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 Assisted Living fac

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)

Short-term goal:

Long-term goal:

Short-term goal:

Long-term goal:

Short-term goal:

Long-term goal:

Reference: