ANGELES UNIVERSITY FOUNDATION

College of Nursing

SUMMER, ACADEMIC YEAR 2013 – 2014

HEALTH ASSESSMENT

MODULE NO. 4
HEALTH HISTORY

Rationale

This self-instructional module is designed and prepared for BSN I students to aid in the
development of their knowledge, skills and attitudes towards health assessment specifically
in the determination and analysis of patients’ present and past health history. Health
assessment is an invaluable skill to learn and master in order to have a complete and
thorough data gathering that will be beneficial for the accuracy and appropriateness of the
nursing interventions to be implemented. Health assessment encompasses the
identification and analysis of both subjective and objective data. One of the most difficult
and challenging to determine are significant subjective data, because it requires the nurse
to be efficient and effective in the use of communication. Hence, before being tasked to
perform subjective data collection, concept of communication should have already been
discussed. Subjective data includes biographic data, chief complaint, history of present and
past Illness, family health history, lifestyle and health practice profile, psychological data,
patterns of Health care and functional assessment.

Learning Objectives
Upon completion of the module, the learner should be able to:
1. Identify the components of a nursing health history.
2. Properly and accurately obtain both objective and subjective data from the patient
3. Plan nursing care relative to the determination of patients’ health history to
enhance continuous validation and acquisition of accurate data
4. Apply knowledge learned together with the nursing process to provide nursing care
to achieve quality nursing management

Recommended Preparation
This module is not created for the purpose of covering the above topic in-depth. The
author strongly recommends that students consult current texts such as case studies for
better understanding and comprehensive learning of the concepts encompassed by the
module. As well, before going through the program, the learner must have an adequate
knowledge in Anatomy and Physiology and Nursing Care Management 100 (Foundations of
Nursing Practice). Also the learner is advised to read the following glossary:

 Biographic data- it also refers to the pertinent demographic data acquired from the
patient which include the basic information regarding his birth, residency, civil
status, and affiliations.
 Chief Complaint- refers to either an objective or subjective data that pertains to the
reason for consultation and seeking care or hospital admission.
 History of Illness- refers to either the history of present illness or the past health
history.
 Lifestyle and Health Practice- refers to the patient’s personal beliefs and practices
that are related to the promotion of health, prevention and cure of illnesses.
 Functional Assessment- refers to the type of assessment that is particular to the
determination of client’s ability to perform self care.

Health Assessment Module No. 3 HEALTH HISTORY page 1

Pre-test: Matching Type
A.
1. Information that identifies a client
2. Information that would determine genetic predisposition
3. It focuses on questions from the earliest beginnings to the present health
4. It takes into account several aspects of the health problem and asks questions whose
answers can provide a detailed description of the concern
5. The major health concern of the patient at the time of admission
6. It assesses the more complex ADLs necessary for living in the community
7. It consists of 10 items that measure a person's daily functioning specifically the activities
of daily living and mobility.
8. These are 11 categories that enable the nurse to determine the following aspects of
health and human function
9. These guidelines outline exercise recommendations for healthy adults and older adults
10. This is a 6 point scale that is considered the most appropriate instrument to assess
functional status as a measurement of the client's degree of Independence

B.
A. Biographic data
B. Chief complaint
C. History of Present Illness
D. History of Past Illness
E. Family Health History
F. Functional Assessment
G. Gordon's Functional Health Patterns
H. Physical Activities of Daily Living
I. Instrumental Activities of Daily Living
J. Katz Index of Independence in Activities of Daily Living
K. Barthel Index

***EVALUATION: A score lower than six (6) is unsatisfactory. It indicates inadequate

knowledge of the topic.

ANSWERS:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

COMPONENTS OF A NURSING HEALTH HISTORY

The health history is an excellent way to begin the assessment process because it
lays the groundwork for identifying nursing problems and provides a focus for the physical
examination. The importance of the health history lies in its ability to provide information
that will assist the examiner in identifying areas of strength and limitation in the
individual’s lifestyle and current health status. Data from the health history also provide
the examiner the specific cues to health problems that are most apparent to the client.
Then these areas may be more intensely examined during the physical assessment. When
a client is having a complete head-to-toe physical assessment, collection of subjective data
usually requires that the nurse take a complete health history. The complete health history
is modified or shortened when necessary. For example, if the physical assessment will
focus on the heart and neck vessels, the subjective data collection would be limited to the
data relevant to the heart and neck vessels.

