Assessment is considered a critical component of the nursing process since the information that will be collected in this phase will be used in the prioritizing, planning and formulation of patient care. The assessment may include but is not limited to, the following aspects: environmental, physical, cultural, psychological, safety, and psychosocial assessments. The most common methods for collecting data are the patient interview, physical examination, and observation
Health history is a crucial part of evaluating a patient’s health status. Full history taking together with a physical examination is warranted for a new patient, while a focused history and physical examination may be sufficient for an established or known patient
A health history is typically done on admission to a hospital or a care agency, or with initial contact with community nursing services, but a health history may be taken whenever additional information may be helpful to inform care
Health history also:
Gives information (subjective data) on how a health condition came about
Normally takes place before the physical assessment.
Includes collection of data/information about the client’s level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness and other health conditions
The purpose of obtaining a health history is to gather data from the patient and/or the patient’s family, so the healthcare team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions
The format may be standardized or adaptable to the unique needs of a client
Guidelines in Taking Health History
Sources of information may include the client, family or significant others, health team members, and the client’s health record. When the client is not capable of giving information, the family and significant others or previous health histories are necessary sources of information.
Most of the information in the health history is SUBJECTIVE data; this information should not be challenged but rather explored with the client to clarify vagueness
Subjective data
Refers to information provided by the patient that focuses on perceptions and feelings.
May include signs and symptoms described by the patient but not noticeable to others.
May also include demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history
Guidelines in Taking Health History
3. The health history should focus on data/information from all the client’sdimensions so that the nurse can develop a holistic health care plan.
4. The recording of data or information must be clear and concise with the use of appropriate terminology.
General Approach in Taking Health History
Present with a professional appearance.
Ensure an appropriate environment (good lighting, comfortable temperaturelack of noise and distractions) and adequate privacy.
Sit facing the patient at eye level, with the patient in a chair or on a bed. Ensure that the patient is as comfortable as possible because obtaining a health history can be lengthy process.
Ask the patient whether there are any questions about the interview before it is started.
Avoid the use of medical jargon. Use terms the patient can understand.
General Approach in Taking Health History
6. Reserve asking intimate and personal questions until rapport is established.
7. Remain flexible in obtaining the health history. This means that you should also be willing to depart from the usual interview structure. You might understand the patient's condition more quickly if you elicit his or her past medical history immediately after the chief complaint, before making a complete evaluation of the present illness. It does not have to be obtained in the exact order.
8. Remind the patient that all information will be treated confidentially.
Main Components of Health History
Demographic or Biographical Data
Source of information
Living situation
Name, age, gender
Main Components of Health History
Chief complaint; history of present illness; reason for seeking health care
Chief complaint
Onset & duration of present health concern
What caused the health concern to occur?
Signs, symptoms, and related problems
Alleviating and aggravating factors
How the concern affects life and activities of daily living?
Previous history and episodes of this condition
Main Components of Health History
Past Health History
Allergies (Including reaction)
Immunization History (If applicable)
Chronic disease(s)
Previous hospitalizations
Previous Surgical Interventions
Mental Health History
Current medications: prescriptions, over-the-counter, herbal remedies
Alcohol consumption and recreational drug use
History of Antibiotic Resistant Organisms (ARO)
Main Components of Health History
Social
Language & ability to communicate
Pertinent health history of family members (heart disease, lungdisease, cancer, hypertension, diabetes, tuberculosis, arthritis,neurological disease, obesity, mental illness, substance use & abuse, genetic disorders)
Main Components of Health History
Developmental Variables
Relationship status
Significant physical and psychosocial changes or concerns
Main Components of Health History
Mental Health Status
Stressors experienced by the individual: Their perception, how theycope, ability to communicate emotion
Coping and stress management
Main Components of Health History
Patterns of health care
What health care resources the client has used in the past and is currently using
CRITICAL COMPONENT: Phase where information will be collected
ASPECTS: Environmental, physical, cultural, psychological, safety, and psychosocial assessments
METHODS: Patient interview, physical examination, and observation
Assessment
Health history taking --> Review of System --> Physical Assessment
Health History
typically done on admission to a hospital or a care agency, or with initial contact with community
Takes place before the physical assessment.
Gives information (subjective data)
collection of data/information about the client’s level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness and other health conditions
Guidelines in Taking Health History
Data/information from all the client’s dimensions= HOLISTIC CARE PLAN
Information must be clear and concise USE OF APPROPRIATE TERMINOLOGY
Main Components of Health History
Demographic or Biographical Data
Chief complaint; history of present illness/Present Health; reason for seeking health care
Past Health History
Social
Family Health History
Life Style
Developmental Variables
Mental Health Status
Patterns of Health Care
Family Health History
Many diseases have a genetic component. It is important to understand the risk and likelihood of a patient developing illnesses based on their family health.
Ask about the health status, age, and, if applicable, cause of death of immediate blood relatives (parents, grandparents, and siblings). Questions to ask include the following:
Tell me about the health of your blood relatives. Does anyone have diseases like cancer, heart problems, or respiratory problems?
Have any of your blood relatives died? If so, do you know the cause of death? What age did they die
Functional Health Assessment
Collects data related to the patient’s functioning and their physical and mental capacity to participate in Activities of Daily Living (ADLs) = are daily basic tasks that are fundamental to everyday functioning (e.g., hygiene, elimination, dressing, eating, ambulating/moving)
Lifestyle, Developmental Variables, Mental Health Status, Patterns of Healthcare
Review of Systems
subjective history taking component as well as an objective based structured interview and physical examination of all the body systems
Serves as a double-check that vital information is not overlooked
covers a broad base of clinical states follows a head-to-toe approach
includes two types of questions: sign or symptom-related and disease related
Physical Assessment: A physical examination involves collecting objective data using the techniques of inspection, palpation, percussion, and auscultation as appropriate
Physical Assessment provides Objective Data:
validate the subjective data obtained
detect any findings not reported in the history
obtain info about the individual's status of health problem
Principles/Guidelines of Physical Assessment
Make client relaxed and comfortable = Modesty is a common trait among females. They will not readily submit themselves for P.E. if their bodies will be exposed
Maintain a well-lighted room = Examining gown and draping sheet should be provided.
Provide privacy and avoid unnecessary exposure = Expose the regions to be examined one at a time
Completely explore the part to be examined, but drape the rest of the body appropriately = Perform the P.E. in an examining room for proper positioning, ensuring privacy and minimizing interruption
Principles/Guidelines of Physical Assessment
Have an order for an examination so as not to miss observing any body part or system – from general to specific, or from head to toe (cephalocaudal)
Follow the plan of order for physical examination which is basically: Inspection, Palpation, Percussion, and Auscultation
Principles/Guidelines of Physical Assessment
The body is bilaterally symmetrical, so, compare findings from one side to another, there is slight deviation. Examine both front and back as well
While examining each region, consider the underlying structures, their function and possible abnormalities
Use all senses: sight, hearing, touch, smell, and most especially, common sense