CEBU TECHNOLOGICAL UNIVERSITY

In consortium with
CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING
HEALTH ASSESSMENT
MODULE 2: HEALTH HISTORY
 may be obtained in a primary setting as a
Health History screening tool, in a secondary setting
once your patient’s condition stabilizes,
PURPOSE: gather subjective data from the
or in a tertiary setting to establish a
patient and/or patient’s family so that the
baseline from which to develop your plan
health care team and the patient can of care.
collaboratively create a plan that will  biographical data
promote health, address acute problems, ◦ patient’s name
and minimize chronic conditions. ◦ age
▪ Provide the subjective database. ◦ gender
▪ Identify patient strengths. ◦ birth date
▪ Identify patient health problems, both ◦ birthplace
actual and potential.
◦ marital status
▪ Identify supports.
◦ race
▪ Identify teaching needs.
◦ religion
▪ Identify discharge needs.
◦ address
▪ Identify referral needs
PARTS:
◦ education
1. Personal Profile ◦ occupation
2. Biographical Data ◦ contact person
3. Reasons of Seeking Health Care ◦ health insurance/social
4. Chief Complaint security number
5. History of Present Health Concern  also include the source of the health
6. Past Health History history and his or her reliability, who
7. Family History referred the patient, and whether or
8. Psychosocial History not the patient has an advance
 Types of Health Histories directive
 A health history may be either past health history
complete or focused − childhood illnesses, surgeries, injuries,
● complete health history hospitalizations, adult medical problems,
medications, allergies, immunizations,
▪ biographical data,
travel, and military service
▪ reason for seeking care
family history
▪ current health status
− familial or genetically linked disorders
▪ past health status
review of systems
▪ family history
− provides a comprehensive assessment to
▪ a detailed review of systems
determine your patient’s physiological
▪ psychosocial profile status.Past or current problems may be
 provides a comprehensive, holistic identified and warrant further
picture of your patient. investigation.
 it screens for actual or potential
● focused health history
problems and identifies your patient’s
▪ focuses on an acute problem
strengths and health promotion patterns
 ▪ questions will relate to that take time. If you do not have enough time
problem to complete the history, do not rush.
 may be indicated when your patient’s Instead, perform a focused history first,
condition is unstable or when time and then complete the history at later
constraints are an issue sessions.
 also be used for episodic follow-up visits  Setting the Scene
for your patient 1. look at your surroundings
 biographical data 2. have a quiet environment that is free of
◦ patient’s name interruptions
◦ age 3. A private room is preferred, but if one is
◦ birth date not available, provide privacy by using
◦ birthplace curtains or screens.
◦ gender 4. Prevent interruptions and distractions so
◦ marital status that both you and your patient can stay
◦ dependents focused on the history
◦ race 5. Make sure that the patient is comfortable
◦ religion and that the room is warm and well lit
◦ address 6. If the patient uses assistant devices, such
◦ education as glasses or a hearing aid, be sure that
◦ occupation she or he uses them during the
◦ contact person assessment to avoid any misperceptions.
◦ health insurance/social 7. tell your patient what you will be doing
security number and why inform him or her if you will be
 also includes the source of the health taking notes, and reassure the patient
history and her or his reliability, who that what he or she says will be
referred the patient, and whether or not confidential.
the patient has an advance directive 8. avoid excessive note taking
 Patient’s Condition 9. Be sure to work at the same level as your
1. determine the condition of your patient patient
→ This condition may prohibit a detailed 10. Avoid anything that may break the flow
health history upon admission of the interview
2. you should obtain a focused history while 11. If the interview is being recorded or
you perform a physical assessment, draw videotaped, be sure to get your patient’s
laboratory studies, obtain an permission before starting
electrocardiogram, and connect your 12. Position the equipment as unobtrusively
patient to a cardiac monitor. as possible
When a patient is in acute distress:
1) ask key questions that focus on the acute COMPONENTS OF THE HEALTH HISTORY
problem  Biographical Data
2) once your patient’s condition stabilizes  provide direct information related to a
3) obtain a more detailed health history current health problem
 alert the risk factors for health problems
 Amount of Time
 point out the need for referrals
1. Allot at least 30 minutes to an hour to
 patient’s ability to provide biographical
obtain a complete health history
data accurately reflects his or her mental
2. Be sure to let your patient know why you
status
are asking these questions and that it will
PILONES,RISHELLE MAE M.
Biographical data include:  If the setting is a primary level
▫ patient’s name of healthcare, there is usually
▫ address no acute problem
▫ phone number − reason generally relates to
▫ contact person health maintenance or
▫ age/birth date promotion
▫ place of birth  For example, the patient states,
▫ gender “I am here for my annual
▫ race physical examination.”
▫ religion 2. If there is an acute problem, ask the
▫ marital status patient to state what the problem is and
▫ educational level how long it has been going on.
▫ occupation  For example, “I have had chest
▫ social security number/ health pain for the last hour.”
insurance 3. If your patient identifies more than one
also include problem, she or he may be confusing
▫ the person who provided the associated symptoms with the primary
history and her or his reliability problem
▫ the person who referred the  Help her or him clarify and
patient prioritize the problems
▫ Information on advance  by asking questions such as,
directives “Which problems are giving
▫ note any special considerations, you the most difficulty?”
such as the use of an 4. In an acute-care setting, the reason for
interpreter seeking care is called the chief complaint
− gives you the patient’s
perspective on the
problem
− a view of the problem
through his or her eyes

