Chapter 3The Health History
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Health History Introduction
• Purpose of the health history
– Subjective data
• Uncomfortable questions
• Therapeutic communication for collaboration
• Nurse uses special techniques and communication skills
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Primary and Secondary Data Sources
• Patient is considered the primary data source
• Charts and family members are considered secondary
data sources
• Subjective information
• Secondary sources
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Reliability of the Source
• Reliable historian
• Inaccurate historian
• The nurse
– Records the person who provides the
information
– Notes any discrepancies
– Identifies other sources (such as previous
records) to confirm the history
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Components of the Health History
• Demographical data
• Reason for seeking care
• History of present illness
– Location
– Duration
– Intensity
– Quality/description
– Aggravating/alleviating factors
– Pain goal
– Functional goal
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Components of the Health History (cont.)
• Past health history
– Current medications and indications
– Family history
• Genogram
• Functional health assessment
– Gordon’s framework
• Growth and development
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Components of the Health History (cont.)
• Review of systems
– General health state
– Nutrition and hydration
– Skin, hair, and nails
– Head and neck
• Eyes
• Ears
• Nose, mouth, and throat
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Components of the Health History (cont.)
• Review of systems (cont.)
– Thorax and lungs
– Heart and neck vessels
– Peripheral vascular
– Breasts
– Abdominal-gastrointestinal
– Abdominal-urinary
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Components of the Health History (cont.)
• Review of systems (cont.)
– Musculoskeletal
– Neurological
– Male genitalia
– Female genitalia
– Anus, rectum, and prostate
– Endocrine and hematologic systems
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Teaching Opportunities
• Gathering information on health-promotion practices
• Identifying patient areas of concern and risk
• Patient teaching throughout review of systems
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Question
Tell whether the following statement is true or false.
The patient’s chart is considered a primary source of
information for the health assessment.
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Answer
False
Rationale: Charts and family members are considered
secondary data sources.
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Psychosocial and Lifestyle Factors
• Social, cultural, and spiritual assessments
• Mental health
• Human violence
• Sexual history and orientation
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Lifespan Considerations
• Pregnant women
• Newborns, children, and adolescents
• Older adults
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Cultural and Environmental Considerations
• Cultural factors influence the beliefs of patients about
their health status
• Illnesses that are more common among groups of
patients
• Patient’s environment might include safety in the home,
transportation issues, or community involvement
• Exposure history
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Question
• Why is it important to assess human violence?
A. Because of the high prevalence of physical abuse in
children and women
B. Because all women are abused during pregnancy
C. Because all women are abused at sometime in their
life
D. Because of the potential for abuse among pregnant
women
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Answer
•
A. Because of the high prevalence of physical abuse in
children and women
•
Rationale: Because of the high prevalence of physical
abuse in children and women, especially during
pregnancy, many nurses routinely question patients
about this (Centers for Disease Control and Prevention,
2008).
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