NCM 100 SKILLS

THE HEALTH HISTORY

A. HEALTH HISTORY - is a collection of data about the client's present and past functioning as it relates to health status.

B. PURPOSES OF HEALTH HISTORY

1. To obtain all relevant information about a client's physical, psychosocial, and spiritual health in an organized manner
using communication skills and interviewing techniques; the health history gathers subjective information.
2. An added benefit is that it provides a forum for the nurse to develop a therapeutic relationship with the client.

C. SOURCES OF DATA
1. PRIMARY - the client, who is the best source of data unless confused, too young or too ill to participate in the interview.
2. SECONDARY - family members/ caregivers/ support people, old medical or health records, and results of laboratory
and diagnostic tests.

D. PRINCIPLES OF HISTORY TAKING

1. Provide privacy: draw the curtains or close the door to the room to eliminate distractions; if the client is tired or ill, ask
the most critical questions first; assure the client that all information is for the records and to generate complete picture of
the client's overall health status; immediately document the data in the chart; do not keep any data on a loose piece of
paper.
2. Maintain confidentiality: assure the client that all disclosed information will remain confidential; do not discuss the client
his/ her family with anyone else who is not an integral member of the team; do not discuss confidential information in the
corridors or on the elevator; keep client records away from unofficial personnel.
3. Plan an appropriate time frame; may require up to 1 or longer; allot enough time to take the history taking; do not rush
through the interview because important cues to the client's health status could be missed, pace the interview so as not to
overtire the client.
4. Gain trust:
a. Approach the client and family in a professional manner; explain the client your role and your rationale for the
interview.
b. If the interview takes place in a non- emergent situation, try to find something in common with the client; this will
relax the client so he or she will feel more at ease.
c. Tell the client if he/ she becomes ill during the interview to alert you right away.
d. Use good communication skills; listen with diligence, demonstrating active listening techniques; be aware of own
nonverbal behavior; maintain good eye contact.
e. Ask appropriate follow - up questions.
f. Be careful with the choice of words; avoid using overly technical language; avoid overreacting to comments made
by the client or family.
g. Remain relaxed during interview.
h. Use touch if appropriate.

5. Note nonverbal cues about client's demeanor, posture, and overall appearance.
a. Physical appearance: including cleanliness, body odor, personal grooming, hygiene, client's eye contact.
b. Signs of physical comfort: diaphoresis, tremors, grimaces, and continual changes in position.
c. Client stress: tears, skin blotching, nervous movements, inability to concentrate, arms folded, diaphoresis; if client
wants to end the interview, respect his or her request and terminate the interaction.
6. Assess client's reliability.
a. Client answers questions with authority and does not change data reported.
b. Client uses proper terminology or words that indicate an understanding of health status; offers pertinent
information about health status; refers to previous ailments and the treatment associated with the illness; does not
change the subject when the nurse and client are discussing an issue; is oriented to person, place, time and event.
c. If the client's family is present, they concur that the data is accurate.
d. An interpreter should be used if the nurse and client cannot communicate in the same language.

7. Conduct the interview in a logical, orderly manner and focus the discussion.
a. Ask open -ended questions to determine the most important issues.
b. Ask pertinent follow - up questions; for example, if a client mentions feeling “jumpy” since beginning a medication, ask
what it meant by the word “jumpy”.

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c. Closed - ended questions should yield “yes or no” responses; closed ended questions clarify previous statements made
by the client or family.
d. Closed - ended questions should be used when asking clients for specific additional information; for example, “ Since
your last heart attack have you experienced any chest pain, dizziness, chest squeezing, or arm pain?”.
8. Clarify discrepancies: elaborate on questionable statements and use active communication skills.
a. Ask question in a clear manner, phrase all questions after determining the intellectual level of the client or family; if a
client does not understand the question, rephrase it or use different terms.
b. Probing questions help yield accurate information if several explanations for a symptom are offered; do not use leading
questions.
c. Connect a client's explanations with the symptoms; seek a logical explanation for the client's descriptions and
symptoms.
d. Provide feedback to convey to the client that his or her communication is being understood; paraphrase the client's
descriptions in order to clarify accuracy of statements; summarize the data collected during the interview.
e. Thank the client and family for their assistance through this process.
f. Allay the client's fears and maintain open communication; be forthright with additional information.
g. Confirm that the client understands the next aspect of care.
h. Data obtained during the interview offers cues to the client's condition and emotional state.
9. Tips on conducting successful interview:
• Maintain poise and exude warmth during the history; the client and / or family may be tense and afraid.
• Use a nonthreatening and nonjudgmental attitude as you begin the interview.
• Address the client in the manner of his or her choosing.
• Be polite and respectful of the client and family.
• Once the client offers the reason for his or her visit, then proceed in a logical, orderly fashion.
• Pace the interview to obtain as much data as possible without overtiring the client or rushing the interview; if the
interview proceeds too quickly, important information may be overlooked.

COMPONENTS OF HEALTH HISTORY:

1. Biographical Data
■ Name
■ Address
■ Telephone no.
■ Gender
■ Marital Status
■ Religion
■ Occupation
■ Name & Contact information for primary care physician/ nurse practitioner
2. Chief Complaint - the problem or reason for which the client is currently seeking treatment.
a. Ask the client / family to describe the reason for seeking treatment.
b. Do a symptom analysis, getting data about each of the following:
• Location: be specific as possible in obtaining and recording the part(s) of the body involved
• Quantity: sometimes referred to the “severity” or “intensity”;
• Quality:
• Setting: location of the client when the symptom(s) began and a description of the events going on that time.
• Timing or chronology: notation of when the symptom first began; slow onset versus sudden; constant versus
intermittent; whether the symptoms disturbs the client's sleep.
• Aggravating Factors: factors that make the symptom worse or better (such as eating, resting, use of medication,
among others)
• Associated factors:
• Document the findings verbatim, using the client's or family's own words.
• Previous state of health and physical capabilities and how current symptom(s) has/ have impacted physical,
emotional, and psychosocial functioning.

3. History of the present illness

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 When the symptoms originally started.
How frequently exacerbations occur, and whether they are gradual or sudden in onset.
The client's understanding of the nature of the problem.
Medications and/ or other therapies used to treat the problem and their degree of success (or lack of success)

4. Past Health History- sometimes referred to as “past history” or “medical history”

• Includes other health problem that a client may have.
• Immunizations: includes childhood immunizations and date of last tetanus prophylaxis, may also include
influenza vaccines.
• Childhood Illness: such as measles, mumps, rubella (German Measles), rubeola; chicken pox, rheumatic fever,
scarlet fever, streptococcal infections, or other major illnesses.
• Prior hospitalizations: including dates, reasons ( includes accidents and injuries as well as illnesses), surgical
procedures, outcomes and any complications experienced (such as reactions to anesthesia or blood products)
• Allergies: Medication allergies ( reaction, symptoms, incudes prescription, over the counter and herbal
products); Food allergies; Seasonal Allergies; Allergy to dyes used in diagnostic procedures (often determined
by asking about allergy to iodine or shellfish).
• Pregnancy history and menstrual history as appropriate for female clients.
• Current medications: prescribed dose, rationale and duration of drug therapy, date and time of last dose; over
the counter medications; herbal remedies; home remedies; complementary or adjuctive health care (if so, have
the client explain the remedies used and effects).
5. Family Health History
• Includes identification of the overall state of health of parents and relatives, any significant and chronic
illnesses, cause of death, and age of time of death.
• The family history is an important factor in treating clients; it can highlight genetically transmitted traits or
disorders; keep in mind that ethnic background also plays a role in the risk of developing certain disorders.
• Establish whether there is a history of hereditary disorders such as coronary heart disease, diabetes mellitus,
stroke, high blood pressure, cancer, obesity, arthritis, bleeding disorders or mental health disorders.
6. Personal/ Social history- includes social data and lifestyle assessment.
• Diet: foods eaten on usual day; number of meals or snacks; who does the shopping and cooking; food
preferences and patterns based on culture/ or religion; usual fluid intake; intake of caffeine (such coffee, tea,
cola)
• Activity and exercise: type, frequency, and duration of exercise; ability to perform activities of daily living
(eating, bathing, elimination, dressing, grooming), ability to move about the at a will (locomotion)
• Sleep and rest: usual number of hours of sleep, sleep problems, and effectiveness of remedies used
• Tobacco used: the number of packs per day (cigarettes) and the number of years of smoking, ; the type,
frequency, and duration of use for other tobacco products
• Substance use: the amount, frequency, and duration of alcohol or recreational drug use
• Living arrangements: include location, type of dwelling, number of stairs to climb, home safety information,
ability to access neighborhood or community resources/ services
• Family Relationships/ Friendships: who is/ are the support person(s) in times of need, effects of illness on the
client and family roles and relationships(dynamics); identification of the next kin
• Psychological data: major lifestyle changes, or stressors experienced, and how the client dealt with them;
client's usual coping patterns; general communication style and ability; appropriateness of verbal and nonverbal
behavior; whether client is seeing mental health professional; significance of current illness to the client; effect
of the current illness on self - esteem or body image.
• Occupation: presence of occupational hazards, such as exposure to carcinogens ( such as asbestos, other
chemicals); distance and length of time the client commutes to work each day and associated concerns ;
amount of time missed from work due to illness; history of a need to change jobs in the past because of illness.
• Travel: out of country, when and amount of time; military service abroad.
• Health Resources used: current and past use of physicians (general and specialist), dentist, folk healers;
satisfaction with care; accessibility to care.