5. At the tertiary level, the problem may be

 Reason for Seeking Healthcare
1. Ask your patient why he or she is seeking
healthcare; then document his or her
direct quote
− patient’s reason for seeking
care is usually related to the
level of preventive healthcare
—primary, secondary, or
tertiary
well defined, a chronic problem, or an
acute problem that is resolving
− the problem does not have the
acuity or life-threatening
urgency of an acute problem
 Current Health Status
 Once you have identified the patient’s
reason for seeking healthcare, assess her
or his current health status
current health status should include the
following:
 Usual state of health.
 Any major health problems.

PILONES,RISHELLE MAE M.
  Usual patterns of healthcare.
 Any health concerns.
For example: Patient is Maryanne Weller, age
42, married, mother of three, full-time teacher.
Usual state of health good. Has yearly physical
with pelvic examination and dental
examination. Last eye examination 1 year ago.
Expresses concern regarding family history of
hypertension and ovarian cancer.
▪ Patients in secondary or tertiary
healthcare settings have an existing
problem
1. perform a symptom analysis to assess
your patient’s presenting symptoms
thoroughly
2. patient’s condition and time constraints
may preclude you from going into too
much detail.
3. you’ll need to zero in on several key
areas to evaluate your patient’s
symptoms
4. determine how disabling this problem is
for your patient
5. ask if he or she has any medical problems
related to the current problems and if he
or she is taking any medications for this
current problem
 PQRST
− provides key questions that will give you
a good overview of any symptom
 Precipitating/Palliative Factors
→ Ask: What were you doing when the
problem started? Does anything
make it better, such as medications
or certain positions? Does anything
make it worse, such as movement or
breathing?
 Quality/Quantity
→ Ask: Can you describe the symptom?
What does it feel like, look like, or
sound like? How often are you
experiencing it? To what degree
does this problem affect your ability
to perform your usual daily
activities?
 Region/Radiation/Related Symptoms
→ Ask: Can you point to where the
problem is? Does it occur or spread
anywhere else? (Take care not to
lead your patient.) Do you have any
other symptoms? (Depending on the
chief complaint, ask about related
symptoms. For example, if the
patient has chest pain, ask if she or
he has breathing problems or
nausea.)
 Severity
→ Ask: Is the symptom mild, moderate,
or severe? Grade it on a scale of 0 to
10, with 0 being no symptom and 10
being the most severe. (Grading on a
scale helps objectify the symptom.)
 Timing
→ Ask: When did the symptom start?
How often does it occur? How long
does it last?
Several scales are used for assessing pain
 (0 to 10) scale
 use scales that rate pain/symptoms with
words like “little pain” or “worst pain
possible
For children
 drawings of happy to sad faces
 photographs of children’s faces
representing “no hurt” to “worst hurt
ever.”
 Crayons may also be used, with different
colors representing different degrees of
symptoms or pain.
PILONES,RISHELLE MAE M.
  Past Health History
Assesses:
 childhood illnesses
 hospitalizations
 surgeries
 serious injuries
 adult medical problems (including
serious or chronic illnesses)
 immunizations
 allergies
 medications
 recent travel
 military service
 identifies any chronic preexisting health
problems, such as diabetes or
hypertension, which may directly affect
the current health problem
 For example, patients with diabetes often
have poor wound healing.
 explain your patient’s response to illness,
healthcare, and healthcare workers.
 be sure to ask for dates, physicians’
names, names of hospitals, and reasons
for hospitalizations or surgeries
 avoid using terms such as “usual,”
“general,” or “routine.”
 For example, “usual” childhood illnesses
vary depending on
 the age of your patient and available
immunizations.
 Family History
 provides clues to genetically linked or
familial diseases that may be risk factors
for your patient
 Ask about the health status and ages of
your patient’s family members
 Ask about genetically linked or common
diseases, such as heart disease, high
blood pressure, stroke, diabetes, cancer,
obesity, bleeding disorders, tuberculosis,
renal disease, seizures, or mental disease.
 Review of Systems
 a litany of questions specific to each body
systemquestions are usually about the
most frequently occurring symptoms
related to a specific system
 used to obtain the current and past
health status of each system
 Identify health problems that your
patient may have failed to mention
previously
 provides clues to health promotion
activities for each particular system
1. if your patient has an acute problem
in one area, every other body
system will be affected, so look for
PILONES,RISHELLE MAE M.
 correlations as you proceed with the
ROS.
2. perform a symptom analysis for
every positive finding and
determine the effect of, and the
patient’s response to, this symptom

PILONES,RISHELLE MAE M.