Health Assessment Nursing History

Nursing History

Nursing History

  • Systematic collection of subjective data and objective data . used to determine a client functional health pattern status.
  • The nurse collects physiological, socio cultural, developmental, and spiritual client data .These data assist the nurse in identifying nursing diagnosis and collaborative problems.

Nursing Diagnosis

North American Nursing Diagnosis Association defines a nursing diagnosis as a clinical judgments about individual, family or community responses to actual & potential health problems &life processes. (NANDA.1994)

 


The taking of nursing health history is implemented in two phases:

 

  • The client interview phase, which elicits the information
  • The recording of data phase

– The nursing health history usually occurs in the examiner’s office, or the client’s home, or hospital room.

 

Guidelines For Taking The Nursing Health History:

  • Establish privacy, comfortable, and quiet environment.
  • Allow the client to state problems and expectations for the interview.
  • Provide the client with an orientation to the structure, purposes, and expectations of the history.
  • Communicate and negotiate priorities with the client.
  • Listen more than you talk.
  • Observe non verbal communications e.g. “body language, voice tone, and appearance”.
  • If the client encountered past health history with any health member, review information before starting interview.
  • Make a judgment about the balance between allowing a client to talk in an unstructured manner and the need to structure requested information.
  • Clarify the client’s definitions of all key terms and descriptors.
  • Avoid questions that can be answered as yes or no if detailed information is desired.
  • Keep notes adequate enough for future recording
  • Record the nursing health history as soon as possible after the interview.

 

Type Of Nursing Health History

 

1. A Complete Health History

This is taken on initial visits to health care facilities.

 

2. An Interval Health History

used to collect information in visits following the one in which an initial data base is collected.

 

3. A Problem – Focused Health History

  • used to collect data about a specific problem system or region.
  • Clients must be able to provide information they , however the nurse must probe, clarify and quantify in structured ways.
  • The nurse should take notes during data collection; however, it is usually not possible to write the entire health history during the interview.
  • Record as much of the health history during interview as possible and the remainder soon after the interview.

 

Components Of Health History

Biographical data

The first information gathered in a complete health history

Client full name Occupation (usual and present)
Address and telephone numbers Source of referral.
Birth date and birth place. Usual source of health care.
Sex and race. Source and reliability of information.
Religion Date of interview.
Marital status.

 

Chief complaint

Reason for hospitalization.

The chief complaint statement is a short subject statement. In the client’s own words, indicates the client’s purpose for requesting health care at this time.

EXAMPLES

  • Chest pain for 3 days.
  • Swollen ankles for 2 weeks.
  • Fever and headache for 24 hours

 

SYMPTOMA ANALYSIS P Q R S T

Provocative or Palliative

First occurrence :

  • What were you doing when you first experienced or noticed the symptom?
  • What to trigger it ? stress? Position?, activity?
  • What seems to cause it or make it worse? For a psychological symptom .
  • What relieves the symptom : change diet? Change position ? Take medication ? Being active?

Aggravation: what makes the symptom worse?

Quality Or Quantity

– QUALITY:

  • How would you describe the symptom- how it feels, looks, or sounds?

QUANTITY:

  • How much are you experiencing now?
  • Is it so much that it prevents you from performing any activity?

 

Region Or Radiation

Region :

  • Where does the symptom occur?

Radiation :

  • Does it travel down your back or arm, up your neck or down your legs?

 

Severity scale

Severity

  • How bad is symptom at its worst?

Course

  • Does the symptom seem to be getting better, getting worse?

 

Timing

Onset :

  • On what date did the symptom first occur

Type of onset :

  • How did the symptom start sudden? Gradually?

Frequency :

  • How often do you experience the symptom ; hourly ? Daily ? Weekly? monthly

Duration :

  • How long does an episode of the symptom last

 

History of present illness

1. Gathering Information relevant to the chief complaint

2. Onset of client’s problem

3. Self medical treatment.

 

Components of present illness

1. Introduction: “client’s summary and usual health”.

2. Investigation of symptoms: “onset, date, gradual or sudden, duration, precipitating factors, frequency, location, quality, and alleviating or aggravating factors”.