Health Assessment Module No. 3 HEALTH HISTORY page 2

 Taking a health history should begin with an explanation to the client of why the
information is being requested such as planning for individualized nursing care.

A complete nursing assessment includes both the collection of subjective data and the
collection of objective data. During the general survey, the COLD SPA mnemonic may be
particularly helpful in exploring unusual signs and symptoms or problems reported as you
and the client ask and answer various questions during the health history interview.

C-O-L-D-S-P-A

Character: The patient will be asked to describe the signs and symptoms. How
does it feel, look, sound, smell and so forth?
Onset: When did it begin?
Location: Where is it? Does it radiate?
Duration: How long does it last? Does it recur?
Severity: How bad is it?
Pattern: What makes it better? What makes it worst?
Associated factors: What other symptoms occur with it?

A. PERSONAL PROFILE
 Biographic data
Biographic data usually include information that identifies the client, such as name,
address, contact numbers, gender, and who provided the information, that is the client or
significant others. The client’s birth date, Social Security number, medical records number,
or similar identifying data may be included in the biographic data section.

When students are collecting the information and sharing it with instructors,
addresses and phone numbers should be deleted and initials are used to protect the client’s
privacy. However, the name of the person providing the information needs to be included
to assist in determining its accuracy. The client is considered the primary source and all
others (including the client’s medical record) are secondary sources. In some cases, the
client’s immediate family or caregiver may be more accurate source information than the
client. An example would be an elderly client’s wife who has kept the client’s medical
records for years or the legal guardian of a mentally compromised client. In any event,
validation of the information by a secondary source may be helpful.

The client’s culture, ethnicity, and subculture may begin to be determined by

collecting data about date and place of birth, nationality or ethnicity, marital status,
religious or spiritual practices, and primary and secondary languages spoken, written, and
read. This information helps the nurse to examine special needs and beliefs that may
affect the client or family’s health care. A person’s primary language is usually the one
spoken in the family during early childhood and the one in which the person thinks.
However, if the client was educated in another language from kindergarten on, that may be
the primary language and the birth language would be secondary.

Gathering information about the client’s educational level, occupation, and working
status at this point in the health history assists the examiner to tailor questions to the
client’s level of understanding. In addition, this information can help to identify possible
client strengths and limitations affecting health status. For example, if the client was
recently downsized from a high-power, high-salary position, the effects of overwhelming
stress may play a large part in his or her health status. Finally, asking who lives with the
client and identifying significant others indicates the availability of potential caregivers and
support people for the client. Absence of support people would alert the examiner to the
(possible) need for finding external sources of support.

 CHIEF COMPLAINT OR REASON FOR VISIT

This category includes two questions: “What is your major health problem or
concerns at this time?” and “How do you feel about having to seek health care?” The first
question assists the client to focus on his most significant health concern and answers the
nurse’s question, “Why are you here?” or “How can I help you?” physicians call this the
client’s chief complaint (CC), but a more holistic approach for phrasing the question may
Health Assessment Module No. 3 HEALTH HISTORY page 3
draw out concerns that reach beyond just a physical complaint and may address stress or
lifestyle changes.

The second question, “How do you feel about having to seek health care?”
encourages the client to discuss fears or other feelings about having to see a health care
provider. For example, a woman visiting a nurse practitioner states her major health
concern: “I found a lump in my breast.” This woman may be able to respond to the second
question by voicing fears that she has been reluctant to share with her significant others.
This question may also draw out descriptions of previous experiences – both positive and
negative – with other health care providers. The chief complaint should be recorded in the
client’s own words.

 HISTORY OF PRESENT ILLNESS

This section of the health history takes into account several aspects of the health
problem and asks questions whose answers can provide a detailed description of the
concern. First, the interviewer must encourage the client to explain the health problem or
symptom as detailed as possible by focusing on the onset, progression, and duration of the
problem; signs and symptoms and related problems; and what the client perceives as
causing the problem. The client may also be asked to evaluate what makes the problem
worse, what alleviates it, which treatments have been tried, what effect the problem has
had on daily life or lifestyle, what expectations are held about recovery, and what is the
client’s ability to provide self-care.

