Chapter 4

The Health History

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

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

o Creates platform for

health promotion

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

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Comprehensive Adult Health History #2
 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

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 Comprehensive Adult Health History #3
 Chief complaint(s)
o Make every attempt to quote the patient’s own words.
o If there are no complaints, report goals.
 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

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Comprehensive Adult Health History #4
 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

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Question #1
 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

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Answer to Question #1
 When a nurse concentrates on just gathering information
about the patient’s problem, he or she is completing a:
 B. Focused assessment
 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.

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

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Comprehensive Adult Health History #6
 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

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Comprehensive Adult Health History #7
 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

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Comprehensive Adult Health History #8
 Past history: key elements (cont.)
o Health maintenance
 Immunizations
 Screening tests
 Safety measures
 Risk factors
Tobacco
Environmental Hazards
Substance abuse
Alcohol

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Alcohol and Drugs
 Misuse of alcohol or drugs often contributes to
symptoms.
 Should routinely ask about current and past use of
alcohol or drugs, patterns of use, and family history.
 Include adolescents and older adults in questioning.

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Alcohol #1
 Assess what patient considers alcohol.
 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?

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

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

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Comprehensive Adult Health History #9
 Family History

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Comprehensive Adult Health History #10

 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

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

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Comprehensive Adult Health History #11
 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

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Question #2
 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

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

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

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

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

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

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Family Violence #2
 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

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

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Question #3
 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

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

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