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Nursing Health AssessmentsNursing Health Assessments

Chapter (3)Chapter (3)Health HistoryHealth History

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Definition of Health HistoryDefinition of Health History

Systematic collection of Systematic collection of subjectivesubjective data which stated with data which stated with clientclient, , and and objectiveobjective data which data which observed by the observed by the nursenurse..

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Definition of (NANAD)Definition of (NANAD)

The North American Nursing Diagnosis The North American Nursing Diagnosis Association (NANAD 1994) defines a Association (NANAD 1994) defines a nursing diagnosisnursing diagnosis as “A clinical as “A clinical judgments about individual, family or judgments about individual, family or community response to actual and community response to actual and potential health problems and life potential health problems and life responses”responses”

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Phases of taking health historyPhases of taking health history

Two phases:-Two phases:-

The interview phaseThe interview phase

The recording phase The recording phase

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Guidelines for Taking Nursing HistoryGuidelines for Taking Nursing History

Private, comfortable, and quiet Private, comfortable, and quiet environment.environment.

Allow the client to state problems and Allow the client to state problems and expectations for the interview.expectations for the interview.

orient the client the orient the client the structurestructure, , purposespurposes, , and and expectationsexpectations of the history. of the history.

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Guidelines for Taking Nursing History cont..Guidelines for Taking Nursing History cont..

Communicate and negotiate priorities Communicate and negotiate priorities with the clientwith the client

Listen more than talk.Listen more than talk.

Observe non verbal communications e.g. Observe non verbal communications e.g. ""body language, , voice tonevoice tone, and , and appearanceappearance".".

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Guidelines for Taking Nursing History cont..Guidelines for Taking Nursing History cont..

Review information about past health Review information about past health history before starting interview.history before starting interview.

Balance between Balance between allowing a client to talk in an unstructured manner and in an unstructured manner and the need to the need to structure requested informationstructure requested information..

Clarify the client's definitions (terms & Clarify the client's definitions (terms & descriptors)descriptors)

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Guidelines for Taking Nursing History cont..Guidelines for Taking Nursing History cont..

Avoid yes or no question (when detailed Avoid yes or no question (when detailed information is desired).information is desired).

Write adequate notes for recording?Write adequate notes for recording?

Record nursing health history soon after Record nursing health history soon after interview. interview.

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Types of Nursing Health HistoryTypes of Nursing Health History

Complete health historyComplete health history: taken on initial : taken on initial visits to health care facilities.visits to health care facilities.

Interval health history:Interval health history: collect collect information in visits following the initial information in visits following the initial data base is collected.data base is collected.

Problem- focusedProblem- focused health history: collect health history: collect data about a specific problemdata about a specific problem

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Components of Health HistoryComponents of Health History

1-Biographical Data: This includes1-Biographical Data: This includesFull nameFull nameAddress and telephone numbers (client's permanent Address and telephone numbers (client's permanent contact of client) contact of client) Birth date and birth place. Birth date and birth place. Sex Sex Religion and race.Religion and race.Marital status.Marital status.Social security number.Social security number.Occupation (usual and present)Occupation (usual and present)Source of referral. Source of referral. Usual source of healthcare.Usual source of healthcare.Source and reliability of information.Source and reliability of information.Date of interview.Date of interview.

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2- 2- Chief Complaint: “Reason For Chief Complaint: “Reason For Hospitalization”.Hospitalization”.

Examples of chief complaints:Examples of chief complaints:

Chest pain for 3 days.Chest pain for 3 days.

Swollen ankles for 2 weeks.Swollen ankles for 2 weeks.

Fever and headache for 24 hours.Fever and headache for 24 hours.

Pap smear needed.Pap smear needed.

Physical examination needed for camp.Physical examination needed for camp.

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3-History of present illness3-History of present illness

Gathering information relevant Gathering information relevant to the chief complaint, and the to the chief complaint, and the client's problem, including client's problem, including essentialessential and and relevantrelevant data, and data, and self medical treatmentself medical treatment..

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Component of Present IllnessComponent of Present IllnessIntroduction: "client's summary and usual Introduction: "client's summary and usual health".health".

Investigation of symptoms: "onset, date, Investigation of symptoms: "onset, date, gradual or sudden, duration, frequency, gradual or sudden, duration, frequency, location, quality, and alleviating or location, quality, and alleviating or aggravating factors".aggravating factors".

Negative information.Negative information.

Relevant family information.Relevant family information.

Disability "affected the client's total life".Disability "affected the client's total life".

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4- 4- Past Health History:Past Health History:The purpose: (to identify all major past The purpose: (to identify all major past

health problems of the client)health problems of the client)This includes:This includes:

Childhood illness e.g. history of Childhood illness e.g. history of rheumatic fever.rheumatic fever.

