NURSING HEALTH HISTORY

• Subjective data


  • Interview
  • Health history
• Subjective data


  Elicited and verified only by the client, clues for possible physiologic, psychological and sociologic problems, may reveal a client's risk for a problem & areas of strengths, obtained through interviewing
• Interview


  A communication process that has two focuses: 1) Establishing rapport and a trusting relationship; to elicit accurate and meaningful information, 2) Gathering information; to identify deviations or strengths
• Phases of the interview

  • Pre-Introductory
  • Introductory
  • Working
  • Summary and Closing
• Pre-Introductory phase


  • Nurse reviews the medical record before meeting with the client, this information may assist the nurse with conducting the interview by knowing some of the client's biographical information that is already documented
• Introductory phase


  • Establish rapport and trust, provide comfort and maintain privacy and confidentiality
• Working phase


  • The nurse elicits the client's comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, the nurse actively listens and uses critical thinking skills to interpret and validate information
• Summary and Closing phase


  • The nurse summarizes information obtained, validates problems and goals with the client, identifies and discusses possible plans to resolve the problem, makes sure to ask if anything else concerns the client and if there are any further questions
• Types of communication during the interview

  • Nonverbal
  • Verbal
• Nonverbal communication to avoid

  • Excessive or Insufficient Eye Contact
  • Distraction and Distance
  • Standing
• Verbal communication

  • Open-ended questions, Close-ended questions, Laundry List, Rephrasing, Well Placed Phrases, Inferring, Providing Information
• Verbal communication to avoid

  • Biased or Leading Questions
  • Rushing through the interview
  • Reading the questions
• Special considerations during the interview

  • Gerontologic Considerations, Cultural Considerations, Emotional Considerations
• Components of the nursing health history

  • Biographic Data
  • Reasons for Seeking Health Care
  • History of Present Health Concern
  • Past Health History
  • Family History of Illness
  • Review of Body Systems for current health problems
  • Lifestyle and Health practices profile
  • Developmental Level
• Biographic Data


  Includes name, address, contact numbers, gender, informant, birth date, place of birth, race or ethnic background, occupation, educational level, significant others, health insurance, nationality, marital status, religious and spiritual practices, languages spoken
• Reasons for Seeking Health Care (Chief Complaint)


  What is your major health problem or concerns at this time? Why are you here? How can I help you? How do you feel about having to seek health care?
• History of Present Health Condition


  Includes signs and symptoms present or felt (COLDSPA)
• Reason/S For Seeking Health Care (Chief Complaint)


  • What is your major health problem or concerns at this time?
  • Why are you here?
  • How can I help you?
  • How do you feel about having to seek health care? Encourages the client to discuss fears and other feelings about having to seek a health practitioner.
• History of Present Health Condition


  1. Signs and Symptoms Present or felt: COLDSPA

  2. Character (How does it feel, look, smell, sound?)

  3. Onset (When did it begin; is it better, worse, or same as it began?)

  4. Location (Where is it? Does it radiate?)

  5. Duration (How long it lasts? Does it recur?)

  6. Severity (How bad is it? From the scale of 1-10, where 10 is the most painful?)

  7. Pattern (What makes it better? What makes it worse? What aggravates the condition?)

  8. Associated factors (What other symptoms do you have with it? Will you be able to continue doing your work, exercise or Activities of Daily Living?)
• PQRST Method for Pain Assessment

  1. Provokes (What causes pain? What makes it better? Worse?)

  2. Quality (What does it feel like? Is it sharp? Dull? Stabbing? Burning? Crushing?)

  3. Radiates (Where does the pain radiate? Is it in one place? Does it go anywhere else? Did it start elsewhere and now localized to one spot?)

  4. Severity (How severe is the pain on a scale of 1 - 10?)

  5. Time (Time pain started? How long did it last?)
• If the client is in the hospital, include: medications taken/ being administered at present, intravenous fluids infused, laboratory findings, other pertinent and relevant information.
• Past Health History


  • Birth, growth, development (congenital abnormalities and other birth defects)
  • Childhood Illnesses (chicken pox, measles, mumps etc.)
  • Immunizations to date (BCG, DPT, OPV, Hepa B, Measles, MMR, Tetanus Toxoid etc.- determine if Fully Immunized or not)
  • Allergies – to food, drugs and other allergens
  • Previous health problems (simple to complicated illnesses)
  • Previous confinement or hospitalization (reason for confinement, date/year and place of hospitalization)
  • Surgeries
  • Pregnancies and Obstetric History (number and type of pregnancies)
  • Previous Accidents, Injuries (mild to severe cases)
  • Pain Experiences
  • Emotional or Psychiatric Problems
• Family Health History


  • Age of parents (if living or deceased – to determine longevity)
  • Parent Illnesses (HTN, DM, CA, Obesity, Arthritis, etc.)
  • Grand parent's Illnesses
  • Aunt's and uncle's age and illnesses
  • Children's age and illnesses
  • Other lifestyle-related cases or habits, such as alcoholism and smoking
• Family Health History includes as many genetic relatives as the client can recall, including maternal and paternal grandparents, aunts and uncles on both sides, parents, siblings, and the client's children. The client's spouse is included but indicated that there is no genetic link.
• Review Of Body Systems For Current Health Problems


