Dimensions of a History

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Last modified 21/03/2015

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Chapter 2. Dimensions of a History

Obtaining a health history is an important component of the health assessment process. The health interview assists in establishing rapport with the parent and child, provides data from which tentative nursing diagnoses can be made, offers an opportunity for the nurse and family to establish goals, and affords the opportunity for the nurse to provide education and support to the family.

The purposes and extent of the health interview vary with the nature of the health care contact. For example, in an emergency situation it is necessary to focus on the chief complaint and the details of past health care contacts. The prenatal and postnatal histories and the psychosocial dimensions can be left for later, unless they are the focus for the concern. When a child has repeated contacts with a health care facility, it is necessary only to update a health history if it has been completed on initial contact. The course of an interview must be modified to fit the situation and the setting. A home setting, for example, can include many distractions and will require adaptation to the family’s environment.

Generally, a direct interview is preferred for a health history, as it facilitates the building of a relationship between the family and the nurse and enables the nurse to make rich observations related to behavior, interactions, and environment. However, if an indirect method, such as a questionnaire, is used, then it is important to review the written responses and follow up any unusual responses with the family.

Guidelines for Interviewing Parents and Children

▪ Follow principles of communication during the interview (see Chapter 1).

▪ Before beginning the interview the nurse must thoroughly understand the purposes of the health history and of the questions that are asked.

▪ If a specific illness or health concern is the reason for the interview, knowledge of the diagnosis helps focus questions related to the chief complaint. The nurse must also be alert to concerns raised by the parent or child that are not related to the diagnosis.

▪ Explain the purpose of the interview, before starting, to the parents and to the child. Cooperation and sharing are more likely to occur if the parents understand that the questions facilitate better care for their child. For the adolescent, understanding the parameters of confidentiality can be crucial to what is shared.

▪ Write brief notations about specific details. Do not try to write finished sentences and keep writing to a minimum. The flow of contact is lost if the nurse spends an extended amount of time writing or staring at a form. Further, the nurse might miss important opportunities to observe behaviors and family interactions if overly committed to recording during the interview.

▪ Know what information is necessary so that the parents and child are not asked for the same type of information repeatedly. Repeat questions only if further clarification is desired.

▪ Give broad openings at the beginning of the interview, such as, “Tell me why you came to see me today.” Use direct questions, such as, “Are the stools watery?” to assist the parent to focus on specific details.

▪ Do not interrupt the parent, child, or parent and interpreter.

▪ Accept what is being said. Nodding, reestablishing eye contact, or saying “uh-huh” provides encouragement to continue. If parents have difficulty recalling specific details (e.g., when specific developmental milestones were achieved), move on to other areas in the history. When this happens, it is important not to make the parents feel that they are “bad parents” because they are unable to remember.

▪ If an interpreter is being used, avoid commenting about the family in the presence of the family.

▪ Listen, and attend to nonverbal cues. The presenting complaint might have little to do with the real concern.

▪ Convey empathy and an unhurried attitude. Sit at eye level, if possible. If the family is from another culture, observe to determine what behaviors are acceptable and therefore empathic to them. Eye contact, for example, is considered disrespectful in some cultures (e.g., Native Americans) rather than indicative of active listening and empathy.

▪ Ensure mutual understanding. Clarify if unsure, and summarize for the parent and child what has been understood.

▪ Integrate the child when possible and when culturally appropriate. Even the very young can answer the question “What do you like to eat?”

▪ Be sensitive to the need to separately interview parents and child, particularly if the child is an adolescent.

▪ Be sensitive to the need to consider who is responsible for health decisions in the family and for child care (see Chapter 1).

Information for Comprehensive History

Information	Comment
Date of History	Identifying Data
Include name of child and nickname (if any), names of parents and guardians, home telephone number, work numbers and hours when parents or guardians work, child’s date of birth, age (months, years), sex, race, language spoken, language understood.	Much of this information might already be on a child’s nameplate or chart.
Source of Referral, if Any
Source of Information
Include relationship of informant to child (child, parent, other) and judgment about reliability of information. If an interpreter has been used, note this as well.	Hesitations and vague or contradictory answers might raise concerns about reliability.
Chief Complaint
Use broad opening statements, such as, “What concerns bring you here today?” Record parents’or child’s own words: “Running to the bathroom since Saturday.”	Note who identified the chief complaint. In some instances a schoolteacher or physician might have expressed the concern. Agreement between parents and another referral source is important to note. Adolescents and parents might differ regarding perception of complaint.