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Patient Interview Guide for Nurses

The student nurse conducted an interview of a patient presenting with a 2-day headache. The patient described the headache as sharp pain localized to the middle of their head, ranging from 8-10 in severity on a pain scale, and triggered by phone use. The nurse obtained the patient's medical history, family history, personal history, social history, and environmental details. No significant findings were reported other than daily vitamin C use.

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Dawn Encarnacion
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0% found this document useful (0 votes)
20 views2 pages

Patient Interview Guide for Nurses

The student nurse conducted an interview of a patient presenting with a 2-day headache. The patient described the headache as sharp pain localized to the middle of their head, ranging from 8-10 in severity on a pain scale, and triggered by phone use. The nurse obtained the patient's medical history, family history, personal history, social history, and environmental details. No significant findings were reported other than daily vitamin C use.

Uploaded by

Dawn Encarnacion
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Introduction

Hello I'm
and I will be your student nurse for today
How would you like me to call you? Ok that's great
Let me just check somehow few of your information
So how old are you?
Where do you live?
When is your birthday?
Are you married? Ok great
So uhm let's get on with the interview is it okay if we start now?

History of present illness


So, what brings you here today? Headache
When this headache starts? 2 days ago
If you are to point the area where it hurts would you please point it? so it hurts in the middle right here
So, it does only occur in that area? Yes
Does it hurt in anywhere else?
So, if you were to describe the headache for me how does it feel like? Is it like throbbing, constant or
sharp? Sharp
Okay so if you were to rate the pain from scale of 1-10, 10 being the most painful and 1 being the
least? Uhm what number would you rate? 8-10 so it ranges from 8-10
How long does this head ache last? Around 5-10 minutes
Does your headache come and go or is it persistent? It comes and go
What were you doing in that moment when it hurt? Like what triggers it? When I'm using my phone
So, may I just ask how long do you usually use your phone? 5-6h
Ooh so do you rest in between those hours? Yes
What are the things you do to ease the pain do you rest?
Do you take any medication?
Besides from headache do you feel any discornfort? You don't have any cough, runny nose any
nausea?
Ok so thank you for that

PAST HISTORY
Ok so (name of dient) for the next part of these interview is about your past self, just aah few
questions about your past, is it okay to you?
So as an adult do you recall back your childhood, about your childhood illnesses, like your chickenpox?
No, I don't know
Okay so you don't recall
So, have you asked your parents before if you've had immunization or vaccine as a child?
So, do you recall the immunization and the vaccines?
Okay so do you have any medications that you take every day? Only Vitamin C
Okay so do you recall any surgeries, do you have any? No, I haven't
So, do you have any serious injuries that needed you to go to the hospital or seek medical care? I
haven't
Okay that's good
So, have you ever been to the hospital again besides when you were born?
Are you up to date on your vaccines, immunizations?
So, are you allergic to anything else, any food, drinks?

FAMILY HISTORY
Okay so now I'm gonna, ask few questions about your family background or if there are any diseases
present in your family?
Do you have a family member that has any diseases or any illnesses?
So, they don't have like diabetes, tuberculosis, how about someone with asthma, how about cancer,
any mental disorders, hepatitis, heart diseases?

PERSONAL HISTORY
How do you feel about yourself today?
Do you feel any discomfort besides your (concern of the patient)?
May I know who you are living with?
Do you have any problems doing any activities?
How about moving around, do you have any difficulties?
So, do you exercise?
Have you never try doing exercises?
How do you find doing exercises?
Can you sleep with ease, do you have any problems sleeping at night?
Do you eat regularly? Like times a day, you don't skip meals?
What type of food do you usually eat?
Do you smoke?
Do you drink any alcohol?
How about work, do you work?
Do you still go to school?

SOCIAL HISTORY?
May 1 know what your hobbies are?
May I know the languages you speak?
Are you in a relationship with someone, intimate relationship with someone?
How about any organization participation in the community are you in any of those?

ENVIRONMENTAL HISTORY
I'm just gonna ask a few questions about your Home
Do you own a house? Does it have any restroom? How about the water supply is it deep well?
But you don't have any trouble about the water? You don't drink from it?

Common questions

Powered by AI

The patient's personal history, including the absence of regular exercise and frequent phone use, plays a significant role in assessing current headache symptoms. These factors indicate a possible link between lifestyle and the triggered symptoms, suggesting intervention might include lifestyle changes as part of the management plan .

Yes, an individual's social history significantly influences their health. The patient's engagement in social activities, interaction in an intimate relationship, and involvement in community organizations can provide mental and emotional health benefits, which could indirectly influence physical health outcomes, such as stress-induced headaches .

The patient's perception of their current health and discomfort can impact the management of their headache symptoms by shaping their attitude towards treatment adherence and lifestyle adjustments. Positive self-perception may enhance willingness to make necessary changes like reducing phone use or starting regular exercise, ultimately aiding symptom management .

The patient reports no known family history of diabetes, tuberculosis, asthma, cancer, mental disorders, hepatitis, or heart diseases. This lack of familial predisposition to these conditions could suggest a lower genetic risk for these ailments. However, without thorough genetic screening, it is not conclusively predictive of future health .

The patient's inability to recall childhood illnesses or vaccinations potentially complicates medical history evaluation and might affect healthcare management strategies. This lack of information may hinder preventive care measures that rely on past immunizations or unresolved childhood medical issues that could manifest later .

The patient's phone usage appears to be directly linked to the frequency and severity of their headaches. The patient reports using their phone for 5-6 hours a day without significant breaks, which coincides with the onset of headaches. The headaches are described as sharp and range from 8-10 in severity on a pain scale, suggesting a strong correlation between prolonged phone usage and headache intensity .

While the patient reports no issues with the water supply, the information about living conditions is limited. However, access to safe water and having a restroom are positive indicators that reduce health risks such as waterborne diseases. The lack of further detail about housing conditions makes it difficult to assess other environmental factors that could impact health .

Thorough knowledge of the patient's personal and family health history steers the healthcare professional towards a more tailored treatment approach. With no serious family or personal health predispositions, the focus might shift to lifestyle modifications and monitoring for any emerging patterns, such as those related to lifestyle-driven headaches .

The patient’s lifestyle seems to lack regular physical activity as they have not reported any exercise habits. They eat regularly and do not skip meals which indicates a degree of dietary stability . However, the absence of exercise might contribute to other health issues or not address potential factors that are causing their current health problems.

The absence of serious injuries or chronic medical conditions in the patient's past suggests a relatively stable health history. This may help eliminate certain chronic or acute conditions as causes for current symptoms, focusing more on lifestyle or environmental factors as potential areas to mitigate headache occurrences .

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