The answers to the questions provide the nurse with a great deal of information
about the client’s problem(s), especially how it(they) affect(s) lifestyle and activities of
daily living. This helps the nurse to evaluate the client’s insight into the problem and the
client’s plans for managing it. The nurse can also begin to postulate nursing diagnoses
from the initial information. In general, the patient is typically asked the following: when
the symptoms started, how often the problem occurs, activity in which the client was
involved when the problem occurred, factors that aggravate or alleviate the problem

 PAST HISTORY
This portion of the health history focuses on questions related to the client’s past,
from the earliest beginnings to the present. These questions elicit data related to the
client’s strengths and weaknesses in her health history. The client’s strengths may be
physical (e.g., optimal body weight), social (e.g., active in community service) emotional
(e.g., expresses feeling openly), or spiritual (often turns to faith for support). The data
may also point to trends of unhealthy behaviors such as being a smoker or lack of physical
activity. The information gained from these questions assist the nurse to identify risk
factors that stem from previous health problems. Risk factors may be to the client or to his
significant others.

Information covered in this section includes questions about birth, growth,

development, childhood diseases, immunizations, allergies, previous health problems,
hospitalizations, surgeries, pregnancies, births, previous accidents, injuries, pain
experiences, and emotional or psychiatric problems.

How clients frame their previous health concerns suggests how they feel about
themselves and is an indication of their sense of responsibility for their own health. Some
clients are very forthcoming about their past health status; other are not. It is helpful to
have a series of alternative questions for less responsive clients and for those who may not
understand what is being asked.

 CURRENT MEDICATIONS OR MEDICATION RECONCILIATION

In this section, the prescription medications, over-the-counter drugs and herbal
remedies that the client has been taking or has taken for a span of time are determined
during interview. Specifically, the client is asked regarding the intake of vitamins and other
supplements, birth control pills, antacids and aspirin. The intended use, dose, frequency
and duration of drug intake and therapeutic or adverse effects felt should be noted with
accuracy. These data would aid in the determination of the relationship of drugs taken to
the present medical complaints (if there is any connection); and it would also help the
Health Assessment Module No. 3 HEALTH HISTORY page 4
 physician evaluate the effects of the drugs taken so as to ascertain if drugs should be
changed, retained or discontinued.

 FAMILY HISTORY OF ILLNESS

As researchers discover more and more health problems that seem to run in families
and that are genetically based, the family health history assumes greater importance. In
addition to genetic predisposition, it is also helpful to see other health problems that may
have affected the client by virtue of having grown up in the family and being exposed to
these problems. For instance, a gene predisposing a person to smoking has not yet been
discovered but a family with smoking members can affect other members in at least two
ways. First, the second-hand smoke can compromise the physical health of nonsmoking
member; second, the smoker may serve as a negative role model for children, including
them to take up the habit as well. Another example is obesity; recognizing it in the family
history can alert the nurse to a potential risk factor.
The family history should include as many genetic relatives as the client can recall.
Include maternal and paternal grandparents, aunts and uncles on sides, parents, siblings,
and the client’s children. Such thoroughness usually identifies those diseases that may skip
a generation such as autosomal recessive disorders. Include the client’s spouse but
indicate the there is no genetic link. Identifying the spouse’s health problems could explain
disorders in the client’s children not indicated in the client’s family history.

Drawing a genogram helps to organize and illustrate the client’s family history. Use
a standard format so others can easily understand the information. Also provide a key to
the symbols used. Usually female relatives are indicated by a circle and male relatives by a
square. A deceased relative is noted by marking an X in the circle or square and listing the
age at death and the cause of death. Identify all relatives, living or dead, by age and
provide a brief list of diseases or conditions. If the relative has no problems, the letters
“A/W” (alive and well) should be placed next to the age. Straight vertical and horizontal
lines are used to show relationships. A horizontal dotted line can be used to indicate the
client’s spouse; a vertical dotted line can be used to indicate adoption. After the
diagrammatic family history, prepare a brief summary of the kinds of health problems
present in the family.

 LIFESTYLE and HEALTH PRACTICE PROFILE

 LIFESTYLE
Ask clients to describe the composition of the family into which they were born and
about past and current relationships with these family members. In this way, you can
assess problems and potential support from the client’s family of origin. In addition, similar
information should be sought about the client’s current family. If the client does not have
any family by blood or marriage, then information should be gathered about any significant
others (including pets) that may constitute the client’s “family.”