7. Review of Systems (ROS) - this section includes questions about the past and current health status in each system
reviewed; it is used to obtain subjective data, in many situations, nursing assessments use a nursing model instead of the
ROS to obtain this information such as , ,
,healthcare agencies generally have a specific form to gather this data (forms based on nursing

a. Skin: skin disease(eczema, psoriasis, hives), changes in moles, dryness of the skin or moisture, itching, bruising,
rashes or other lesions, changes in hair or nails, sun exposure.
b. Head: headache, dizziness, hearing aid use, tinnitus, vertigo, earaches, infections, discharge and characteristics

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c. Eyes: vision problems, (blurring, blind spots, reduced acuity), double vision (diplopia), glaucoma, cataracts, eye pain,
redness, discharge or watering, swelling, method of vision correction being used

d. Ears: hearing loss, hearing aid use, tinnitus, vertigo, earaches, infections, discharge and characteristics

e. Nose/ sinuses: frequency and severity of colds, sinus pain or obstruction, discharge, nosebleeds, allergies, reduced
sense of smell

f. Mouth/ throat: pain and lesions in mouth ( or tongue), toothaches, change in sense of taste, frequency of sore throats,
bleeding gums, dysphagia, hoarseness, history of tonsillectomy,frequency of dental care and presence of any dental
prosthesis

g. Neck: pain, mobility, enlarged or tender lymph nodes, goiter, lumps or other swelling
h. Breasts: history of breast disease or surgery, pain, lumps, rashes, nipple discharge, knowledge and performance of
breast self - examination (BSE); date last mammogram

i. Axilla: rash, lumps, tenderness, or swelling

j. Respiratory: history of lung disease (tuberculosis, pneumonia,asthma, bronchitis, emphysema), shortness of breath
(amount and trigerring factors, such as activity level),wheezes, or other noises associated with respiration, cough, sputum
production (color, amount, and if relevant, timing), pain associated with breathing, hemoptysis, and exposure to pollutants
or other inhaled toxins.

k. Cardiovascular: history of heart disease, murmur, hypertension, or anemia; chest pain (precordial, retrosternal,
radiation, and other pain characterisitcs); dyspnes on exertion (specify amount); orthopnea, paroxysmal nocturnal dyspnea
(PND); edema, nocturia

l. Pheripheral vascular: discoloration of extremities (especially feet and ankles; note whether associated with activity);
coolness, numbness or tingling of lower limbs (note relationship to activity and time of day); history of intermittent
claudication, ulcerations, thrombophlebitis, or varicose veins

m. Gastrointestinal (GI): appetite, nausea and vomiting, constipation or diarrhea, frequency of bowel movements and
whether any recent changes, tarry or bloody stools, history of rectal conditions (such as hemorrhoids), food intolerances,
dysphagia, heartburn, pyrosis (upper GI burning with sour eructation), indigestion, abdominal pain (with or without eating),
history of GI disorder, antacid use, and prescribed diet.

n. Urinary: frequency, urgency, or dysuria; nocturia; polyuria or oliguria; characteristics of stream (narrowed, hesitancy,
straining); cloudy urine or hematuria; incontinence; history of urinary bladder (renal disease o calculi, urinary tract
infections); pain in back, flank, suprapubic area, or groin.

o. Male genital: lumps, hernia, penile lesion or discharge, pain in testicles or penis, knowledge and performance of
testicular self - examination (TSE), sexual health practices (contraceptive method and prevention of sexually transmitted
diseases).

p. Female genital: menstrual cycle ( age of menarche, last monthly period, duration of cycle, premenstrual pain,
intermenstrual spottingor metrorrhagia, dysmenorrhea, amenorrhea, menorrhagia) vaginal itching, or discharge, age at
menopause, menopausal manifestations, postmenopausal bleeding, last Pap test and gynecological exam, sexual health
practices.

q. Musculoskeletal:muscle pain, weakness or cramping; difficulty with gait or activities; back pain or stiffness, history of
back pain or disease; use of mobility aids and satisfaction with ability to perform ADLs.

r. Neurologic: weakness, tics or tremors, paralysis, problems with coordination, paresthesias (numbness
and tingling),recent or distant memory disorder, nervousness, mood changes, history of depression or other mental health
problem, hallucination, history of stroke, fainting or blackouts, seizure disorder.

s. Hematologic: easy bruising or bleeding, swollen lymph nodes, history of blood transfusion and reaction, exposure to
radiation or other toxins.

t. Endocrine:history of diabetes, thyroid disease, adrenal disease, abnormal hair distribution, change in skin
(pigmentation, texture), excessive sweating, relationship between appetite and weight, hormone therapy.

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PREPARING FOR PHYSICAL ASSESSMENT

Purpose
• Determine the following: objective data (both normal and abnormal); the level of client's health; possible anomalies
and whether they are life altering or life - threatening; whether findings are considered normal for the client;
comparison of findings with client's personal and family history.
• Regular physical assessments: evaluate the health of the client and offer a baseline for comparison.
• Provides the healthcare professional with data for planning intervention.

EQUIPMENT NEEDED

Techniques
Use the senses of vision, hearing, smell, and touch when conducting a physical assessment; the skills needed
include the four listed below which should be practiced until mastery occurs.

A. INSPECTION - a physical assessment technique that utilizes observation to obtain important information about a
client's state of health.
• In order to maximize inspection, it is important to have adequate lighting to visually inspect the body without
distortions or shadows; lighting can be sunlight or artificial.
• Items to assess using the skill of inspection include the following:
■ Overall appearance
■ Demeanor, eye contact
■ Interactions with other healthcare professionals and family
■ Skin color, hair, nail beds, skeletal deformities
■ Clothing appropriate for weather conditions
■ Congruence of verbal and nonverbal behavior
■ Sense of smell: does the client have a peculiar odor
B. PALPATION - is a physical assessment technique that utilizes touch to obtain important information about a client's
state of health
• It uses the sensation of touch and pressure of the hands and fingers to determine masses, elevations,
temperature, organ position, and any abnormal findings.
• The ulnar surfaces of the hands and fingers are the most common areas are used for palpation; the hands should
be warm and gentle; wear gloves as appropriate to the area being examined.
• Palpation can be light or deep depending on the area of the body being examined; the nurse controls amount of
pressure
■ Light palpation is 1 cm in depth
■ Deep palpation is about 4 cm in depth
■ Deep palpation should occur after light palpation
C. PERCUSSION - is a skill in which the finger of one hand touches or taps a finger of the other hand to generate
vibration, which in turn produces a specific, diagnostic sound; the sound changes as the practitioner moves from one area
to the next
• To become proficient, the novice should practice this skill; the novice can listen to the change in sounds as they
percuss various areas of the body
• Sounds can be classified as tympanic, hyperresonant, resonant, dull, or flat.
D. AUSCULTATION - uses the sense of hearing to identify sounds produced by the body; some sounds can be heard and
identified without a stethoscope; others can only be identified in a quiet environment with a stethoscope
• Allot enough time to listen carefully to the produced sounds; if in doubt, consult another healthcare professional for
a second opinion
• Place stethoscope over bare skin to eliminate alterations in sound caused by clothing
• Listen to the sound, the duration, pitch, intensity

• Must isolate sounds; if the client has a large amount of chest or back hair, wet the hair down to diminish extra sounds.

PROMOTING COMFORT DURING PHYSICAL ASSESSMENT

1. Provide a comfortable room
2. Minimize distractions
3. Ensure client privacy
4. Provide adequate lighting

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5. Normalize room temperature

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