NCM 106 RLE PRELIMS notes #1
Health HISTORY
INTERVIEW
• A planned communication or a conversation
with a purpose
Purposes of Interview
1. Get or give information
2. Identify problems of mutual concern
3. Evaluate change
4. Teach
5. Provide counseling or therapy
Types of Interview Questions
CLOSED-ENDED QUESTIONS
• Used in directive interview
• Restrictive, generally requires a “yes” or
“no” or short factual answers giving
specific information
• Often begin with “when”, “where”,
“who”, “do (did, does)”, “is (are, was)”
• Types of Interview Questions
OPEN-ENDED QUESTIONS
• Used in non-directive interview
• Invite clients to discover and explore,
elaborate, clarify, illustrate their
thoughts or feelings
• Answers are longer than two words
• Gives clients freedom to divulge
information that they are ready to
disclose
• Useful in the beginning of an interview
or to change topics and to elicit
attitudes
• May begin with “what” or “how”
Types of Interview Questions
LEADING QUESTIONS
• Is closed, used in directive interview
• Directs client’s answer
• Gives clients less opportunity to decide
whether the answer is true or not
Basic Guidelines for conducting a Health History
• Listen attentively, using all your senses, and
speak slowly and clearly.
• Clarify points that are not understood.
• Plan questions to follow a logical sequence.
• Ask only one question at a time. Multiple
questions limit the client to one choice and
may confuse the client.
• Do not impose your own values on the client.
• Avoid using personal examples, such as
saying, “if I were you,…”
• Nonverbally convey respect, concern, interest,
and acceptance.
• Be aware of the client’s and your own body
language.
• Be conscious of the client’s and your own
voice inflection, tone, and affect.
• Sit down to talk with the client (be at an even
level).
• Use & accept silence to help the client search
for more thoughts or to organize them.
• Use eye contact to be calm, unhurried, and
sympathetic.
• gerontologic variations in communication
• cultural variations
• emotional variations
Ethical Use of History or Physical Examination data
 The decision to participate is voluntary
 Maintains confidentiality
 Promote professional conduct
 Biographic Data
 Chief complaint or Reason for seeking care
 History of Present Illness
o Location
o Character or Quality
o Quantity or Severity
o Timing
o Setting
o Aggravating or Relieving factors
o Associated factors
o Patient’s perception
 Past Health History
 Family History
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NCM 106 RLE PRELIMS notes #1
GORDON’S FUNCTIONAL HEALTH PATTERN
1. Health Perception and Health Management Pattern
• Describes the client’s perceived health & well
being and how health is managed.
• Client’s general health?
• Regular check up?
• Most important things you do to keep
healthy?
• Use of cigarettes, alcohol, drugs?
• Perform self exams, i.e. Breast/testicular self-
examination?
• In past, has it been easy to find ways to carry
out doctor’s or nurse’s suggestions?
• What do you think caused current illness?
• What actions have you taken since symptoms
started?
2. Nutritional and Metabolic Pattern
• This pattern describes food and fluid
consumption relative to metabolic need &
pattern indicators of local nutrient supply.
• Typical daily food intake including snacks?
• Use of supplements, vitamins?
• Typical daily fluid intake?
• Weight loss/gain? Height loss/gain?
• Appetite?
• Food or eating: Discomfort, swallowing
difficulties, diet restrictions, able to follow?
• Healing – any problems? Skin problems:
lesions? Dryness? Dental problems?
Examination (examples of objective data):
• Skin assessment, oral mucous membranes,
teeth, actual weight/height, temperature.
Abdominal assessment.
3. Elimination Pattern
• Describes the pattern of excretory function
(bowel, bladder, skin).
• Bowel elimination pattern (describe)
Frequency, character, discomfort, problem
with bowel control, use of laxatives (i.e. type,
frequency), etc.?
• Urinary elimination pattern (describe)
Frequency, problem with bladder control?
• Excess perspiration? Odour problems? Body
cavity drainage, suction, etc.?
Examination (examples of objective data):
• If indicated, examine excretions or drainage
for characteristics, colour, and consistency.
Abdominal assessment.
4. Activity/Exercise Pattern
 This pattern describes activity level, exercise
program, and leisure activities.
History (subjective data):
• Sufficient energy for desired and/or required
activities?
• Exercise pattern? Type? regularity?
• Spare time (leisure) activities?
• Perceived ability for feeding, grooming,
bathing, general mobility, toileting, home
maintenance, bed mobility, dressing and
shopping?
Examination (examples of objective data):
Demonstrate ability for the following criteria:
• Gait. Posture. Absent body part. Range of
motion (ROM) joints. Hand grip - can pick up
pencil?
• Respiration. Blood pressure. General
appearance.
• Musculoskeletal, cardiac and respiratory
assessments.
5. Sleep/Rest Pattern
 Describes patterns of sleep, rest, and
relaxation.
History (subjective data):
• Generally rested and ready for activity after
sleep?
• Sleep onset problems? Aids? Dreams
(nightmares), early awakening?
• Rest / relaxation periods?
Examination (examples of objective data):
• Observe sleep pattern and rest pattern if
applicable
• Frequent yawning, inability to concentrate,
etc.
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NCM 106 RLE PRELIMS notes #1
6. Cognitive-Perceptual Pattern
 Describes the ability of the individual to
understand and follow directions, retain
information, make decisions, and solve
problems.
History (subjective data):
• Hearing difficulty? Hearing aid?
• Vision? Wears glasses? Last checked? When
last changed?
• Any change in memory? Concentration?
• Important decisions easy/difficult to make?
• Easiest way for you to learn things? Any
difficulty?
• Any discomfort? Pain?
Examination (examples of objective data):
• Orientation.
• Hears whispers? Reads newsprint?
• Grasps ideas and questions (abstract,
concrete)?
• Language spoken. Vocabulary level.
• Attention span.
7. Self-Perception/Self-Concept Pattern
 Describes client’s self-worth, comfort, body
image, feeling state.
History (subjective data):
• How do you describe yourself?
• Most of the time, feel good (or not so good)
about self?
• Changes in body or things you can do?
Problems for you?
• Changes in the way you feel about self or
body (generally or since illness started)?
• Things frequently make you angry? Annoyed?
Fearful? Anxious? Depressed?
• Not able to control things? What helps?
• Ever feel you lose hope?
8. Role-Relationship Pattern
• Live alone?
• Family? Family structure? Any family problems
you have difficulty handling
(nuclear/extended family)? Family or others
depend on you for things? How well are you
managing?
• If appropriate – How families/others feel about
your illness?
• Problems with children?
• Belong to social groups?
• Close friends? Feel lonely? (Frequency)
• Things generally go well at work / school?
• If appropriate – income sufficient for needs?
• Feel part of (or isolated in) your
neighborhood?
9. Sexuality/Reproductive Pattern
History (subjective data):
• If appropriate to age and situation – Sexual
relationships satisfying? Changes? Problems?
• If appropriate – Use of contraceptives?
Problems?
• Female – when did menstruation begin? Last
menstrual period (LMP)? Any menstrual
problems?
• (Gravida/Para if appropriate)
10. Coping/Stress Tolerance Pattern
History (subjective data):
• Any big changes in your life in last year or
two? Crisis?
• Who is most helpful in talking things over?
Available to you now?
• Tense or relaxed most of the time? When
tense, what helps?
• Use any medications, drugs, alcohol to relax?
• When (if) there are big problems in your life,
how do you handle them? Most of the time,
are these ways successful?
11. Value/Belief Pattern
 Describes the patterns of values, beliefs
(including spiritual), and goals that guides the
client’s choices or decisions.
History (subjective data):
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NCM 106 RLE PRELIMS notes #1
• Generally get things you want from life? • Colorectal • Cervical
• Prostate • Colorectal
• Important plans for future? • Liver • Lung
• Religion important to you? f appropriate - • Leukemia  Ovary
Does this help when difficulties arise?