 SOCIAL DATA
Questions about social activities help the nurse to discover what outlets the client
has for support and relaxation and if the client is involved in the community beyond family
and work. Information in this area also helps to determine the client’s current level of
social development.

 PSYCHOLOGIC DATA
In this section, the major stressors experienced and the client’s perception of them
are assessed. Their usual coping pattern with a serious problem or a high level of stress
and their communication style.

 PATTERNS OF HEALTH CARE

All health care resources the client is currently using and has used in the past. (e.g.
specialists, dentist, folk practitioners, health clinic, health center)

B. FUNCTIONAL ASSESSMENT
Normal aging changes and health problems frequently show themselves as declines in
the functional status of older adults. Decline may place the older adult on a spiral of
iatrogenesis leading to further health problems. One of the best ways to evaluate the
Health Assessment Module No. 3 HEALTH HISTORY page 5
health status of older adults is through functional assessment which provides objective data
that may indicate future decline or improvement in health status, allowing the nurse to
intervene appropriately. Independence means that the person needs no assistance at any
part of the task. The following are the discussion on the different functional assessment
tool.

 Gordon's Functional Health Patterns

Marjorie Gordon in 1987 proposed functional health patterns as a guide for
establishing a comprehensive nursing data base. These 11 categories make possible a
systematic and standardized approach to data collection, and enable the nurse to
determine the following aspects of health and human function. They are as follows:
1. Health Perception and Health Management. Data collection is focused on the
person's perceived level of health and well-being, and on practices for maintaining
health. Habits that may be detrimental to health are also evaluated, including
smoking and alcohol or drug use. Actual or potential problems related to safety and
health management may be identified as well as needs for modifications in the home
or needs for continued care in the home.
2. Nutrition and Metabolism Assessment is focused on the pattern of food and fluid
consumption relative to metabolic need. The adequacy of local nutrient supplies is
evaluated. Actual or potential problems related to fluid balance, tissue integrity, and
host defenses may be identified as well as problems with the gastrointestinal system.
3. Elimination. Data collection is focused on excretory patterns (bowel, bladder, skin).
Excretory problems such as incontinence, constipation, diarrhea, and urinary
retention may be identified.
4. Activity and Exercise. Assessment is focused on the activities of daily living
requiring energy expenditure, including self-care activities, exercise, and leisure
activities. The status of major body systems involved with activity and exercise is
evaluated, including the respiratory, cardiovascular, and musculoskeletal systems.
5. Cognition and Perception. Assessment is focused on the ability to comprehend
and use information and on the sensory functions. Data pertaining to neurologic
functions are collected to aid this process. Sensory experiences such as pain and
altered sensory input may be identified and further evaluated.
6. Sleep and Rest. Assessment is focused on the person's sleep, rest, and relaxation
practices. Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation
may be identified.
7. Self-Perception and Self-Concept. Assessment is focused on the person's
attitudes toward self, including identity, body image, and sense of self-worth. The
person's level of self-esteem and response to threats to his or her self-concept may
be identified.
8. Roles and Relationships. Assessment is focused on the person's roles in the world
and relationships with others. Satisfaction with roles, role strain, or dysfunctional
relationships may be further evaluated.
9. Sexuality and Reproduction. Assessment is focused on the person's satisfaction or
dissatisfaction with sexuality patterns and reproductive functions. Concerns with
sexuality maybe identified.
10. Coping and Stress Tolerance. Assessment is focused on the person's perception
of stress and on his or her coping strategies Support systems are evaluated, and
symptoms of stress are noted. The effectiveness of a person's coping strategies in
terms of stress tolerance may be further evaluated.
11. Values and Belief. Assessment is focused on the person's values and beliefs
(including spiritual beliefs), or on the goals that guide his or her choices or decisions.

Organizing Data According to Gordon's 11 Functional Health Patterns

Functional Pattern Describes Examples

Health Pattern

Health Client's perceived pattern of Compliance with medication

Perception/ health and well-being and regimen, use of health-promotion
Health how health is managed. activities such as regular exercise,
Health Assessment Module No. 3 HEALTH HISTORY page 6
 Organizing Data According to Gordon's 11 Functional Health Patterns
Management annual check-ups.
Pattern of food and fluid
Nutritional- consumption relative to Condition of skin, teeth, hair,
Metabolic metabolic need and pattern; nails, mucous membranes; height
indicators of local nutrient and weight.
supply.