  • Gastrointestinal (Appetite, dysphagia, indigestion, food idiosyncrasy, abdominal pain, heartburn, eructation, nausea, vomiting, hematemesis, jaundice, constipation, or diarrhea, abnormal stools (clay-colored, tarry, bloody, greasy, foul smelling), flatulence, hemorrhoids, recent changes in bowel habits)
• Lifestyle and Health Practices Profile


  It deals with the client's human responses, which include nutritional habits, activity and exercise patterns, use of medications and substances, self- concept and self- care activities, social and community activities, relationships, values and belief systems, education and work, stress level, coping style and environment.
• Lifestyle and Health Practices Profile - Nutrition and Weight Management


  • Average 24 hour intake (food/ fluid)
  • Food eaten: type of food based on the food pyramid, who buys, prepares and cooks the food
  • Frequency of meal times: snacks, breakfast, lunch and dinner, fluids/ substances consumed and its amount, when and where meals are eaten
  • Changes in eating pattern: prior to and during admission or hospital stay
• Lifestyle and Health Practices Profile - Activity Level and Exercise


  • Level and type of activity in the workplace or at home during an average week
  • Inquire about regular exercise and its schedule: calisthenics, aerobics, sports, etc.
• Lifestyle and Health Practices Profile - Sleep and Rest


  • Focus on sleep patterns: how many hours a night the person sleeps, interruptions, whether the client feels rested, problems with sleeping, rituals to promote sleep, concerns the client may have regarding sleeping habits
  • Inquire whether the client is getting enough rest and sleep
• Lifestyle and Health Practices Profile - Elimination


  • Frequency of voiding, its amount and characteristic, problems, etc
  • Frequency of bowel movement, characteristics, problems, etc.
• Lifestyle and Health Practices Profile - Medication and Substance Use


  • Use of drugs, of any form and in excessive amounts can increase the client's risk for disease
  • Use of vitamins and herbal supplements
  • Prescribed medications may interact with some herbal supplements (drug interaction)
  • Alcohol and Tobacco use: type and amount of alcohol intake, number of cigarettes per day
  • Use of Over-the-Counter drugs
• Lifestyle and Health Practices Profile - Self- Concept and Self- Care Responsibilities


  • Health Attitudes
  • Talents/ Special Skills or Abilities
  • Self Care and Hygiene
  • Ability to perform Activities of Daily Living
  • Health related practices: Health Promotion and Disease Prevention such as Immunizations, Screening and regular Check-up, Practice of Safe Sex, etc.
  • Physical Competencies: Ability to move about, perform routines, household chores, etc
• Lifestyle and Health Practices Profile - Social Activities


  • Family Living and Interaction
  • Leisure and Relaxation activities
  • With whom does the client socialize frequently?
  • Do you think you have enough time to socialize?
  • Time Management
  • Community Activities and Organizations Involvement
  • Contribution to society
• Lifestyle and Health Practices Profile - Relationships


  • The most important person/s in life
  • Significant others and support system
  • Relationship with spouse and children
  • Relationship with in- laws, relatives, extended family members
  • Relationship with co- workers, superiors
  • Sexual relationship
  • Decision making
  • Pets at home
• Lifestyle and Health Practices Profile - Values and Belief Systems


  • Philosophical, spiritual and religious beliefs
  • The most important thing in life
  • Religious affiliation: Status of membership and its importance to the client's life
  • Is a relationship with God an important part of your life?
  • What gives you strength and hope?
  • Mass attendance, Church Service, Rituals and other Religious activities involvement
  • How does religious belief affect health?
• Lifestyle and Health Practices Profile - Education and Work


  • Level of understanding and client teaching
  • Future educational plans to pursue
  • Occupation, Status of Employment
  • Nature of work and its effect to health
  • Work- related stress
  • Who is the main provider in the family? Is the income enough to meet the family's needs?
  • Problems encountered at work and feeling of satisfaction and enjoyment
• Lifestyle and Health Practices Profile - Stress Levels and Coping Styles


  • Types of things that make the client angry, upset
  • Stress level- based on the client's perception
  • Greatest Stressors in life
  • Support System in times of crises
  • Conflict management
• Lifestyle and Health Practices Profile - Environment


  • Environmental hazards
  • Presence of breeding sites of vectors
  • Riverbanks, fields, irrigation and drainage, presence of trees
  • Stray dog, snakes and other rodents
  • Type of neighborhood, congested houses
  • Juvenile delinquency, crime rates and incidence, violence
  • Presence of community facilities: health center, hospital, church, hall, school, market, etc.
  • Distance of house to community facilities and hospitals
• Developmental Level


  • State of Maturity (based on Erikson's Psychosocial Development)
  • Mental and Emotional Competencies
  • Ability to maintain eye contact
  • Coherence, appropriateness of response, answers, mood and actions
  • Congruence between verbal and non-verbal communication
  • Presents the right attitude and behavior at the right time and place
  • Coping ability and Self- acceptance