Autonomous University of Nuevo León

Nursing School

PHASE-2.- Report #1 Clinical Interview / Build the nursing clinical history

Interview:

U.A. HEALTH STATUS ASSESSMENT

DRA: Norma Edith Cruz Chávez

Alexandra Montserrat Bárcenas Tovar 1906835

Maria Fernanda Mendoza Rivas 1928115
Lourdes Meza Bárcenas Board 1991604
Nitzia Alejandra Reyna Diaz 1913668

GRUPO: 05 SEMESTRE: 2

Delivery date: 03/07/2020

Interview Weber (2018) Ball, [Link] (2019) Bickley, L.S, Szilagyi, P.G.
 Autonomous University of Nuevo León
School of Nursing

Clinic (2018)

Definition A medical history of Discover the details of the It's a social conversation,
nursing usually patient's concern, explore expressed with your freedom
precede the your own points of view and you are
your expectations about the visit, and
physical examination and guide
show an interest and a curiosity responsible only for yourself.
to the nursing staff real, and create a bond with it.
regarding the devices
and systems that must
to value oneself. It is also from
help to establish
a relationship between the
nurse
the patient, and allows him to
this last one to participate in the
identificación de
problems and objectives.

Purpose(s) The interview of Discover the details of the The goals of this interview
nursing is a process of patient concern, explore it is to listen and improve your
of communication that is your expectations about the visit, and well-being through the
focus on the answers show an interest and a curiosity trust.
of development, real and create a bond with him.
psychological, physiological, His ability to help you
sociocultural and will increase if you identify your
spirituals of the patient, worries, believe in them and
that can be treated try to solve them.
through interventions If one acts successfully, nature
of nursing or unique and intimate of the interview and the
interdependent. physical examination will result
reinforced.

Structure of It is structured by three The identification data: Identification date:

the interview and main phases. name date, time, age, includes age, sex, occupation
steps to follow The introductory phase thatgender identity, race, source and marital status.
consists of presenting oneself to of the information and source of
patient. Explain the reference. Reliability: Varies from
purpose of the interview. Reason for concern. agreement with the memory of
Explain the types of Anamnesis of illness or of patient and their trust and
questions that are going to current problem. talent.
 Autonomous University of Nuevo León
School of Nursing

formulate the reason why Medical history Reason(s) for the consultation: one
that notes are taken, the Family background or more symptoms or concerns
electronic record Personal background and what do they do to the patient
make sure that the social seek medical attention.
information is System Review
confidential. Current illness: is
Then follows the phase of describe how it developed
work that consists of each symptom includes
obtain data about the beliefs and feelings of the
family background and patient about the
personal review disease. It may include
health problems medications, allergies and
tobacco and alcohol consumption,
during the interrogation
for devices and systems, that are often
lifestyle and habits of pertinent.
health. Finally continue
with the phase of
recap and closure that
it consists of summarizing the
information that has been
obtained from the patient
during the work phase
and verify the problems and
objectives with this.

Interview Weber (2018) Ball, [Link] (2019) Bickley, L.S, Szilagyi, P.G. (2018)
a
Clinic

Techniques The types of questions that are Speak comfortably with the The interview is a series of
of They must be employed. patient especially about questions; require a
communicate open questions to obtainyour expectations and very refined sensitivity regarding
action/the perceptions and feelings concerns. of feelings and keys
Patient communication. Use questions. Obtain basic information: behavioral traits of the person.
action closed to obtain edad de la paciente ,estado civil,
effective specific information. menstrual period
Types of assertions that are habitual/normal, probable date
they carry out. of birth, occupation, and father of
Rephrase it or repeat it. baby and his occupation.
 Autonomous University of Nuevo León
Faculty of Nursing

perception about the Background of the disease

patient responses for or of the current problem: obtain
to reflect or clarify the a description of pregnancy
information. current and healthcare
Promote the patient's speech previous
through expressions such as Obstetric history:
yes, I agree or information about everything
nod with your head. previous pregnancies.
Menstrual history;
information about age in
that menarche was predicted.

DifferentiateAll professionals of the The medical model focuses on The medical model focuses on
as between health evaluations are conducted for the patient's concern, the a single aspect (physical), while
the issue professional judgments expectations about the visit are what the nursing model
physics, has an interest and
Model regarding the patients, in perceives the person as a whole
curiosity of creating a bond
doctor nursing, the purpose of the with him, analyzing his condition of (physical, mental, emotional and
nurse medical history and the examination
health and exploring their spiritual).
I was physics differs greatly from capabilities.
the one from another professional of the

health. In the nursing model, its

The nursing approach the interview is complete,
it allows organizing the information
looking for chronic problems,
keeping track and data
and promotes the obtaining of physical, mental, and emotional,
comprehensive data for formulating
and thus be able to make a diagnosis
nursing diagnoses. of nursing.
Two methods are presented for
work: a generic approach and
one based on patterns
functional.

Interview Weber (2018) Ball, [Link] (2019) Bickley, L.S, Szilagyi, P.G. (2018)
a
Clinic

Recome The types of questions that Be kind; -Ask open-ended questions and
foundation are carried out. They must be guarantee physical comfort and listen carefully to the narration
es use open-ended questions emotional of the patient.
general to obtain the make sure you have connected Follow a complete sequence and
 Autonomous University of Nuevo León
School of Nursing

s perceptions and feelings with the patient with confidence and systematic approach to carry out the
of the patient. Use frankness, anamnesis and physical examination.
closed questions for confirm that everything that has Keep an open mind to
obtain information happened during the interaction is both, the patient and the data
specific. clearly understood by her clinics.
Types of assertions that patient and that he can explain Always include 'the worst case scenario'
are carried out. the agreed plan. possible in the list of possibilities
Rephrase or repeat your Regardless of the place of the explanations of the problem of
perception about the interview, make everyone be there patient and confirm that it can be
patient responses for as comfortable as possible. dispose of safely.
reflect or clarify the Position yourself so that there is no Analyze any error in the
information. large tables, furniture or equipment obtaining or interpreting the
Promote speech of the electronics between you and him data.
patient through patient. Apply the principles of
expressions like 'uh-huh', 'yes' If possible, put a clock where evaluation of the evidence
I agree or nods you can see it in a way that does not clinics to the information and the
with the head. it is evident that you are looking at the patient tests.
hour (e.g., behind the chair of
patient).
Make yourself comfortable and at ease,

maintaining eye contact and a

dialogue tone.
His attitude can calm the
patient and thus relieve the
concern or the pain that
constitute their main reason for
unease.
Focus on the situation
concrete, granting that it
moment all the priority and
putting aside distractions
personal and professional.

Structure Biographical data The identification data: Identification date: includes

of the Reasons for request nombre fecha, hora, edad, identidad edad, sexo, ocupación y estado
Anamnesis health care of gender, race, source of the civil
sister or Assessment of the condition información y fuente de referencia. Reliability: Varies according to
History actual through ALICIAA Cause for concern. with the patient's memory and his
Clinic Personal background Medical history of the disease or of the trust and demeanor.
Family Background current problem. Reason(s) for the consultation: one or
 Autonomous University of Nuevo León
School of Nursing

-Interrogation by devices and Medical history more symptoms or concerns than

problem systems of Family background they make the patient seek
current health Personal and social background medical attention.
Lifestyle and habits of System review -Current condition: the
health describe how each one developed
Level of development symptom, includes beliefs and
patient's feelings about
of the disease. It can include
medications, allergies and
tobacco and alcohol consumption, which
They are often relevant.
-Background: they are mentioned and
they enumerate the diseases of the
childhood, the dates of the events
in at least four categories
medical, surgical,
gynecological and psychiatric.
They include practices of
health maintenance.
Family background:
they describe or outline the age
and the state of health, as well as the
age and cause of death of
brothers, parents, and grandparents.
They document the presence or
absence of diseases
specifics in the family.
Personal background and
social: describe the level
educational, family origin, home
actual, personal interests and style
of life.
Review of devices and
systems: document the presence
or the absence of symptoms
habits related to each
one of the devices and systems
main bodily
 Autonomous University of Nuevo León
School of Nursing

Bibliographic References

Weber, J. R. (2018)Manual de valoración de la salud en enfermería. 8a edición. Editorial

Wolters Kluwer.
Bickley, L.S (2017) BATER guide to physical examination and clinical history 9th Edition Wolters
Kluwers. Barcelona, Spain
ball JW Dainis, E Manual Seidel Physical Examination 9th Edition Barcelona, Spain