Elimination Patterns of excretory Frequency of bowel movements,

function (bowel, bladder, and voiding pattern, pain on urination,
skin). Includes client's appearance of urine and stool.
perception of normal"
function.

Activity – Patterns of exercise, activity, Exercise, hobbies. May include

Exercise leisure, and recreation. cardiovascular and respiratory
status, mobility, and activities of
daily living.

Cognitive- Sensory-perceptual and Vision, hearing, taste, touch,

Perceptual cognitive patterns. smell, pain perception and
management; cognitive functions
such as language, memory, and
decision making.

Sleep-Rest Patterns of sleep, rest, and Client's perception of quality and

relaxation. quantity of sleep and energy,
sleep aids, routines client uses.

Self- Client's self-concept pattern Body comfort, body image, feeling

Perception/ and perceptions of self. state, attitudes about self,
Self Concept perception of abilities, objective
data such as body posture, eye
contact, voice tone.

Role- Client's pattern of role Perception of current major roles

Relationship engagements and and responsibilities (e.g., father,
relationships. husband, salesman); satisfaction
with family, work, or social
relationships.

Sexuality- Patterns of satisfaction and Number and histories of

Reproductive dissatisfaction with sexuality pregnancy and childbirth;
pattern; reproductive difficulties with sexual
pattern. functioning; satisfaction with
sexual relationship.

Coping / Stress General coping pattern and Client's usual manner of handling
Tolerance effective of the pattern in stress, available support systems,
terms of stress tolerance. perceived ability to control or
manage situations.

Value – Belief Patterns of values, beliefs Religious affiliation, what client

(including spiritual), and perceives as important in life,
Health Assessment Module No. 3 HEALTH HISTORY page 7
 Organizing Data According to Gordon's 11 Functional Health Patterns
goals that guide client's value-belief conflicts related to
choices or decisions. health, special religious practices.

 Physical Activities of Daily Living

The American College of Sports Medicine (ACSM) and the American Heart Association
(AHA) has created physical activity guidelines. These guidelines outline exercise
recommendations for healthy adults and older adults. This recommendation typically
applies to healthy adults between 18 and 65 yr of age, and to persons in this age range
with chronic conditions not related to physical activity (e.g. hearing impairment). During
pregnancy and the postpartum period additional precautions may be needed. The present
preventive recommendation specifies how adults, by engaging in regular physical activity,
can promote and maintain health, and reduce risk of chronic disease and premature
mortality.

Guidelines for Healthy Adults under 65

Do moderately intense cardio 30 minutes a day, five days a week or Do vigorously
intense cardio 20 minutes a day, 3 days a week and Do eight to 10 strength-training
exercises, eight to 12 repetitions of each exercise twice a week.
Moderate-intensity physical activity means working hard enough to raise your heart
rate and break a sweat, yet still being able to carry on a conversation. It should be noted
that to lose weight or maintain weight loss, 60 to 90 minutes of physical activity may be
necessary. The 30-minute recommendation is for the average healthy adult to maintain
health and reduce the risk for chronic disease.

Guidelines for Healthy Adults over age 65 or adults 50-64 with chronic
conditions, such as arthritis
Do moderately intense aerobic exercise 30 minutes a day, five days a week Or Do
vigorously intense aerobic exercise 20 minutes a day, 3 days a week And Do eight to 10
strength-training exercises, 10-15 repetitions of each exercise twice to three times per
week And If you are at risk of falling, perform balance exercises And Have a physical
activity plan.
Both aerobic and muscle-strengthening activity is critical for healthy aging.
Moderate-intensity aerobic exercise means working hard at about level-six intensity on
a scale of 10. You should still be able to carry on a conversation during exercise. Older
adults or adults with chronic conditions should develop an activity plan with a health
professional to manage risks and take therapeutic needs into account. This will maximize
the benefits of physical activity and ensure your safety.

