Chapter 4 The Complete Health HistorNURS220 Chapter 4 The Complete Health History
The Health History Sequence
The purpose to obtain of health history is together subjective data and objective data.
Subjective date also include: The Health History Sequence
Biographical data
Source of history
Reason for seeking care
Present health or history of present illness
Past health
Family history
Review of systems
Functional assessment including activities of daily living (ADLs)
Biographical Data
Biographical date include:
Name
Address and phone number
Age and birth date
Birthplace
Sex
Marital status
Race
Ethnic origin
Occupation: usual and present
Source of History
Source of History:
Patient, relative, friend
Record who furnishes information
Reliability of the informant
Note whether the person appears well or ill
Reason for Seeking Care
Reason for Seeking Care:
Brief spontaneous statement in person’s own words describing reason for visit
Symptom: subjective sensation person feels from disorder
What person says is reason for seeking care is recorded and enclosed in quotation marks to indicate
person’s exact words
Sign: objective abnormality that can be detected on physical examination or in laboratory reports
Avoid translating into a medical diagnosis.
Present Health or History of Present Illness (HPI)
Present Health or History of Present Illness(HPI):
Location
Character or quality
Quantity or severity
Timing
Setting
Aggravating or relieving factors
Associated factors
Patient’s perception
Present Health or History of Present Illness
“Tell me about your abdominal pain?”
Character/Quality describe symptoms, feeling, appearance, burning,
Onset (Timing): when. When did the pain start , when did u feel the problem?
Location: where, does it radiate?
Duration (Timing): how long.
Severity: how bad, pain scale
Pattern (Aggravating or relieving factors): what improves it? Worsens it? what make the pain worse or better
Associated factors: any other symptoms associated with primary SX(symptoms) such as fever, chill, urine fr.
Affects client (Patient’s perception). Potential anxiety
Setting – where was the person or what ws the person doing when symptoms started?
PQRSTU
PQRSTU
May find it helpful to organize data/ different pneumonic
P: provocative or palliative: what brings it on? What makes it better? Worse?
Q: quality or Quantity: how does it look, feel, sound? Intense? Severe?
R: region or Radiation – Where is it? Radiating?
S: severity scale: Scale 0-10- Better? Worse?
T: timing: Onset- when does it occur? How long does it last? How often?
U: understand patient’s Perception of the problem. What does it mean?
Past Health
Past Health:
Childhood illnesses; MMRV strep throat, v. cough, chicken pork
Accidents or injuries ; head injury, wound, burn, fracture,
Serious or chronic illnesses; HIV infection, cancer, Hepatitis, DM, HTN, depression, heart disease,
Hospitalizations ; cause of the hospitalization, how long there, name of the doctor, name of the hospital, how recover
Surgeries; type of surgery, date, name of hosp/doctor, how the person recover
Obstetric history; # of pregnancy, # of miscarry, # of children living, the sex,
Immunizations;
Last examination date: hearing, EKG, pap smear, mammo
Allergies; foods, know the reaction such as rash, running eye, sob
Current medications; know the name/brand, does, ask how pt take each day, what it is for, sig affect of it
Family History
Family History:
May use genogram- See page 49 of example of genogram (family tree: 3 generation such as parent, grandpa, sibling
Culture and genetics: biographic data, spiritual resources /religion, past health, Health perception
Cross-Culture Care Implications
Cross-Culture Care Implications:
Additional questions for new immigrants
Biographical data
Spiritual resource and religion: assess if certain procedures cannot be done
Past health: what immunizations, if any
Health perception
How does person describe health and illness
How does person see problems he or she is now experiencing
Nutrition: taboo foods or food combinations
Review of Systems
Review of System
Purposes:
1- Assess past and present health for each body system
2- check for omitted data
3- Evaluate health promotion practices
The order of the examination is generally a head to toe examination.
Document as present or absent, or denies headache, cough etc. Avoid terms such as negative or positive.
Review of Systems:
General overall health state
Skin
Hair
Head
Eyes
Ears
Nose and sinuses
Mouth and throat
Neck
Breast
Axilla
Respiratory system
Cardiovascular
Peripheral vascular
Gastrointestinal
Urinary system
Male genital system
Female genital system
Sexual health
Musculoskeletal system
Neurologic system
Hematologic system
Endocrine system
Collecting Objective Data:
Physical setting; by providing comfort area for pt, gown, pen light
Preparing oneself: introduce yourself, explain the procedure, wash hand before or after the procedure
Approaching the patient: leave room when pt changing clothes, be organize or limit unnecessary position change
Positions for Physical Assessment
Positions for Physical Assessment: include
Supine
Dorsal recumbent
Sims position
Prone
Knee chest
Lithotomy
Validating Data
Validating Data:
Validating: purpose is to confirm or verify that subjective and objective data are reliable and accurate. Look for
inconsistent findings.
Methods of Validation
Clarify data
Verify data with another health care professional
Compare objective findings with subjective findings.
Assessment (ADL)
Functional Assessment (ADL):Fumeanctional
It uses to measure a person selfcare
Self-esteem, self-concept
Activity and exercise
Sleep and rest
Nutrition and elimination
Interpersonal relationships and resources
Spiritual resources
Coping and stress management
Personal habits
Illicit or street drugs
Environment and work hazards
Intimate partner violence
Occupational health
Psychosocial Interview - Adolescent
Psychosocial Interview-Adolescent:
Method of interviewing focuses on assessment of:
Home environment,
Education and employment,
Eating, peer-related
Activities,
Drugs,
Sexuality,
Suicide and depression, and
Safety from injury and violence