You will interview a non-family member, geriatric patient age 65 years or older. You can interview a patient at clinical, a neighbor, someone from church, the local nursing home, or an Assisted Living
Patient Interview worksheet Present Health and concerns (important to obtain any current expressed health concern in the client’s own words. If the illness is chronic, ask if there have been any recent changes and what was done) ­­­­­­­­­­­­­­­­­­___________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Past Health History of illnesses/injuries/fractures past history of serious injuries and fractures ___________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Describe general health (obtain any current expressed health concern in the client’s own words. If the illness is chronic, ask if there have been any recent changes and what was done) __________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Major illnesses (ask about any major illness(es) ________________________________________________________________________ Childhood illnesses/diseases (measles, mumps, rubella) __________________________________________________________________ Accidents or injuries (include age/year) ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Serious or chronic illnesses (include age/year) ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Hospitalizations (what for?) __________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Past surgeries (name procedure, age) ___________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Obstetric history (# pregnancies) _______________ Children presently living ____________ Family History—Specify Which Relative(s) health status of the client’s siblings, parents, grandparents, spouse, and children Heart disease___________________________ High blood pressure______________________ Stroke________________________________ Diabetes_______________________________ Blood disorders________________________ Breast or ovarian cancer___________________ Cancer _______________________________ Sickle cell _____________________________ Arthritis______________________________ Asthma _______________________________ Obesity_______________________________ Alcoholism or drug addiction ______________ Mental illness __________________________ Suicide ________________________________ Seizure disorder ________________________ Kidney disease __________________________ Tuberculosis ____________________________ Activity and Exercise: Daily profile, usual daily activity Independent (I), needs assistance (A) or totally dependent (D) with the following ADLs: Feeding _____________ Bathing _____________ Hygiene, dressing, toileting __________ Transferring _____________ Walking (assistive devices) _____________ Standing _____________ Climbing stairs __________ Leisure activities___________________________________________ Exercise pattern (type, amount per day or per week) __________________________________________ Sleep and Rest: Sleep patterns, daytime naps, any sleep aids used _______________________________ Nutrition Diet _______________________________________________________________ Do you need assistance with meals ______________________________________ How many meals do you eat/day ________________________________________ What food do you enjoy to eat __________________________________________ Who is present at mealtimes? ___________________________________________ Have you had any recent weight loss/gain in the past month? __________________ Interpersonal Relationships and Resources: Describe your role in the family ________________________________________________________________________ Do you have a good relationship with family and friends ____________________________________________________ Who is your support when you encounter a problem or issue _________________________________________________ How much time do you spend alone in a day? _____________________________________________________________ Is this pleasurable or isolating? _________________________________________________________________________ Coping and Stress Management: Describe stresses in life now __________________________________ _______________ Change(s) in past year_______________________________________________________ Methods used to relieve stress ________________________________________________ Are these methods helpful? __________________________________________________ Personal Habits: Daily intake caffeine (coffee, tea, colas) ___________________________________________ Smoke cigarettes? ____________________________ Number packs per day _____________ Daily use for how many years __________________ Age started ______________________ Ever tried to quit? ____________________________ Were you successful? _____________ Drink alcohol ______________ Amount of alcohol (per day/week) ____________________ Perception of Own Health: How do you define your present health? ______________________________________________________________________ How do you view of own health now ________________________________________________________________________ Do you have any concerns with your health? __________________________________________________________________ What do you expect will happen to your health in future? ________________________________________________________ _______________________________________________________________________________________________________ Do you have any health goals _______________________________________________________________________________ What are your expectations of your nurses and physicians ________________________________________________________ Daily Medications Inquire with your client what medications they are presently taking. Ask the client why he/she is taking the medication(s). Name Dose Frequency Why are you taking the medication? Was the patient knowledgeable of their daily medications? Will your patient require any education on their medications? Conclude how your patient interview was conducted. (in their room, public sitting area, in the am, etc) Include a summary of your interview with your client. What went well? What are some areas to improve upon?
