Health Assessment Chapter 4: The Complete Health History

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 health status.*
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)
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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 analysis. If you find it helpful, use the mnemonic PQRSTU to do this.
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 System. Hematologic System.
Endocrine System.
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 occupational hazards.
Intimate Partner Violence. Health perceptions.
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 disease diagnosis or pathology. So be sure to record the person’s *reason for seeking care*, not your assumption about the problem.
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 last 5 years. Last examinations. Current medications. (Look closely……polypharmacy.) Functional assessment is important. Can they perform ADL’s adequately? Know the baseline!
HEEADSSS
Method of interviewing focuses on assessment of the *H*ome environment, *E*ducation and Employment, *E*ating, peer-related *A*ctivities, *D*rugs, *S*exuality, *S*uicide/depression, and *S*afety.
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 support systems.
(Interpersonal relationships and resources such as support systems are assessed during the functional assessment of the complete health history.)
*4. Reliability of informant. Correct.*
(The source of history is a record of who furnishes the information, how reliable the informant seems, and how willing he or she is to communicate. In addition, there should be a note of any special circumstances, such as the use of an interpreter.)
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, financial status, and value-belief system.
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

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