reviewer

• Components of Health History

  • Collection of Subjective Data
  • Biographical information: General Data
  • Reason for seeking health care
  • History of present health concern; physical symptoms related to each body part or system
  • Personal health history
  • Family history
  • Health and lifestyle practices (risk factors, nutrition, activity, cultural beliefs, family structure, community, environment
  • Developmental level
  • Review of systems

  
• Biographical Data


  • Name
  • Address
  • Phone Number
  • Gender
  • Provider of History
  • Birth Date
  • Place of Birth
  • Race/ethnic background
  • Language spoken (primary & secondary)
  • Marital status
  • Educational level
  • Occupation
  • Support person
• Reason for seeking help

  Major health problem or concern at the time of visit
• History of present health concern using COLDSPA

  1. Character - How does it feel?

  2. Onset - When did it started? Is it getting better, worse or same since it begun?

  3. Location - Where is it? Does it radiate? To where?

  4. Duration - Since when? How long that it last? When it recurs?

  5. Severity - From the scale of 1 to 10…?

  6. Pattern - What makes it better? What makes it worse?

  7. Associated Factors - What other symptom do you have with it? Does it improve upon resting?
• PQRST Pain Analysis Pneumonics

  1. P: Provocative/Palliative - What provokes and relieve the pain

  2. Q: Quality - Describe the character of the pain (Sharp, Stabbing)

  3. R: Radiates - Is the pain localized or does it spread to other areas

  4. S: Severity - How bad is the pain? Does it interfere with ADL (Activities of Daily Living)?

  5. T: Timing - When does the pain occurs, how long does it last; How long before it recurs?
• Past Health History


  • Problems at birth
  • Childhood Illnesses
  • Immunization to date
  • Adult Illnesses (physical, emotional, mental)
  • Surgeries
  • Accidents
  • Prolonged pain
  • Allergies
  • Physical, emotional, social and spiritual weaknesses
  • Physical, emotional, social and spiritual strengths
• Health, Lifestyle Practices


  • Description of Typical Day (Describe What is a typical day for you)
  • Nutritional habits (What do you usually eat in a typical day)
  • Activity and exercise (Do you follow a regular exercise plan; leisure)
  • Sleeping pattern and rest (Tell me about your sleeping pattern?)
  • Substance use (How much beer, wine, alcoholic beverages do you drink on average
  • Self-concept and self-care responsibilities (What are your talents; How do you do your medical check-ups or screenings)
  • Social activities (what do you do for fun and relaxation)
  • Relationships (What is your relationship with your children; Do you have any pets)
  • Values and Beliefs (What is most important to you in life)
  • Education and Work (Tell me about your experiences in school)
  • Stress Levels and Coping Mechanism (What type of things make you angry)
  • Environment (What risk are you aware of your environment-school)
• Review of System (ROS)

  • Skin - rashes, excessive sweating, balding, dandruff
  • Head/neck - sore throat, enlarged lymph nodes
  • Eyes - vision, excessive tearing, blurring
  • Ears - difficulty in hearing, discharge
  • Mouth - lesions, pain in swallowing, caries
• Patients' Rights


  • Right to Appropriate Medical Care
  • Right to Informed Consent
  • Right to Privacy and Confidentiality
  • Right to Information
  • Right to Choose Health Care Provider and Facility
  • Right to Self Determination
  • Right to Religious Belief
  • Right to Medical Records
  • Right to Leave
  • Right to Refuse Participation in Medical Research
  • Right to Correspondence and to Receive Visitors
  • Right to Express Grievances
  • Right to be informed of his rights and obligations as a patient
• Phases of Nursing Process

  • Assessment: Subjective
  • Assessment: Objective
  • Observation and Data Collection
  • Collection of Subjective Data
  • Collection of Objective Data
• Types of Health Assessment

  • Initial Comprehensive
  • On-Going/Partial
  • Focused or Problem-Oriented
  • Emergency
• Physical characteristics