 Instrumental Activities of Daily Living (IADL)

The Lawton IADL scale was developed by Lawton and Brody in 1969 to assess the
more complex ADLs necessary for living in the community. Competence in skills such as
shopping, cooking, and managing finances is required for independent living. IADLs are
often performed by a person who is living independently in a community setting during the
course of a normal day, such as managing money, shopping, telephone use, and travel in
community, housekeeping, preparing meals, and taking medications correctly. Increasing
inability to perform IADLs may result in the need for care facility placement. Because IADL
function is usually lost before ADL function (such as bathing, eating, and using the toilet),
assessment of IADLs may identify incipient decline, physical, cognitive, or both, in an older
adult who might otherwise appear capable and healthy.

The Lawton IADL scale takes 10 to 15 minutes to administer and contains eight
items, with a summary score from 0 (low function) to 8 (high function). Each ability is
measured by the scale relies on either cognitive or physical function, though all require
some degree of both. Low scores on other activities, such as housekeeping (a broad
category encompassing simple tasks such as washing dishes or mowing the lawn), may
more obviously point to problems in physical function. The scale can be administered with
a written questionnaire or by interview. The patient or a knowledgeable family member or
caregiver may provide answers. It is appropriate for use with older adults admitted to a
Health Assessment Module No. 3 HEALTH HISTORY page 8
hospital, a short-term skilled nursing facility, or a rehabilitation facility, as well as with
community dwellers. The scale is generally not useful for older adults in long-term care
facilities, where residents perform few IADLs without assistance.

INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE (IADL)

by M.P. Lawton & E.M. Brody
A. Ability to use telephone 5. Does not participate in any
1. Operates telephone on own initiative housekeeping tasks 0
looks up and dials numbers, etc. 1 E. Laundry
2. Dials a few well-known numbers 1 1. Does personal laundry completely 1
3. Answers phone but does not dial 1 2. Launders small items;
4. Does not use telephone at all. 0 rinses stockings, etc. 1
3. All laundry must be done by others. 0
B. Shopping
1. Takes care of all shopping needs F. Mode of Transportation
independently 1 1. Travels independently on public
2. Shops independently transportation or drives own car. 1
(small purchase) 0 2. Arranges own travel via taxi, but does
3. Needs to be accompanied on any not otherwise use public transportation.1
shopping trip. 0 3. Travels on public transportation when
4. Completely unable to shop. 0 accompanied by another. 1
C. Food Preparation 4. Travel limited to taxi or automobile
1. Plans, prepares and serves adequate withassistance of another. 0
meals Independently 1 5. Does not travel at all. 0
2. Prepares adequate meals if supplied
With ingredients 0 G. Responsibility for own medications
3. Heats, serves and prepares meals or 1. Is responsible for taking medication in
prepares meals but does not maintain correct dosages at correct time. 1
adequate diet. 0 2. Takes responsibility if medication is
4. Needs to have meals prepared and prepared in advance (separate dosage) 0
served. 0 3. Is not capable of dispensing own
medication. 0
D. Housekeeping
1. Maintains house alone or with H. Ability to Handle Finances
occasionalassistance (e.g. “heavy work 1. Manages financial matters
domestic help”) 1 independently(budgets, writes checks,
2. Performs light daily tasks such as pays rent, bills goes to bank), collects and
dishwashing, bed making 1 keeps track of income. 1
3. Performs light daily tasks but cannot 2. Manages day-to-day purchases, but
maintain acceptable level of cleanliness.1 needs help with banking, major
4. Needs help with all home maintenance purchases, etc. 1
tasks. 1 3. Incapable of handling money. 0