• If appropriate – will being here interfere with Overview of Cancer

any religious practices?  General Signs and symptoms of cancer
• Health beliefs/values?  CAUTION
 Unexplained weight loss
 Fever, fatigue
ONCOLOGY NURSING  Pain, skin changes
Overview of Cancer Factors that contribute to the development of
cancer
 Cancer is defined as a group of diseases
characterized by the abnormal growth and  Heredity
spread of cells.
 Environment
 Cancer is the second leading cause of death
globally  Lifestyle

•Incidence of cancer worldwide  Aging

• There were 17 million new cases of cancer Heredity

worldwide in 2018.  All cancer has a genetic basis, but not all
• The four most common cancers occurring cancer is inherited.
worldwide are lung, female breast, bowel and  Only 10-15% of all cancers are inherited.
prostate cancer.
 Environment
• These four account for more than four in ten
of all cancers diagnosed worldwide  Air pollutants

• Worldwide there will be 27.5 million new  Bacteria and pollutants in water
cases of cancer each year by 2040.
 Exposure to environmental chemicals
• Worldwide Statistics
 Radiation
INCIDENCE MORTALITY  Asbestos
• Lung Cancer • Lung
• Breast • Colorectal  Lifestyle
(female)
• Colorectal • Stomach  Cigarette smoking
• Prostate • Liver
 Excessive alcohol intake
• Stomach • Breast
(female)  Diet

 Exposure to UV radiation
• Philippine Statistics
 Increased exposure to sexually acquired
INCIDENCE MORTALITY viruses
• Breast • Lung
• Lung • Liver  A variety of drugs
• Colon • Breast •Nursing Responsibility
• Liver • Colon
• Prostate • Leukemia  Support the idea that cancer is a chronic
illness that has acute exacerbation

• Philippine Setting  Assess own level of knowledge relative to the

pathophysiology of the disease process
MALE FEMALE
• Lung • Breast
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NCM 106 RLE PRELIMS notes #1
 Make use of current research findings and
practices in the care of the patient

 Identify patients at high risk for cancer

 Participate in primary and secondary

prevention efforts

 Assess the learning needs, desires and

capabilities of the patient with cancer

 Collaborate with members of a

multidisciplinary team