HA lec outline

• Definition of Health History:

  • Systematic collection of subjective data stated by the client, and objective data observed by the nurse
• Collecting SUBJECTIVE Data:

  • Consists of sensation or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, personal information
• Interviewing:

  • Obtaining a valid nursing health history requires professional, interpersonal and interviewing skills
  • Two focuses: establishing rapport and trusting relationship with the client to elicit accurate and meaningful information, gathering information on the client's development, psychological, physiologic, sociocultural and spiritual status
• Phases of Interview:

  • Introductory phases
  • Working phase
  • Summary phase or closing phases
• Types of Communication:

  • Nonverbal communication: appearance, demeanor, facial expression, attitude, silence, listening
  • Verbal communication: open-ended questions, closed-ended questions, laundry list, rephrasing, well-placed phrases, inferring, providing information
• Special Consideration:

  • Gerontologic
  • Cultural
  • Emotional
• Method of Collecting Data:

  • Interviewing
  • Two approaches of interview: directive (interviewer directs the interview and asks specific questions), non-directive (conversational type and allows topics to be examined as they arise)
• Types of Interview Questions:

  • Open-ended questions
  • Closed-ended questions
• Planning the Interview and Setting:

  • Time
  • Place
  • Seating arrangement
  • Distance
  • Language
• Phases of Taking Health History:

  • The interview phase
  • The recording phase
• Guidelines for Taking Nursing History:

  • Private, comfortable, and quiet environment
  • Allow the client to state problems and expectations for the interview
  • Orient the client to the structure, purposes, and expectations of the history
  • Communicate and negotiate priorities with the client
  • Listen more than talk
  • Observe non-verbal communications e.g. "body language, voice tone, and appearance"
• Purpose of Health History:

  • To elicit information about all the variables that may affect the client's health status
  • To obtain data that help the nurse understand and appreciate the client's life experience
  • To initiate a non-judgmental, trusting interpersonal relationship
• Types of Nursing Health History:

  • Complete health history
  • Interval health history
  • Problem-focused health history
• Components of Health History:

  • Biographical data
  • Chief complaint or reason for visit
  • History of present illness
  • Past health history
  • Family history of illness
  • Review of systems
  • Lifestyle
  • Social data
  • Psychological data
  • Pattern of health care
• Component of Health History:

  • Biographical Data:
  • Chief Complaint: "Reason For Hospitalization"
  • History of Present Illness
• Component of Present Illness:

  • Introduction: "client's summary and usual health"
  • Investigation of symptoms: onset, date, gradual or sudden, duration, frequency, location, quality, alleviating or aggravating factors
  • Negative information
  • Relevant family information
  • Disability "affected the client's total life"
  • COLDSPA: Character, Onset, Location, Duration, Severity, Pattern, Associated factors
• Component of Past Health History:

  • Problems at birth
  • Childhood illness e.g. history of rheumatic fever
  • Adult illnesses (physical, emotional, mental)
  • History of accidents and disabling injuries
• Childhood illnesses: e.g. history of rheumatic fever
• Adult illnesses (physical, emotional, mental)
• History of accidents and disabling injuries
• History of hospitalization:

  • Time of admission, date, admitting complaint, discharge diagnosis, and follow-up care
  • Maintenance medications
• History of operations: reasons and procedures
• History of immunizations and allergies
• Physical examinations and diagnostic tests
• Medication use
• Gynecologic/obstetric history:

  • LMP, Menarche, Pregnancies, births
• Pain experiences
• Psychiatric history:

  • Emotional or psychiatric problems/illness and time frame
  • Diagnoses, hospitalizations, and treatments
• Family History:

  • Purpose: to learn about the general health of the client's blood relatives, spouse, and children
  • Identify any illness of environmental, genetic, or familiar nature that might have implications for the client's health problems
  • Includes family history of communicable diseases, heredity factors associated with causes of some diseases, strong family history of certain problems, health of family members (maternal, parents, siblings, aunts, uncles, etc.), cause of death of family members (immediate and extended family)
• Environmental History:

  • Purpose: to gather information about the client's surroundings, including physical, psychological, social environment, and presence of hazards, pollutants, and safety measures
  • Includes home and neighborhood condition (residency, type of environment, environmental risks)
• Current Health Information/Lifestyle:

  • Allergies: environmental, ingestion, drug, other
  • Habits: alcohol, tobacco, drug, caffeine
  • Medications taken regularly (prescribed by doctors or self-prescription)
  • Exercise pattern
  • Rest and Sleep pattern (daily routine)
  • Pattern of life (sedentary or active)
  • Activities of Daily Living (ADL)
• Psychosocial History:

  • Includes how the client and their family cope with disease or stress
  • Assess if there are psychological or social problems affecting the client's general health
  • Major stressors, communication, self-concept, mood, usual coping mechanisms
• Review of Systems (ROS):

  • Collection of data about the past and present of each of the client's systems
  • Identifies hidden problems and provides an opportunity to indicate client strength and liabilities
  • Assessment of physical, sociologic, and psychological health status
• Nutritional Health History:

  • Obtain data about 24-hour dietary intake (foods and fluids), eating habits and patterns, quality and quantity of food, sources of food
• Assessment of Interpersonal Factors:

  • Includes ethnic and cultural background, spoken language, values, health habits, family relationship, self-concept perception of strength, desired changes, sexuality, developmental level and concerns, stress response, coping pattern, support system, perceptions of current anticipated stressors
• Educational history
• Occupational history
• Economic status
• Review of Systems:

  • General: usual weight, recent weight change, clothing that fits more tightly or loosely than before, weakness, fatigue, fever
  • Skin: rashes, lumps, sores, itching, dryness, changes in hair or nails, changes in moles
  • Head, Eyes, Ears, Nose, Throat (HEENT): various assessments and conditions
• Continuation of Review of Systems:

  • Neck: lumps, swollen glands, goiter, pain, stiffness
  • Breasts: lumps, pain or discomfort, nipple discharge, self-examination practices
  • Respiratory, Cardiovascular, Gastrointestinal, Peripheral Vascular, Urinary, Genital, Musculoskeletal, Psychiatric, Neurologic, Hematologic, Endocrine: assessments and conditions