You will interview a non-family member, geriatric patient age 65 years or older. You can interview a clinical patient, a neighbor, someone from church, the local nursing home, or an Assisted Living facility.
You will need to:
- Obtain verbal permission from your interviewee
- Complete the interview packet
- Write a reflective paper about your interview and experience less than 3 pages.
- Perform a minimum of 2 geriatric assessment tools during your interview and include the results in your paper.
Patient Interview Project [Document]
Interview Worksheet [Document]
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 DiagnosisNANDA Nursing DiagnosisUse the following information:Nursing Diagnosis/Problem Statement ________________________________R/T (what is the cause of the symptom) ________________________________As evidenced by (Specific symptoms) ________________________________ | Expected OutcomesShort term goal: Create a SMART goal that relates to hospital stayLong term goal: Create a SMART goal that is appropriate for discharge | Nursing InterventionsThis 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:
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?