You will interview a non-family member, geriatric patient age 65 years or older. You can interview a patient at clinical, a neighbor, someone from church, the local nursing home, or an Assisted Living
Herzing University NM424 Patient Interview Project Student name ____________________________________________ Date of interview ____________ Patient initials ________ Room ___________ Gender __________ Age ___________ DOB ____________ Allergies __________________________________________________________________________________________________ Code Status ________________ Primary Medical Diagnosis (es) _________________________ ________________________ ____________________________ Secondary Medical Diagnoses (up to 10) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Surgical History ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Laboratory Data Interpretation is the potential reason the result is abnormal. Your interpretation is explaining WHY you think the patient’s lab value is abnormal based on the patient’s medical history and/or current situation. Date Test Normal Value Patient Result Interpretation (why would this lab value be abnormal?) Reference: Diagnostic Studies Date Test Findings/Implications Daily Medications (Scheduled, Supplements, Vitamins) Medication (include generic and brand) Classification Route Dose Frequency Side Effects (include 3-5) Reason Reference: Patient Interview Present Health and concerns (important to obtain any current expressed health concern in the client’s own words. If the illness is chronic, ask if there have been any recent changes and what was done) ­­­­­­­­­­­­­­­­­­_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Past Health History of illnesses/injuries/fractures past history of serious injuries and fractures _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Describe general health (obtain any current expressed health concern in the client’s own words. If the illness is chronic, ask if there have been any recent changes and what was done) _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Major illnesses (ask about any major illness(es) ________________________________________________________________________ Childhood illnesses/diseases (measles, mumps, rubella) __________________________________________________________________ Accidents or injuries (include age/year) _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Serious or chronic illnesses (include age/year) ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Hospitalizations (what for?) _______________________________________________________________________________________ ______________________________________________________________________________________________________________ Past surgeries (name procedure, age) ________________________________________________________________________________ ______________________________________________________________________________________________________________ Obstetric history (# pregnancies) _______________ Children presently living ____________ Family History—Specify Which Relative(s) health status of the client’s siblings, parents, grandparents, spouse, and children Heart disease___________________________ High blood pressure______________________ Stroke________________________________ Diabetes_______________________________ Blood disorders________________________ Breast or ovarian cancer___________________ Cancer _______________________________ Sickle cell _____________________________ Arthritis______________________________ Asthma _______________________________ Obesity_______________________________ Alcoholism or drug addiction ______________ Mental illness __________________________ Suicide ________________________________ Seizure disorder ________________________ Kidney disease __________________________ Tuberculosis ____________________________ Activity and Exercise: Daily profile, usual daily activity Independent (I), needs assistance (A) or totally dependent (D) with the following ADLs: Feeding _____________ Bathing _____________ Hygiene, dressing, toileting __________ Transferring _____________ Walking (assistive devices) _____________ Standing _____________ Climbing stairs __________ Leisure activities___________________________________________ Exercise pattern (type, amount per day or per week) __________________________________________ Sleep and Rest: Sleep patterns, daytime naps, any sleep aids used _______________________________ Nutrition Diet _______________________________________________________________ Do you need assistance with meals ______________________________________? How many meals do you eat/day ________________________________________ What foods do you enjoy eating __________________________________________? Who is present at mealtimes? ___________________________________________ Have you had any recent weight loss/gain in the past month? __________________ Interpersonal Relationships and Resources: Describe your role in the family ________________________________________________________________________ Do you have a good relationship with family and friends ____________________________________________________? Who is your support when you encounter a problem or issue _________________________________________________? How much time do you spend alone in a day? _____________________________________________________________ Is this pleasurable or isolating? _________________________________________________________________________ Coping and Stress Management: Describe stresses in life now __________________________________ _______________ Change(s) in past year_______________________________________________________ Methods used to relieve stress ________________________________________________ Are these methods helpful? __________________________________________________ Personal Habits: Daily intake caffeine (coffee, tea, colas) ___________________________________________ Smoke cigarettes? ____________________________ Number packs per day _____________ Daily use for how many years __________________ Age started ______________________ Ever tried to quit? ____________________________ Were you successful? _____________ Drink alcohol ______________ Amount of alcohol (per day/week) ____________________ Perception of Own Health: How do you define your present health? ______________________________________________________________________ How do you view of own health now ________________________________________________________________________? Do you have any concerns with your health? __________________________________________________________________ What do you expect will happen to your health in future? ________________________________________________________ _______________________________________________________________________________________________________ Do you have any health goals _______________________________________________________________________________? What are your expectations of your nurses and physicians ________________________________________________________ Daily Medications Inquire with your client what medications they are presently taking. Ask the client why he/she is taking the medication(s). Name Dose Frequency Why are you taking the medication? Was the patient knowledgeable of their daily medications? Will your patient require any education on their medications? Conclude how your patient interview was conducted. Include a brief summary of your interview with your client. What went well? What are some areas to improve upon? Review your assessment of the patient information that you collected from the chart and also assessment information from you patient interview. Analyze and identify client problems, phase 2 of the nursing process. Use accurate and appropriate spelling and grammar. Problem #1 __________________________________________________________________ Problem #2 __________________________________________________________________ Problem #3 __________________________________________________________________ NURSING PROCESS Complete 3 nursing diagnoses (NANDA) based on your patient problems listed below. Relate diagnosis to a problem your patient is having during the day you cared for them and/problem which correlates with medical diagnosis. Nursing Diagnosis NANDA Nursing Diagnosis Use the following information: Nursing Diagnosis/Problem Statement ________________________________ R/T (what is the cause of the symptom) ________________________________ As evidenced by (Specific symptoms) ________________________________ Expected Outcomes Short term goal: Create a SMART goal that relates to hospital stay Long term goal: Create a SMART goal that is appropriate for discharge Nursing Interventions This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes) #1 Short-term goal: Long-term goal: 1. 2. 3. #2 Short-term goal: Long-term goal: 1. 2. 3. #3 Short-term goal: Long-term goal: 1. 2. 3. Reference: