Chapter 4

The Health History

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Types of Health Histories
v Comprehensive Health Assessment
o Admission of new patient
v Focused or Problem-Oriented Assessment
o Returning patient
v Follow-up History
o Problem or treatment evaluation
v Emergency History
o Focused on emergent problem

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Comprehensive or Focused?
v Comprehensive v Focused
o New patients in all o Established patients,
settings especially routine or
urgent care visits
o Provides fundamental
and personalized o Focused concerns or
knowledge symptoms
o Strengthens nurse– o Assesses symptoms
patient relationship restricted to specific
body system
o Provides baseline
o Creates platform for
health promotion

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Comprehensive Adult Health History #1
v Identifying data and source of the history
v Chief complaint(s)
v History of Present Illness (HPI)
v Past history
v Family history
v Review of systems
v Health patterns

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Comprehensive Adult Health History #2
v Initial information
o Date and time of history
o Identifying data: age, gender, birth date, marital or
relationship status, occupation, other as appropriate
§ Source of history
o Reliability

Copyright © 2018 Wolters Kluwer · All Rights Reserved

 Comprehensive Adult Health History #3
v Chief complaint(s)
o Make every attempt to quote the patient’s own words.
o If there are no complaints, report goals.
v History of present illness (HPI)
o Chronologic account of problem(s)
o Onset of problem(s)
o The setting in which it developed
o Any treatments

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Comprehensive Adult Health History #4
v HPI: Key elements
o Seven attributes of each principle symptom (OLD
CART or OPQRST)
o Self-treatment by patient or family
o Past occurrences of the symptom(s)
o Pertinent positives and/or negatives from the review
of systems
o Risk factors or other pertinent information related to
the symptom

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question #1
v When a nurse concentrates on just gathering information
about the patient’s problem, he or she is completing a:
A. Comprehensive health assessment
B. Focused assessment
C. Follow-up history
D. Emergency history

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer to Question #1
v When a nurse concentrates on just gathering information
about the patient’s problem, he or she is completing a:
v B. Focused assessment
v When the nurse focuses on gathering information about
the patient’s problem, they are conducting a focused or
problem-oriented assessment. The comprehensive health
assessment is used with new patients. The follow-up
history is appropriate when the patient is returning to
have a problem or treatment plan evaluated. The
emergency history is conducted in emergency situations
focused on the patient’s emergent problem.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Comprehensive Adult Health History #5
v Past history: key elements
o Allergies
§ Include specific reaction
§ Medication, food, insects, environmental factors

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Comprehensive Adult Health History #6
v Past history: key elements (cont.)
o Medications
§ Prescription
§ Over-the-counter
§ Herbal supplements
§ Vitamins/Mineral supplements
§ Oral contraceptives
§ Medications borrowed from family members or
friends

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Comprehensive Adult Health History #7
v Past history: key elements (cont.)
o Childhood illnesses
§ Measles, rubella, mumps, whooping cough,
chickenpox, rheumatic fever, scarlet fever, polio
§ Chronic conditions (e.g., asthma)
o Adult illnesses
§ Medical
§ Surgical
§ Accidents
§ Psychiatric

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Comprehensive Adult Health History #8
v Past history: key elements (cont.)
o Health maintenance
§ Immunizations
§ Screening tests
§ Safety measures
§ Risk factors
ØTobacco
ØEnvironmental Hazards
ØSubstance abuse
ØAlcohol
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Alcohol and Drugs
v Misuse of alcohol or drugs often contributes to
symptoms.
v Should routinely ask about current and past use of
alcohol or drugs, patterns of use, and family history.
v Include adolescents and older adults in questioning.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Alcohol #1
v Assess what patient considers alcohol.
v Screening tool: CAGE
o Have you ever felt the need to Cut down on
drinking?
o Have you ever felt Annoyed by criticism of your
drinking?
o Have you ever felt Guilty about drinking?
o Have you ever taken a drink first thing in the
morning (Eye-opener) to steady your nerves or get
rid of a hangover?

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Alcohol #2
v Positive CAGE results: 2 or more affirmative answers
v If detect misuse, ask about:
o Blackouts
o Seizures
o Accidents
o Injuries while drinking
o Job problems
o Conflicts
o Legal problems

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Illicit Drugs
v Focus questions to distinguish use from misuse
v Adapt CAGE questions by adding “or drugs”
v Ask about patterns of use
v Ask about modes of consumption

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Comprehensive Adult Health History #9
v Family History

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Comprehensive Adult Health History #10

v Review of Systems
o Address each body system, from head to toe
o Most questions pertain to symptoms
o May uncover problems patient has overlooked
o Do not use medical terms

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Review of Systems
v General v Peripheral vascular
v Skin v Urinary
v HEENT v Reproductive
v Neck v Musculoskeletal
v Breasts v Psychiatric
v Respiratory v Neurologic
v Cardiovascular v Hematologic
v Gastrointestinal v Endocrine

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Comprehensive Adult Health History #11
v Health Patterns
o Self-perception/self-concept
o Value-belief
o Activity-exercise
o Sleep-rest
o Nutrition
o Role-relationship
o Coping-stress-tolerance

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question #2
v A good tool to use to assess alcohol and drug use is the:
A. PAGE questionnaire
B. RAGE questionnaire
C. CART questionnaire
D. CAGE questionnaire

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer to Question #2
v A good tool to use to assess alcohol and drug use is the:
v D. CAGE questionnaire
v The most widely used screening questions are the CAGE
questions about cutting down, annoyance if criticized,
guilty feelings, and eye-openers.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Guidelines for Sensitive Topics
v The single most important rule is to be nonjudgmental.
v Explain why you need to know certain information.
v Find opening questions for sensitive topics and learn the
specific kinds of information needed for your
assessments.
v Consciously acknowledge whatever discomfort you are
feeling. Denying your discomfort may lead you to avoid
the topic altogether.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

The Sexual History
v Determine risks for pregnancy
v Determine risks for sexually transmitted diseases (STDs)
v Sexual practices may be related to patient’s symptoms
v Sexual dysfunction may result from use of medication or
misinformation
v Be matter-of-fact in questioning
v Use specific language
v Make no assumptions about the patient

Copyright © 2018 Wolters Kluwer · All Rights Reserved

The Mental Health History
v Be aware of cultural constructs
v Be sensitive to reports of mood changes or symptoms of
possible depression
v Ask open-ended questions initially, then move to more
specific
v Ask about using psychotropic medications
v If patient seems depressed, ask about thoughts of
suicide

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Family Violence #1
v Many authorities recommend routine screening for
domestic violence.
v Start with general questions and move to more specific.
v If abuse is suspected, it is important to spend part of
encounter alone with the patient.
v Do not force the situation.
v Ask parents how they cope with their crying baby.
v Be alert to nonverbal communication.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Family Violence #2
v Physical abuse should be considered in the following
situations:
o If injuries are unexplained, inconsistent with story,
concealed, or cause embarrassment
o If patient has delayed getting treatment for trauma
o If a past history of repeated injuries or “accidents”
o If patient or person close to patient has history of
alcohol or drug abuse
o If partner tries to dominate the interview, will not
leave the room, or seems unusually anxious or
solicitous

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Documenting the Health History
v Form of documentation is frequently computerized
v Must be accurate and thorough

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question #3
v If the nurse who is conducting the interview feels
uncomfortable asking about certain subjects, then it is
okay to ignore those questions.
A. True
B. False

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer to Question #3
v If the nurse who is conducting the interview feels
uncomfortable asking about certain subjects, then it is
okay to ignore those questions.
v B. False
v The nurse’s role is to learn about the patient and help the
patient achieve better health. Consciously acknowledge
what discomfort you are feeling. Ask in a matter-of-fact
tone. Look into strategies for becoming more comfortable
with sensitive areas.

Copyright © 2018 Wolters Kluwer · All Rights Reserved