of abdominal mass. There is no family history of asthma, stroke, mental illness, cancers, seizure disorder, tuberculosis, arthritis, and breast cancer and kidney disease. On the next page is the genogram to show this information clearly and concisely.
Client presented with 72kg weight. Her weight is stable for the last 3 months .She is well hydrated and well nourished. Nil fatigue and weakness. On the interview of the skin, she denies any skin diseases like eczema, psoriasis, and hives. Nil discolorations on skin. No excessive bruising rashes or lesions. Client is advised on the use of skin lotions to keep skin moist and sunscreen cream when exposed to sunlight. She denies any recent hair loss or change in hair texture. Nails are well kept and clean, there is no change in shape, colour or brittleness. She usually has headaches but denies any head injury, dizziness or vertigo. There are no difficulties with her vision, no eye pain, diplopia, redness or swelling. No watering or discharging from the eyes.
She is advised to wear glasses and eye wash frequently with eye checks. There is no earache, on infection or ear discharges. Being advised on ear wicking and the use of hearing aid if needed. No nose discharge, no nose bleeds, no nasal obstructions or any sinus pain. There is no change in sense of smell. Client denies any mouth pain, any gum bleeding, lesion, any frequent sore throat, any voice change or altered taste. She denies history of tonsillectomy .Client is advised on regular dental checks and the use of dentures if needed. There is no neck pain, no limitation of movement, no lump or swelling, no enlarged or tender nodes or goitre. No pain, lump, nipple discharge, rash on breast. No breast disease as confirm by the client. She is advised on self-examination of breast frequently and visit breast clinic if any abnormalities detected. Denies any tenderness, lump, swelling or rashes on axilla.
When being interview on respiratory system, she denies any history of lung disease like asthma, emphysema, bronchitis, pneumonia and tuberculosis. No chest pain with breathing, wheezing or noisy breathing, no shortness of breath. She denies any precordial or retrosternal pain, nil palpitation, no nocturnal dyspnoea, no oedema and no history of heart murmur, hypertension, coronary heart disease or anaemia, therefore cardiovascular system is intact.
She denies any coldness, numbness and tingling. No swelling of legs, no discoloration in hands or feet, no varicose vein, thrombophlebitis or ulcers. Advised on avoiding standing or sitting too long and the use of supporting hose. Peripheral vascular system is intact.
On interview of gastrointestinal system, she confirmed that her appetite is good, food well tolerated, no dysphagia, nil heart burns, nil pain in associated with eating, nil abdominal pain, nil pyrosis, nil nauseating and vomiting, no history of abdominal diseases, passing toilet well, no black stool, no rectal bleeding or rectal conditions.
She denies any urine frequency or urgency, no dysuria, polyuria or oliguria. Urine is clear in colour and there is no history of urinary disease. No pain in flank, groin, super pubic region or low back pain.
Her menarche at 16 years of age and her last normal menses was on December 22nd. She explained that her menses is irregular due to her contraceptive pills. She denies any dysmenorrhea, vaginal discharge. She is married and sexually active. Both of them are satisfied in having sex.She denies any difficulty or painful sexual intercourse. She claimed that she is free from any sexual transmitted diseases.
When asking on musculoskeletal system, she denies any history of arthritis or gout, no point pain stiffness or swelling. No deformity and no limitation or noise with joint motion. There is no muscle pain, cramps, weakness or problems with gait or with coordinated activities.
Client denies any history of seizure disorder, stroke, fainting or blackouts. Motor function is intact. Nil tremors, weakness. Sensory function is intact, no numbness or tingling. There is no memory disorder therefore cognitive function is intact. No nervousness, no mood change, no depression and no history of mental health dysfunction or hallucination. Mental status is intact.
On assessing on haematological system, she denies any skin or mucous membrane bleeding, no excessive bruising, no lymph node swelling and no exposed to toxic agent or radiation or had any blood transfusion and reacted.
There is no history of diabetes or diabetic symptoms like polyuria, polydipsia or polyphagia. No history of thyroid disease, tolerating heat and cold well, no change in skin pigmentation and texture, no excessive sweating. There is also no abnormal hair distribution, nervousness, tremors or a need for hormonal therapy.
Functional assessment measures a client’s self-ability in the areas of physical health such as bathing, dressing, toileting and eating. For the client am interviewing, she is a registered midwife and attending a part-time course on Bachelor of Nursing- lateral entry at the Fiji National University, School of Nursing and Medical Services. She receives her salary every 2 weeks and husband also assist financially every week as a worker at a private company. Her financial status is stable and income is adequate for lifestyle and health concerns. She maintains her values and strong belief in her religion. She takes part in religious practices. Self-care behaviour refers to actions or decision that a client makes in order to cope with a health problem or to improve her health.