History of accidents and disabling injuriesHistory of accidents and disabling injuries

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Past Health History. Cont…Past Health History. Cont…

History of hospitalizationHistory of hospitalization (time of (time of admission, date, admitting complaint, admission, date, admitting complaint, discharge diagnosis and follow up care.discharge diagnosis and follow up care.

History of operationsHistory of operations "how and why this "how and why this done"done"

History of immunizations and allergiesHistory of immunizations and allergies..

Physical examinations and diagnostic Physical examinations and diagnostic tests.tests.

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5-Family History5-Family History

The purpose: to learn about the general The purpose: to learn about the general health of the client's health of the client's blood relativesblood relatives, , spouse, and children and to spouse, and children and to identify any identify any illness of environmental geneticillness of environmental genetic, or , or familiar naturefamiliar nature that might have that might have implications for the client's health implications for the client's health problems. problems.

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Family History. Cont…Family History. Cont…

Family history of communicable diseases.Family history of communicable diseases.

Heredity factors associated with causes of Heredity factors associated with causes of some diseases.some diseases.

Strong family history of certain problems.Strong family history of certain problems.

Health of family members "maternal, parents, Health of family members "maternal, parents, siblings, aunts, uncles…etc.".siblings, aunts, uncles…etc.".

Cause of death of the family members Cause of death of the family members "immediate and extended family"."immediate and extended family".

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6-Environmental History:6-Environmental History:

purposepurpose

"to gather information about surroundings "to gather information about surroundings of the client", including physical, of the client", including physical, psychological, social environment, and psychological, social environment, and presence of hazards, pollutants and presence of hazards, pollutants and safety measures."safety measures."

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7- Current Health Information 7- Current Health Information

The purpose is to record major, current, The purpose is to record major, current, health related information.health related information.

AllergiesAllergies: environmental, ingestion, drug, : environmental, ingestion, drug, other.other.

HabitsHabits "alcohol, tobacco, drug, caffeine" "alcohol, tobacco, drug, caffeine"

MedicationsMedications taken regularly "by doctor or self taken regularly "by doctor or self prescriptionprescription

ExerciseExercise patterns. patterns.

SleepSleep patterns (daily routine). patterns (daily routine).

The pattern life (sedentary or active)The pattern life (sedentary or active)

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8- Psychosocial History8- Psychosocial History::

Includes :Includes :

How client and his family cope with How client and his family cope with disease or stress, and how they responses disease or stress, and how they responses to illness and health.to illness and health.

You can assess if there is psychological You can assess if there is psychological or social problem and if it affects general or social problem and if it affects general health of the client.health of the client.

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9- Review of Systems (ROS)9- Review of Systems (ROS)

Collection of data about the past and the Collection of data about the past and the present of each of the client systems.present of each of the client systems.

((Review of the client’sReview of the client’s physical, sociologic, physical, sociologic, and psychological health status may and psychological health status may identify hiddenidentify hidden problems and provides an problems and provides an opportunity to indicate client strength and opportunity to indicate client strength and liabilities liabilities

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Physical SPhysical SystemsystemsWhich includes assessment of:-Which includes assessment of:-

General review of skin, hair, head, face, eyes, ears, General review of skin, hair, head, face, eyes, ears, nose, sinuses, mouth, throat, neck nodes and breasts.nose, sinuses, mouth, throat, neck nodes and breasts.Assessment of respiratory and cardiovascular system.Assessment of respiratory and cardiovascular system.Assessment of gastrointestinal system.Assessment of gastrointestinal system.Assessment of urinary system.Assessment of urinary system.Assessment of genital system.Assessment of genital system.Assessment of extremities and musculoskeletal Assessment of extremities and musculoskeletal system.system.Assessment of endocrine system.Assessment of endocrine system.Assessment of heamatoboitic system.Assessment of heamatoboitic system.Assessment of social system.Assessment of social system.Assessment of psychological systemAssessment of psychological system..

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10- Nutritional Health History10- Nutritional Health History

““Discussed Before”Discussed Before”

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11- Assessment of Interpersonal Factors.11- Assessment of Interpersonal Factors.

This includes :-This includes :-

Ethnic and cultural background, spoken Ethnic and cultural background, spoken language, values, health habits, and family language, values, health habits, and family relationship.relationship.

Life style e.g. rest and sleep patternLife style e.g. rest and sleep pattern

Self concept perception of strength, desired Self concept perception of strength, desired changeschanges

Sexuality developmental level and concernsSexuality developmental level and concerns

Stress response coping pattern, support system, Stress response coping pattern, support system, perceptions of current anticipated stressors.perceptions of current anticipated stressors.

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