3. Negative or positive finding relate to chief complain .

4. Relevant family information.

5. Disability system “affected the client’s total life”.

 

Past health history

The purpose of the past history is to identify all major past health problems

1. Child hood illness e.g. history of rheumatic fever.

2. History of accidents and disabling .

3. History of hospitalization .

4.History of operations “how and why this done”

5. History of immunizations and allergies.

6. Physical examinations and diagnostic

7.Supportive devices – cane, walker, eyeglasses, dentures. tests.

 

Family history

The purpose of the family history is to learn about the general health of the client’s blood relatives, spouse, and children and to identify any illness of environmental, genetic, or familiar nature

1- Family history of communicable diseases.

2- Heredity factors .

3- Strong family history of certain problems.

4- Health of family members .

5- Cause of death of the family members “immediate and extended family”.

 

Environmental history

The purpose of environmental history is “to gather information about surroundings of the client”, including physical, psychological, social environment, and presence of hazards, pollutants and safety measures.”

 

Current health information

1. Allergies: environmental, ingestion, drug, other.

2.  Habits “alcohol, tobacco, drug, caffeine”

3. Medications taken regularly “by doctor or self prescription

4. Exercise patterns.

5. Sleep patterns.

6. The pattern of sedentary and active activities in the client’s usual routine is explored.

 

Psychosocial history

  • How client and his family cope with disease or stress.
  • The nurse can assess if there is psychological or social problem and if it affects general health of the client.

 

Review of systems (ROS)

1- General review, skin, hair, head and face, eyes, ears, nose and sinuses, month and throat, neck nodes, and breasts.

2- Assessment respiratory and cardiovascular systems.

3- Assessment of gastrointestinal system.

4- Assessment of urinary system.

5- Assessment of genital system.

6- Assessment of extremities and musculoskeletal system.

7- Assessment of endocrine system.

8- Assessment of hematopoietic system.

9- Assessment of social system.

10- Assessment of psychological system

 

Assessment of interpersonal factors

1- Ethnic and cultural back ground

2- Life styles.

3- Self concept

4- Sexuality: developmental level and concerns.

5- Stress responses

 

Functional health pattern (NANDA)

1- Health Perception: Health Management Pattern

2- Nutritional: Metabolic Pattern

3- Elimination Pattern

4- Activity: Exercise Pattern

5- Sexuality: Reproduction Pattern

6- Sleep: Rest Pattern

7- Sensory: Perceptual Pattern

8- Cognitive Pattern

9- Role: Relationship Pattern

10- Self: Perception-Self-Concept Pattern

11- Coping-Stress Tolerance Pattern

12- Value: Belief Pattern

 

Health Perception-Health Management Pattern

1- Determine how the client perceives and manages his or her health.

2- Compliance with current and past nursing and, medical recommendations.

3- The client’s ability to perceive the relationship between activities of daily living and health.

 

Subjective Data

Client’s Perception of Health:

Describe your health.

Client’s Perception of Illness

Describe your illness or current health problem.

Health Management and Habits

Tell me what you do when you have a health problem.

Compliance with Prescribed Medications and Treatments

Have you been able to take your prescribed medications?

If not, what caused your inability to do so?

 

Objective Data

Refer to General Physical Survey.

 

Associated Nursing Diagnoses

Wellness Diagnoses

  • Effective Management of Therapeutic Regimen

Risk Diagnoses

  • Risk for Injury
  • Risk for Suffocation
  • Risk for Trauma

Actual Diagnoses

  • Altered Growth and Development
  • Ineffective Management of Therapeutic Regimen: Individual
  • Ineffective Management of Therapeutic Regimen: Family
  • Ineffective Management of Therapeutic Regimen: Community Noncompliance.

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