HA

• Data collection methods

  Include phases of the interview: Pre-Introductory, Introductory, Working, Termination
• Aspects of health assessment

  • Nursing Health History - collection of data for judgments, wellness promotion, teaching
  • Physical Examination - Carried out systematically in a cephalocaudal or head to toe approach
• If data collection is inadequate or inaccurate, incorrect nursing judgments may adversely affect the remaining phases of the process: diagnosis, planning, implementation, & evaluation
• Assessment is the first and most critical phase of the nursing process
• Collection of subjective data

  Integral part in interviewing the client for obtaining health history
• Sources of data

  • Client, Support people, Client records, Health care professionals, Literature, Observation
• Health assessment


  • Gathering information about the health status of the client
  • Analyzing & synthesizing data
  • Making judgments about the effectiveness of nursing interventions
  • Evaluating client care outcomes
  • Nursing process is circular, not linear
• Interview

  Planned communication to get or give information, identify problems, evaluate change, teach, provide support, counsel, or provide therapy
• The assessment phase of the nursing process is ongoing & continuous throughout all phases
• Types of data

  • Subjective data: Symptoms or covert data apparent only to the person affected
  • Objective data: Signs or overt data detectable by an observer, measurable, testable
• Observation

  Gather data using the senses consciously and deliberately
• Learning outcomes

  • Discuss the role of nurses in health assessment process.
  • Discuss the types, methods, techniques & components of assessment.
  • Identify & explain the process of Health History & Physical Assessment.
  • Discuss the data collection methods.
  • Discuss the phases of interview, types of interview and factors to consider during interview.
  • Discuss the steps of nursing health history.
• Types of Interview

  • Directive Interview
  • Non-Directive Interview
  • Information Gathering Interview
• Things to Avoid During an Interview

  • Feeling personally uncomfortable
  • Using clichés
  • Offering false reassurance
  • Asking persistent or probing questions
  • Changing the subject
  • Taking things literally
  • Giving advice
  • Jumping to conclusions
  • Leading the patient
  • Biasing yourself
  • Letting family members answer for the patient
  • Asking more than one question at a time
  • Not allowing enough response time
  • Using medical jargons
  • Assuming rather than clarifying & validating
  • Taking the patient’s responses personally
• Nursing Health History (Patient Interview)
• Complete Health History
• Factors to Consider During the Interview
• Summary & Closing Phase - Nurse

  1. Summarize - Restate / Clarify

  2. Summarizes the information obtained during the working phase & validates problems & goals with the client

  3. Identifies & discusses possible plans to resolve the problem (nursing diagnoses & collaborative problems) with the client

  4. Makes sure to ask if anything else concerns the client for any further questions
• Examining

  1. Screening Examination - review of systems

  2. Physical Examination
• Obtaining Health History

  1. Provides information on the patient’s health status, physical, psychosocial, cultural, & spiritual identity

  2. Requires 30 to 60 minutes

  3. Patient may complete health history forms before interview

  4. Some information may be obtained from medical records & updated during interview
• Review of Systems

  Each body system is addressed
• Phases of the Interview

  1. Summary & Closing Phase - Nurse

  2. Direct Interview

  3. Non-Directive Interview

  4. Information Gathering Interview
• Types of Interview Questions

  • Closed Questions
  • Open-Ended Questions
  • Neutral Questions
  • Leading Questions
• Health History – comprehensive record of the patient’s current & past health. Gathered during the initial health assessment interview
• Steps of Health Assessment

  Collection of subjective data through interview & health history
• Complete Health History


  1. Lay the groundwork for identifying nursing problems & provides a focus for the PE

  2. Identify areas of strength & limitation in lifestyle & current health status

  3. Provide examiner with specific cues to health problems that are most apparent to the client

  4. Modified or shortened when necessary
• Reasons for seeking health care

  1. Major health problem or concern

  2. Feelings about seeking health care
• Past Health History

  Ask about childhood illness, childhood immunizations, adult illnesses, past surgeries or accidents
• Biographical data summary

  • Name
  • Age
  • Address
  • Phone
  • Gender
  • Provider of history
  • Birth date
  • Place of birth
  • Race or ethnic background
  • Primary & secondary languages
  • Marital Status
  • Religious or Spiritual Practices
  • Educational Level
  • Occupation
  • Significant others or support persons
• Chief complaint

  1. Question the client about major health problem or concerns

  2. History of Present illness using COLDSPA: Character, Onset, Location, Duration, Severity, Pattern, Associated Factors
• Collection of Biographical Data

  1. Include information that identifies the client or significant others

  2. Client is considered the primary source, all others are secondary sources

  3. In some cases, immediate family or caregiver may be a more accurate source

  4. Validation of information by a secondary source may be helpful
• Proband


  Person around whom the pedigree is created
• Family Health History (FHH)


  Document information in a genogram & in a list of familial diseases
• Document the history in the form of a pedigree

  Three-generations pedigree
• Health & Lifestyle Practices Profile - Nutritional & Weight Management


  Questions uncover food habits that are health promoting as well as those that are less desirable. Sample questions may include: "What do you usually eat during a typical day? Please tell me the kinds of foods you prefer, how often you eat throughout the day, and how much you eat?" "Do you eat out at restaurants frequently?"
• Health & Lifestyle Practices Profile - Substance use

  Information provides the nurse with information concerning lifestyle and a client’s self-care ability
• Past Health History - Sample questions

  1. "What diseases did you have as a child?"

  2. "What immunizations did you get & are you up to date now?"

  3. "Do you have any chronic illnesses? If so, when were they diagnosed? How are they treated? How satisfied have you been with the treatment?"

  4. "What illnesses or allergies did you have? How were the illnesses treated?"
• Lifestyle & Health Practices Profile

  1. Current medications

  2. Health & Lifestyle Practices Profile
• Steps of Health Assessment

  1. Past Health History

  2. Family Health History (FHH)

  3. Lifestyle & Health Practices Profile
• Current medications - Sample questions


  "What medications have you used in the recent past and currently, both those that your doctor prescribed and those you can buy over the counter at a drug or grocery store? For what purpose did you take the medication? How much (dose) and how often did you take the medication? Do you take any medications not prescribed for you but prescribed for a family member/friend or purchased on the street?"