C. FUNCTIONAL ASSESSMENT TESTS

 Newborns- APGAR scoring system
This scoring system was devised by Dr. Virginia Apgar, an anesthesiologist, in 1952 as a simple
and repeatable method to quickly and summarily assess the health status of newborns immediately after
delivery. It was originally intended to assess newborn condition as a result of maternal anesthesia
administration. The term APGAR as well stands for the following newborn assessment concentrations: A:
activity of the neonate (muscle tone); P: Pulse rate; G: Grimace (reflex irritability); A: Appearance (skin
color); and R: Respiration (breathing rate and effort). The table below summarizes the pattern of scoring
for APGAR.
SIGN 0 POINT 1 POINT 2 POINTS
Absent/ Limp or
A Activity Arms and Legs flexed Active movement
“floppy tone”
P Pulse Absent Below 100 bpm Above 100 bpm
Grimaces (face only Sneezes, coughs,
G Grimace No response
during suctioning) pulls away
Normal (pink), except
Blue-gray, pale Normal (pink) over
A Appearance for extremities/
all over entire body
acrocyanosis
Health Assessment Module No. 3 HEALTH HISTORY page 9
 Slow, irregular, weak Normal rate and
R Respiration Absent
cry effort, good cry
A score is given for each sign at one minute and five minutes after delivery. APGAR
on the 10th minute after birth may be required if there are additional problems with the
newborn.. A score of 7 to 10 is considered normal, while 4 to 6 indicates the need to
perform some resuscitative measures. Lastly, a score of 0 to 3 signifies a need for
immediate resuscitation.

 Developmental Screening Test (DST)

The Denver II Developmental Screening Test or the DDST, a test devised by DR.
William Frankenburk and colleagues from Denver, Colorado, is most widely used screening
test for young children which aims to determines the relative areas of advancement and
delay in their development. Different from an intelligence examination, the DDST ascertains
what a child can do at a specific age, particularly from birth (zero year old) to six years of
age. DDST is designed for utilization by clinicians, teachers, or other early childhood
professionals to monitor the development of infants and preschool-aged children. This
enables examiner to recognize children whose developmental standing deviates
considerably from that of normal children which warrants further investigation to establish
the need for treatment. The tests cover four general functions which are personal social
(such as smiling), fine motor adaptive (such as grasping and drawing), language (such as
combining words), and gross motor (such as walking).
 Katz Index of Independence in Activities of Daily Living
The Katz Index of Independence in Activities of Daily Living, commonly referred to as
the Katz ADL, is the most appropriate instrument to assess functional status as a
measurement of the client's degree of Independence. The highest possible score is 6 which
indicate a high level of independence, and as the score goes down, the patient is becoming
more and more dependent on the caregiver.

KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING

Activities Independence Dependence
Points (1 or 0) (1 Point) (0 Points)
NO supervision, direction or WITH supervision,
personal assistance direction, personal
assistance or total care

BATHING (1 POINT) Bathes self (0 POINTS) Need help with

completely or needs help in
Points: _______ bathing only a single part of the
body such as the back, genital
area or disabled extremity
DRESSING (1 POINT) Get clothes from
closets and drawers and puts on
Points: _______ clothes and outer garments
complete with fasteners. May
have help tying shoes.
TOILETING (1 POINT) Goes to toilet, gets on
and off, arranges clothes, cleans
Points: _______ genital area without help.
bathing more than one part
of the body, getting in or
out of the tub or shower.
Requires total bathing
(0 POINTS) Needs help
with dressing self or needs
to be completely dressed.
(0 POINTS) Needs help
transferring to the toilet,
cleaning self or uses
bedpan or commode.

TRANSFERRING (1 POINT) Moves in and out of (0 POINTS)Needs help in

bed or chair unassisted. moving from bed to chair
Points: _______ Mechanical transfer aids are or requires a complete
acceptable transfer.

CONTINENCE (1 POINT) Exercises complete (0 POINTS) Is partially or

self control over urination and totally incontinent of bowel
Points: _______ defecation. or bladder

Health Assessment Module No. 3 HEALTH HISTORY page 10

 FEEDING (1 POINT) Gets food from plate (0 POINTS) Needs partial
into mouth without help. or total help with feeding or
Points: _______ Preparation of food may be done requires parenteral feeding.
by another person.

 Barthel Index
The Barthel Index consists of 10 items that measure a person's daily functioning
specifically the activities of daily living and mobility. The items include feeding, moving
from wheelchair to bed and return, grooming, transferring to and from a toilet, bathing,
walking on level surface, going up and down stairs, dressing, continence of bowels and
bladder.
The assessment can be used to determine a baseline level of functioning and can
be used to monitor improvement in activities of daily living over time. The items are
weighted according to a scheme developed by the authors. The person receives a score
based on whether they have received help while doing the task. The scores for each of
the items are summed to create a total score. The higher the score the more
independent the person. If a person does about 50% independently then the "middle"
score would apply.
THE BARTHEL INDEX
Activity Score

