King Saud University
College of Nursing
Health Assessment (NUR 224)
General Survey & Health History
Part 1
1
Outline
 Learning objectives
 Health history
Definition.
Nursing vs. Medical history.
Components of health history.
 How to obtain health history:
Interview
Records review
 Documentation
2
Learning Objectives
At the end of this module the learner should be able to:
Understand the structure and purpose of health history in order
to collect relevant information.
Recognize the importance of applying the three phases of
interview to collect a comprehensive history from clients.
Take a complete health history using standard format.
Interpret data collected in terms of chief symptoms and
complaints
3
Definition of Health assessment
Health assessment is the first step of the nursing
process. It involves collecting two types of data:
1- Objective data
 Obtained through interviewing patient.
 Referred to as symptoms.
 Feeling perception & concerns that cannot be observed by
others
2- Subjective data
 Obtained through observation, standard assessment technique,

laboratory & diagnostic test.
Referred to as signs as it can be seen, heard, or felt, by
someone other than the patient or client).
Purposes of health assessment
• Surveying the clients health status (current) and risk factors for
particular health problem (potential).
• Identifying undetected disease
• Screening for a specific disease such as diabetes
• Identifying risks for particular health problem
• Determining functional impact of disease (i.e. response to
actual or potential health problem)
• Evaluating the effectiveness of health care plan
Three health assessment components.
 Part one deals with obtaining a comprehensive health history
and utilizing effective interviewing techniques.
 Part two focuses on acquiring appropriate skills to perform
physical examination.
 Part three evaluates the client nutritional status.
Health History:
Is the collection of data about an individual's health state by
interviewing the client and review of records.
Purpose :
 to collect different type of information, to form the client’s data
base, which:
1- Helps the nurse discover significant health problem
2- Used to make judgment or diagnosis about the clients past and
current health status.
3- Used in developing the nursing care plan.
Difference between Nursing health history
and Medical health history
 Medical health history :Concentrates on
symptoms and progression of diseases
 Nursing health history: Focuses on the client’s
functional health patterns, responses to changes in
Health status & alteration in life style.
The element of health history
 Biographic information: age, sex, educational level,
marital status, occupation, living arrangements.
 Chief complaint: the client reasons for seeking health
care (usually in the clients own word).
 Present health status or illness: the record of the
current issue from the starting of the onset until now.
 Past Health history: general state of health, childhood,
adult and psychiatric illness, accident and injuries, operations
and hospitalization
 Current health status: medication, allergies to food
or medication, smoking, drug abuse, diet, screening
test, immunization, sleep pattern, exercise,
environmental hazards, and safety measures.
 Family history: age and health status of parents,
siblings, and children; cause of death for immediate
family members.
 Psychosocial factors, lifestyles: cultural beliefs that
influence health management; religious or spiritual
beliefs and daily living activities.
 Nutrition: dietary habits, preferences, or restrictions
Starting the interview:
a. Address the client by name.
b. Introduce yourself and your role.
c. Explain the purpose of the interview
d. Tell the client how long the interview will last
e. Reassure the client that the data will be kept confidential.
f. Formulate a general impression about client as a whole
(posture, speech, signs of distress, facial expression, dressing,
grooming and hygiene)
Observe client nonverbal message
 Physical appearance
 Posture Gesture
 Facial expression
 Eye contact
 Voice
2-Working phase:
It is the data gathering phase. Verbal
skills for this phase include questioning the client, and the nurse
responses to what the client says.
Open ended question
Closed question
*It require patient to talk about his problem,
expressing feeling, opinions, and idea
*It elicits yes or no answers
* It enhance the development of nurse –
patient rapport
* It limits the development of nurse
patient rapport
* They take less time
* It helps you gather more information than
can be gathered with closed question
example:
* It can convey interest and trust because of
the freedom it’s provides
*Are you the only one in your family
with lung problems?
example:
*Why did you come to the hospital to night?
*How would you describe the problems you
are having with your breathing?
* Do you ever get short of breath?
Communication skills during the interview
1-Facilitation:
Use phrases to encourage the client to continue. Example: (please
continue).
2-Silence:
Keep silent for second to have a chance to assess the client ability to
organize his thoughts.
3-Confirmation:
Repeat the information given by patient to clear up any
misunderstanding.
4-Clarification:
To seek understanding when the client words are
confusing
5-Reflection:
Repeating part of what the clients has just said, to focus
attention on specific phrase it demands the client’s
elaboration on meaning or feeling.
6-Empathy: recognizes the feeling of the client and
puts it into words. It helps the client feels accepted
and can deal with the feeling openly.
7-Summary: final review of what you understand the
person has said.
Ten traps of interviewing
 Providing false reassurance.
 Giving unwanted advice.
 Using authority.
 Using avoidance language.
 Using of professional jargons.
 Using leading or biased questions.
 Talking too much.
 Interrupting.
 Being judgmental.
 Usage of indirect language while dealing with frightening topics
3. Closure phase:
 It is the phase that eases the closing of the interview,
summarizes and sums it up .It concludes what the client
and nurse agree the health state to be.
 Restating the information that was covered during
interview
 Do not introduce any new topic
 Signal that the interview is about to end (example only 2
question left, within 5 min we will finish).
 Discuss only specific points
3. Closure phase (cont.):
 Request validation of the patient/client
perception
 End the interview /conclusion brings it to close.
 Offer the client chance for final addition. (ex: is
there anything else you would like to mention?).
 Thank the client.
 Explain the next steps. Plans can be made for the
future.
B. Review of records:
 It is an objective data collected through review of
documentations related to the client health status.
Such as:
 Medical diagnosis.
 Nursing notes.
 Laboratory and diagnostic studies performed.
 Referral notes.
Data documentation:
 Documentation is a major part of a complete health
history
 Data should be recorded in a factual manner and not
interpreted by the nurse. To increase accuracy the
nurse should record subjective data in the client own
words
Question?
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