The purpose of the complete health history
is to
collect subjective data
, which is what the person says about himself or herself.
By combining this subjective data with objective data from the physical examination and diagnostic tests, you create a database to make a judgment about the person's h
No matter what form is used to record the health history, plan to gather data in eight
categories.
Biographic data
Source of history
Reason for seeking care
Present health history/illness
Past health information
Family history
Review of systems
Cultural
No matter what form is used to record the health history, plan to gather data in eight
categories:
1. Biographic data.
2. Source of the history
3. Reason for seeking care.
4. Present health or history of present illness.
5. Past history.
6. Family history.
7. Review Systems.
8. Functional assessment or activities of daily living (ADLs)
First in health history sequence
First, collect
biographic data
, such as the patient's name, address, and date of birth as well as language and communication needs.
Second in health history sequence
Second,
note the source of the history
, which is usually the patient, but may be someone else, such as a relative or interpreter.
Third in health history sequence
Third, obtain the
reason for seeking care
, formerly known as the chief complaint. In the patient's own words, briefly describe the reason for the visit.
Fourth in health history sequence
Fourth, record the
present health or history of present illness.
For a well person, briefly note the general state of health. For a sick person, chronologically record the reason for seeking care. When a patient reports a symptom, perform a symptom analys
PQRSTU stands for
Provocative or palliative.
Quality or quantity.
Region or radiation.
Severity scale.
Timing.
Understanding the patient's perception of the problem.
OLD CARTS
Onset.
Location.
Duration.
Character.
Associated symptoms.
Relieving factors.
Timing.
Severity......plus
Medications and treatments tried.
Fifth in health history sequence
Fifth, investigate
past health events
, such as illnesses, injuries, hospitalizations, and
allergies as well as current medications.
Sixth in health history sequence
Sixth, gather a
family history
to help detect health risks for the patient. To aid in this process, draw a pedigree or
genogram.
Seventh in health history sequence
Seventh, perform a
review of systems
to evaluate the past and present health of each body system, double-check for significant data, and assess health promotion practices. For each body system, assess for symptoms and health-promoting behaviors.
Review of Systems
General overall.
Skin. Hair. Head. Eyes/Ears/Nose/Sinuses.
Mouth/Throat. Neck. Breast/Axilla.
Respiratory system. Cardiovascular system.
Peripheral vascular. Gastrointestinal.
Urinary system. Male/Female Genital.
Sexual health. Musculoskeletal.
Neurologic
Eighth in health history sequence
Finally, perform a
functional assessment
, including activities of daily living, such as bathing dressing, toileting, eating, walking, housekeeping, shopping, cooking, and other factors.
Functional Assessment
Self esteem/self concept. Activity/exercise.
Sleep/rest. Nutrition/elimination.
Interpersonal relationships/resources.
Spiritual resources. (FICA: faith, influence, community, and address)
Coping and stress management. Personal habits.
Environmental occup
When obtaining a
child's health history
, use the same structure you would use for an adult, but make pertinent modifications or additions. Additions include:
A
prenatal and perinatal
history.
The
parents' description
of the present problem.
Any childhood
illnesses or accidents
.
Immunization data
.
A
developmental overview
.
And a
nutritional
history.
Health History variety
The depth of information obtained for each health history category may vary from one setting to another. However, you should address all categories before making a diagnosis or judgment about the patient's health status.
When taking an older adult's health history,
also ask additional questions. For example, explore
changes in activities
of daily living that may result from the
aging process
or
chronic illness
. Remember that the impact or burden of a disease may be more important to an older adult than the actual d
Consider Kids...
Prenatal status. Course of labor and delivery. Postnatal status. Developmental history. Growth. Milestone achievement. Current development (1 month-preschooler). Nutritional history. Family history. Review of Systems and Functional assessment.
The Comprehensive Older Person's Evaluation
is particularly useful because it addresses: Basic and instrumental activities of daily living
And physical, social, psychologic, demographic, financial, and legal issues.
May take a while to figure out WHY they are really there.
General health in the las
HEEADSSS
Method of interviewing focuses on assessment of the
H
ome environment, *E*ducation and Employment,
E
E
hod of interviewing focuses on assessment of the *H*ome environment, *E*ducation and Employment, *E*ating, peer-related
A
ctivities,
D
rugs, *S*exuality
Which of the following is included in documenting a history source?
1. Appearance, dress, and hygiene.
(Appearance, dress, and hygiene are observations included in the general survey.)
2. Cognition and literacy level.
(Cognition and literacy level is part of the mental status assessment.)
3. Documented relationship of sup
To determine the patient's perception of pain,
the nurse would determine the meaning of the symptom by asking how it affects daily activities and what the patient thinks the pain means.
The nature or character calls
for specific descriptive terms to describe the pain.
Aggravating factors are determined by
asking the patient what makes the pain worse.
Relieving factors are determined by
asking the patient what relieves the pain, what is the effect of any treatment, what the patient has tried, and what seems to help.
CAGE is a screening questionnaire
to identify excessive or uncontrolled drinking (e.g., C = Cut down; A = Annoyed; G = Guilty; E = Eye opener).
Depression is assessed during
the review of systems and during the mental status assessment (mood and affect). The Geriatric Depression Scale, Short Form (Yesavage and Brink, 1983) is an assessment instrument for use with the older adult.
Coping and stress management are assessed
during the functional assessment of the complete health history
The health history will assess
lifestyle, including such factors as exercise, diet, risk reduction, and health promotion behaviors.
The purposes of the review of systems are
to evaluate the past and present health state of each body system, to double-check in case any significant data were omitted in the present illness section, and to evaluate health promotion practices.
The reason for seeking care is
a statement in the person's own words that describes the reason for the visit.
Objective data is
the observations obtained by the health care professional during the physical examination.
For the well person, the present health or history of present illness is
a short statement about the general state of health.
review of systems is limited to
the patient statements or subjective data.
When recording information for the review of systems,
When recording information for the review of systems, the interviewer should record the presence or absence of all symptoms, otherwise it is unknown which factors were asked.
Functional assessment measures
a person's self-care ability. The areas assessed under the self-esteem and self-concept section of the functional assessment include education, financial status, and value-belief system. Areas covered under self-esteem and self-concept include: education,
The eight critical characteristics of any symptom reported in the history of the present illness are:
P = provocative or palliative;
Q = quality or quantity;
R = region or radiation;
S = severity scale;
T = timing; and
U = understand patient's perception.
A reliable person always gives the
same answers, even when questions are rephrased or are repeated later in the interview.
The adolescent interview during the health history should be
with the youth alone; the parent(s) may wait in the waiting area and complete other past health questionnaire forms.
The infant and nutritional info:
The amount of nutritional information needed depends on the child's age; the younger the child is the more detailed and specific the data should be.
reason for seeking care has replaced chief complaint because
the newer term incorporates wellness needs