Feeding
0 = unable
5 = needs help cutting, spreading butter, etc., or requires 0 5 10
modified diet
10 = independent

Bathing
0 = dependent 0 5
5 = independent (or in shower)

Grooming
0 = needs to help with personal care 0 5
5 = independent face/hair/teeth/shaving (implements provided)

Dressing
0 = dependent
0 5 10
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)

Bowels
0 = incontinent (or needs to be given enemas)
0 5 10
5 = occasional accident
10 = continent

Bladder
0 = incontinent, or catheterized and unable to manage alone
0 5 10
5 = occasional accident
10 = continent

Toilet Use
0 = dependent
0 5 10
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)

Transfers (bed to chair and back) 0 5 10 15

0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
10 = minor help (verbal or physical)

Health Assessment Module No. 3 HEALTH HISTORY page 11

 15 = independent

Mobility (on level surfaces)

0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards
10 = walks with help of one person (verbal or physical) > 50 0 5 10 15
yards
15 = independent (but may use any aid; for example, stick) > 50
yards

Stairs
0 = unable
0 5 10
5 = needs help (verbal, physical, carrying aid)
10 = independent

TOTAL (0 - 100) ________

D. REVIEW OF SYSTEMS
 Assessment in Pregnancy

The assessment additions to pregnant patients include the determination of the Last
Menstrual Period or LMP, Expected Date of Delivery/ Confinement or EDD/ EDC and Age of
Gestation or AOG which refers to the duration of pregnancy in months. It also includes the
determination of patient’s past obstetrical history, related medical and family history of
illness, signs and symptoms relative to pregnancy and pregnancy-related conditions,
activities and employment, sexual activity, psychosocial status and diet history.

The client’s LMP is determined by asking the client to recollect the first day of the last
menstruation before the commencement of amenorrhea due to pregnancy. The EDC is
ascertained by using Naegele’s rule, named after Franz Karl Naegele, a German
obstetrician, which requires the following procedures/ computations:

1. Subtract 3 months from the month of LMP

2. Add 7 to the first day of LMP
3. Add one to the year
Or
1. Add 9 to the month of LPM
2. Add 7 to the first day of LMP

Example: LMP is June 17, 2009

6 17 9
-3 +7 +1
3 / 24 / 10 = Expected date of delivery/ confinement

 Pediatric additions to health history

Pediatric additions to assessment include measurement of head circumference,

determination of weight and height and the status of immunization. These assessment data
are significantly important in the establishment of the child’s nutritional status and
normalcy of growth and development. Additionally, the client’s immunization status is
ascertained to give the clinician the information required to assess the susceptibility to
certain communicable illnesses and the probability of resistance to these.

 Geriatric additions to health history

Geriatric additions to assessment include the determination of immunization status,

current prescription medications, over-the-counter drugs, activities of daily living and
social support, which were already discussed in the previous sections of the module.
Special consideration is given to geriatric clients regarding the relative effects of drugs to
their body, the activities the engage in and their psychosocial needs.

Health Assessment Module No. 3 HEALTH HISTORY page 12

Post-test: Matching Type

A.
1. Information that identifies a client
2. Information that would determine genetic predisposition
3. It focuses on questions from the earliest beginnings to the present health
4. It takes into account several aspects of the health problem and asks questions whose
answers can provide a detailed description of the concern
5. The major health concern of the patient at the time of admission
6. It assesses the more complex ADLs necessary for living in the community
7. It consists of 10 items that measure a person's daily functioning specifically the
activities of daily living and mobility.
8. These are 11 categories that enable the nurse to determine the following aspects of
health and human function
9. These guidelines outline exercise recommendations for healthy adults and older adults
10. This is a 6 point scale that is considered the most appropriate instrument to
assess functional status as a measurement of the client's degree of Independence

B.
A. Biographic data
B. Chief complaint
C. History of Present Illness
D. History of Past Illness
E. Family Health History
F. Functional Assessment
G. Gordon's Functional Health Patterns
H. Physical Activities of Daily Living
I. Instrumental Activities of Daily Living
J. Katz Index of Independence in Activities of Daily Living
K. Barthel Index

***EVALUATION: A score lower than six (6) is unsatisfactory. It indicates inadequate

knowledge of the topic.

ANSWERS:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Health Assessment Module No. 3 HEALTH HISTORY page 13