For this client, she used to do gardening and going out to watch movies and sometimes she wants to stay away from her kids which these relieves her headache. She manages to do her usual daily activities with no assistance or without mobility aid. She enjoyed her leisure activities like reading, meditating every day when the children are away for school. Sleeping pattern is disturbed at times when she is rostered for night shift. She sleeps long for about 8 hours in the day time when children are gone for school. She admits that she uses to hold onto a zip which aids her in sleeping. Listening to music and watching movies are other health care behaviours. On this day of interview she had Weetbix with milk for breakfast, boiled tubua and tuna for lunch and had fish and chips for dinner. This menu is not typical of most days. Most of time she buys and prepares food for the family. The food is always adequate and available for the whole family at all times. She denies any food shortage. Husband and the 3 children are always present at meal times. Other self-care behaviour is buying fast food from restaurants and sometimes they get food from their backyard garden.
With interpersonal relationship and resources- She is a wife, a mother, a care giver, a role model a teacher, a counsellor in her family. She gets along very well with family, friends and co-workers. She gets support from husband and sometimes from a neighbour when facing problems. She spends about 4 hours being alone in a day and she is enjoying it. Sometimes she does flower gardening as other self-care behaviour.
Coping and stress management-She finds it stressful now because of being attending part time course and working same time along with managing her family. It was not stressful for the past years because she was just concentrating on working and family and she managed well. The stress is the part time course. Stress is relieved when she had assistance from co-worker on her work and study. They sometimes going out and eat in restaurants and this really help a lot. She denies on daily intake of caffeine, she takes only once in a week. She denies smoking but takes alcohol occasionally. The last day of alcohol intake was in December last year. She only consumed 6 bottles of 500mls of tribe. She denies any drinking problem, no use of street drugs, No marijuana, cocaine, crack cocaine, Amphetamines, Barbiturates, LDS, and Heroin. Never been in treatment for drugs or alcohol.
Environmental /Hazards-She lives in a concrete house with husband and her 3 children in a village setting. A clean and well ventilated house with nice and caring neighbourhood. Mostly her neighbours are family relations. The area is safe and adequate heat and utility and the transport is not a problem. She involves herself in community contributions and takes part in community functions. Some of the hazards at home are burning, poisoning, falling and drowning. At works she is exposed to disease and infections. She denies any travelling in other countries and involved in military services.
Intimate partner violence- Things are going on well at home and she is safe. She is not emotionally or physically abused by her partner or someone else. And denies being hit, slapped, kicked, pushed or shoved or physically hurt. She was not at any time being force into having sex and not afraid of partner.
Occupational health- she is registered senior midwife who attends to obstetric and gynae cases. Also attended to medical and surgical paediatric cases at times after a general outpatient is closed. She is being exposed to inhalants, chemicals in a work place. Masks are used at times when in stock to reduced being exposed. There is no such programme known of that has been designed to monitor the exposure. She denies any health problems that she thinks are related to her job. She loves caring for the people that is why she loves the job so much.
Perception of own health- She defines health as a holistic wellbeing of a person. Viewing her own health now, she claimed that she is well and healthy and only the worry is the headache that might ends up with complications. Her concern is to get rid of the headache. She expects good health in the future and not to have high blood pressure from the headache. Her goal in life is to stay fit, stay healthy and be happy. She expects the nurses, physician and the interdisciplinary team to work together as a team and to give good advised and treatment to get rid of the headache.
Spiritual resources- religious faith and spirituality plays a role in her life. She takes part in religious sharing with family. She considers herself as spiritual. She is part of religious organisation in her community. She has faith in herself, stated knowing God will help in maintain good health.
Development stage based on Erik Erickson’s model of psychosocial development- I chose stage 7 which is Generativity vs. Stagnation for this client. She is on her middle age and she has contributed to the world, usually through family and work.
To conclude I would say that health interview is very important in order to get subjective date from client. As mentioned by Cox 2019), the client’s history is the major subjective source of data about the client’s health status. To obtain good subjective date, one should have a good relationship with the client. The first expressions counts. Maintain client’s confidentiality and ensure privacy is maintained at all times. Avoid all distractions before interviewing a client. Obtaining good data will help in implementing good treatment of care to the client. After interviewing this client I found out that the cause of headache is just the stress from attending her course, over worked at workplace and the children are giving her hard times. The relieve of her headache is to stay alone at times and involved the children in some activities so that they do not bother her.
References
- Cox, C. (2010). Physical Assessment for Nurses, 2e. Oxford: Wiley Blackwell
- Jarvis, C. (2016).Physical Examination & Health assessment
- Ester, MEZ. (2013). Health assessment and Physical Examination, 5e.Virginia
- Weber Janet. (2013). Health Assessment in Nursing, 5e.
