Health History Guidelines

By the end of the chapter you should be able

to:
 Explain why assessment is important
 Understand how assessment informs the
planning of care
 Use a structured approach to gain a patient
history and interpret findings
 Describe how discharge is planned starting
from admission.
 A dynamic health assessment is the foundation of all
nursing care and physical assessment is part of every
holistic health evaluation.

 An effective assessment will ensure that a patient

receives all the nursing care that is required, and will
provide a baseline from which progress can be measured.

 To ensure that nursing care is planned and delivered

effectively a structured approach called the ‘nursing
process’ is used.
 Nursing Process is a planned, problem-solving
approach to meeting a patient’s health care
and nursing needs
(Lippincott 2000).

 It is a systematic sequence of events in which

the first stage is to assess a patient’s needs by
the collection of objective and subjective
information.
Assessment

Assessment is the first step of the nursing

process.

 It involves the orderly collection of

Subjective and Objective information about
the client’s health status.
Collecting Subjective Data
SUBJECTIVE DATA

 Elicited and verified only by the client.

 Provides clues to possible physiologic ,

psychological and sociological problems

 Information is obtained through interview

Subjective Data

 Sensation or symptoms
 Feelings
 Perceptions
 Desires
 Preferences
 Beliefs
 Ideas
 Values
 Personal information
INTERVIEW

 Establishing rapport and a trusting relationship

with the client to elicit accurate and meaningful
information

 Gathering information on the clients

developmental, psychological, physiological,
sociocultural and spiritual statuses to identify
deviations that can be treated with nursing and
collaborative interventions that can be enhanced
through nurse client collaboration
Phases of Interview

 Introductory Phase

 Working Phase

 Summary and Closing Phase

Complete Health History
 Objective data are observable, measurable, and verifiable by more than one
person.

A fundamental systematic approach is used based on a combination

of head-to-toe and body systems assessments, which
 are expanded as appropriate to the client’s situation
 and setting. By using a systematic approach, you en-
 sure that signs are not overlooked and that time is
 used efficiently. Through the process of data collection,
 meaningful information, including health status,
 actual and potential health problems, and areas of
 focus for priority health promotion, is identified. The
 process of physical assessment is utilized in outpatient,
 inpatient, and/or home health services.