Ha lec outline subjective

• 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, and personal information
• Interviewing:

  • Requires professional, interpersonal, and interviewing skills
  • Focuses on establishing rapport, 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 Considerations:

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

  • Interviewing with two approaches: Directive and Non-Directive
  • Types of interview questions: Open-ended questions, Closed-ended questions
• Planning the Interview and Setting:

  • Time, Place, Seating Arrangement, Distance, Language
• Interacting with Clients with Various Emotional States:

  • Anxious, Angry, Depressed, Manipulative, Seductive clients
  • Discussing sensitive issues
• Phases of Taking Health History:

  • Interview phase
  • Recording phase
• Guidelines for Taking Nursing History:

  • Private, comfortable, and quiet environment
  • Listening more than talking
  • Observing non-verbal communications
  • Balancing structured and unstructured information
• Purpose of Health History:

  • Elicit information affecting the client's health status
  • Obtain data to understand the client's life experience
  • Initiate a non-judgmental, trusting 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
• Family History:

  • 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:

  • Home and neighborhood conditions
  • Type of environment and environmental risks
  • Presence of hazards, pollutants, and safety measures
• 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:

  • Coping with disease or stress
  • Response to illness and health
  • Major stressors
  • Communication
  • Self-concept
  • Mood
  • Usual coping mechanisms
• Review of Systems (ROS):

  • Collection of data about the past and present of each client system
  • Assessment of physical, sociologic, and psychological health status
  • Assessment of various body systems such as skin, hair, respiratory, cardiovascular, gastrointestinal, urinary, genital, extremities, musculoskeletal, endocrine, hematopoietic, and neurologic systems
• Nutritional Health History:

  • 24-hour dietary intake (foods and fluids)
  • Eating habits and patterns
  • Quality and quantity of food
  • Sources of food
• Assessment of Interpersonal Factors:

  • Ethnic and cultural background
  • Spoken language
  • Values, health habits, and family relationships
  • Self-concept perception of strength and desired changes
  • Sexuality, developmental level, and concerns
  • Stress response, coping patterns, support systems, perceptions of current anticipated stressors
• Educational History
• Occupational History
• Economic Status
• Review of Systems:

  • General health status
  • Skin, head, eyes, ears, nose, throat
  • Neck, breasts
  • Respiratory, cardiovascular
  • Gastrointestinal, peripheral vascular
  • Urinary, genital
  • Musculoskeletal, psychiatric
  • Neurologic, hematologic
  • Endocrine