  • Skin color
  • Posture
  • Hygiene
• Body Functions


  • Heart rate
  • Respiration
• Appearance


  • The way he dress
  • Neatness
• Measurements


  • BP
  • Weight
  • Height
  • Temperature
• Results


  • Laboratory
  • X-ray findings
• Physical examination techniques


  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• Observation from family or by significant others can provide objective data e.g. Pale, looks poorly nourished, underweight, LGF, in mild respiratory distress
• Initial Comprehensive Health Assessment

  • Complete with PMH, Fam Hx
  • Lifestyle, Health Practices, etc.
  • Done in any health setting
  • Entire PE (body systems)
• On-Going/Partial Health Assessment


  • Follow-up data
  • Mini overview
  • To determine changes (Deteriorate, improved)
• Focused or Problem-Oriented Health Assessment

  • Already with a comprehensive data but came due to a particular problem E.g. DOB (focus on chest auscultation)
• Emergency Assessment

  • Very Rapid assessment performed during life threatening situations (E.g. First AID)
• Interview

  Tool to obtain a valid nursing health history
• Interview - Establishing rapport and trusting relationship


  • In order to effectively collect data (Accurate and meaningful information)
• Interview Phases

  • Pre-introductory
  • Introductory
  • Working Phase
  • Summary and Closing Phase
• Pre-introductory Phase

  • Nurse reviews the medical record before meeting with the client
  • Knowing client's already documented information thereby assist the nurse in conducting the interview
• Introductory Phase

  • Introduce self to the client
  • At same eye level
  • Nurse explain the purpose of interview
  • Discusses the type of questions that will be asked, reason of taking notes, confidentiality/privacy
  • Shall ensure patient to be comfortable physically and emotionally
  • This is the time to develop rapport and trust
• Working Phase

  • Nurse elicit client's comments and information about major biographical data, reasons for seeking care/ health issue/problems, past health history, family history, lifestyle and health practices, etc.
  • Nurse listen and observe cues, use critical thinking to interpret and validate information.
  • Collaborative to know the problem.
  • Free flowing, can be structured with specific questions (dependent on time availability and type of data needed)
• Summary and Closing Phase

  • Summarizing of information during the working phase and validates problem.
  • Provide goals with the client, discuss plan to resolve issues.
  • Listen for further questions if any.
• What to Avoid During an Interview

  • Excessive or insufficient eye contact
  • Distraction and distance-avoid being occupied by something else during the interview
  • Avoid standing while client is sitting (same eye level). Not to see you are superior.
  • Avoid Biased and leading questions-might provide questions that are not true.
  • Rushing through the interview
  • Reading the questions
• Special Considerations During an Interview

  • Gerontologic Variation
  • Cultural and Ethnic Variability
  • Emotional Variation in Communication
• Interacting with Anxious Clients

  • Provide simple, concise, organized info
  • Explain who you are, along with roles/purpose
  • Not to hurry (decrease any external stimuli)
• Interacting with Angry Clients

  • Approach shall be calm, reassuring and in-control manner
  • Allow to ventilate their feelings. If out of control, do not argue or touch the client
  • Avoid arguing with them
  • Obtain help from other HCW as needed
• Interacting with Depressed Clients

  • Express interest and understanding
  • Respond in a neutral manner
  • Do not try to communicate in an upbeat manner as it will not help the client
• Interacting with Manipulative Clients

  • Provide structure and set limits
  • Manipulation vs request
  • Obtain an objective opinion with a colleague
• Interacting with Seductive Clients

  • Set firm limits and avoid responding to subtle seductive behaviors
  • If overt sexuality continues, do not interact without a witness
  • Report inappropriate action to your superior
• Discussing Sensitive Issues

  • Sexuality, dying, spirituality, as it may affect clients' health.
  • Allow time for clients to ventilate; Ask simple questions in a non-judgmental
  • Refer
• Non-Verbal Communication

  • Appearance
  • Demeanor
  • Facial expression
  • Attitude
  • Silence
  • Listening
• Non-Verbal Cues to Avoid

  • Crossing arms
  • Sitting back
  • Tilting head away from the patient
  • Thinking about other things
  • Looking blank and inattentive
  • Engaging with an electronic device instead of the client
• Verbal Communication Techniques

  • Open ended questions
  • Closed ended questions
  • Laundry list
  • Rephrasing
  • Well phrased phrases
  • Inferring
  • Providing information