Health History

M. Celeste Wayne, DNP, RN, CNE

NURSING PROCESS
Health Assessment

Health History
Subjective information
Physical Assessment
Objective information
Health Assessment

Comprehensive
Ongoing partial
Focused
Emergency
Health Database

Nursing Health History

Physical Assessment
Lab Results
Diagnostic Tests
Medical Records
Nursing Health History

Assessment of the patient by interview to identify the

patient’s health status, strengths, health risks, actual
and potential health problems as well as health-
promotion activities, sources of strength or available
resources for adaptation and need for nursing care

Subjective account of the patient’s current and past

health status
Nursing Health History
Provides the nurse with the opportunity to observe
the patient’s nonverbal communication, use of eye
contact, and other body language
to establish an effective nurse–patient relationship
Patient can obtain information as well
Nurses use therapeutic communication skills and
interviewing techniques during health history-taking
Patient Interview
Interview: planned communication for a specific
purpose (health data collection)
Four phases
Preparatory phase
Introduction
Working phase
Termination

Strong interview skills

Interview Techniques
Prepare for the interview: get organized
Provide privacy
Establish rapport
Use appropriate language
Communicate effectively
Listen actively
Observe: use your senses
Termination: be as organized as the opening
Interview Techniques
Cultural considerations
Be sensitive to patient’s uniqueness; respect the
unfamiliar and differences
Avoid making stereotypes
Be sensitive in how different cultures communicate
Eye contact; touch

Be familiar with the general health beliefs,

variances, and risk factors for alterations in health
of various groups to provide care within a cultural
context
Components of Health History
Biographical Data

Reason for Seeking Health Care

History of Present Illness

Past Health History

Family History

Environmental History

Functional Health Assessment

Psychosocial and Lifestyle Factors

Review of Systems (ROS)

Components of Health
History
Biographical Data
Name
Age
DOB
Address
Primary MD
Billing/Insurance Info
Note preferred language
Components of Health History

Reason for Seeking Health Care

Determine the main reason patient is seeking
health care, called chief complaints
Ask open-ended question
When recorded, the statement is enclosed in
quotation marks to indicate the clients words. Ex.
“I’ve had chest pain since early morning.”
Patient states “ My stomach hurts and I feel awful.”
Avoid paraphrasing
Components of Health History
History of Present Illness/Concern
Ask the patient to describe the chief complaints
Dig for details: Onset of the problem, location,
duration, intensity, quality/description,
relieving/exacerbating factors, associated factors,
past occurrences, any treatments, and how the
problem has affected the patient
Components of Health
History
History of Present Illness/Concern
Ask the patient to quantify the symptom; rate
the intensity of pain on a scale of 1 to 10
Explore associated symptoms
Nausea, SOB, palpitation, or sweating
Use terms the patient is familiar with
Seven Attributes of a Symptom
Location: Where is it? Does it radiate?
Quality: What is it like?
Quantity or severity: How bad is it? (For pain, ask for a rating on a
scale of 1 to 10.)
Timing: When did (does) it start? How long does it last? How often
does it come?
Setting in which it occurs: Include environmental factors, personal
activities, emotional reactions, or other circumstances that may have
contributed to the illness
Exacerbating factors: Is there anything that makes it better or worse?
Associated manifestations; Have you noticed anything else that
accompanies it?
- Bates’ Nursing Guide to Physical Examination and History Taking
OLD CART
Onset
Location
Duration
Character
Aggravating/Alleviating symptoms
Radiation
Timing
OPQRST
Onset
Provoking factors
Quality
Radiation
Site
Timing

- Bates’ Nursing Guide to Physical Examination and History Taking

Components of Health
History
Past Health History
Allergies; reaction
Medical and Surgical history
Childhood and adult illnesses
Chronic health problems and treatment
Previous surgeries or hospitalizations
Accidents or injuries
Obstetric history

Date of most recent immunizations

Components of Health
History
Past Health History
Health maintenance screenings

Dates and results; use of safety measures

Prescribed and over-the-counter medications

Vitamins, supplements, and any home or herbal
remedies
Include the name, dose, route, frequency, and purpose
for each medication
Components of Health
History
Family History
Obtain data about immediate and blood
relatives: Parents, siblings, and grandparents
(maternal and paternal)
Determine whether the patient is at risk for
illnesses of a genetic or familial tendency and to
identify areas of health promotion and illness
prevention
DM, HTN, CVA, CAD, Pulmonary disease, arthritis, CA,
renal disease, mental illness, and alcoholism
Components of Health History
Social History (Lifestyle Factors)
Lifestyle patterns
Caffeine
Tobacco
2 PPD x 20 years or 40 pack-years
To determine pack-years: The number of cigarette
packs the patient smokes per day multiplied by the
number of years he has been smoking
Recreational Drug Use: “street” drugs
Alcohol (ETOH) - CAGE questionnaire
CAGE Questionnaire
Have you ever thought you should Cut down your
drinking?
Have you ever been Annoyed by criticism of your
drinking?
Have you ever felt Guilty about your drinking
Do you ever have an Eye-opener (a drink) in the
morning?
Two or more affirmative answers suggest alcohol misuse

- Adapted from Mayfield D, McCleod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening
instrument. Am J Psychiatry 131:1121-1123, 1974
Components of Health History
Environmental Assessment
Provides data about patient’s home environments
and any support systems that may be needed
Living conditions
Presence of any barriers or risks to patient’s safety
Layout of rooms: stairs
Functional utilities
Heat, running water, electricity, telephone service,
smoke detectors, carbon monoxide detectors?
Available community resources
Components of Health
History
Functional Assessment
Assess the patient’s ability to perform Activities of
Daily Living (ADL) or self-care activities
Eating, bathing, dressing, and toileting
Ability to perform Instrumental Activities of Daily
Living (IADL) – those needed for independent living
Housekeeping, meal preparation, management of
finances, and transportation
Components of Health History
Psychosocial
Reveals the patient’s support system
Spouse, children, family members, friends
Recent losses/death in the family
Stress: Coping mechanisms
Religious/Spiritual
Strong influence on patient’s health, illness and medical
treatment.
ex. Jehovah’s Witnesses
Source of emotional support during illness
Church, religious organization affiliation.
Other spiritual group → resource during or after illness or
hospitalization
Review of Systems (ROS)
Review of Systems (ROS)
A series of questions concerning each organ system
and region of the body, asked of the patient during
history taking and physical examination in order to
gain an optimal understanding of the patient’s
illness and medical history
Usually subjective data (as perceived by the patient)
Reinforces initial impression of the patient’s health
problems
May prompt patient to mention additional signs and
symptoms – not just the one that distresses him most
Review of Systems
General Overall Health State
Present weight (gain or loss; time period for loss -
gradual, sudden, desired, or undesired)
Pain or discomfort
Fatigue
Weakness or malaise
Fever
Chills
Sweats or nights sweats
Sleeping patterns, difficulty sleeping
Review of Systems

Integumentary System
Unusual hair loss or breakage
Skin lesions or discoloration
Rashes, itching, dryness
Unusual nail breakage or discoloration
Family history – skin disorders: psoriasis, skin cancer
Exposure to agents that can cause cancer (coal, tar, arsenic
compounds, or radium)
Excessive sun exposure

Health Promotion: Use of sunscreen; American Cancer

Society (ACS) recommends regular skin self examination
(SSE) and a whole body screening by a HCP
Review of Systems
Musculoskeletal System
Normal activity pattern; exercise routinely performed
Competitive sports involvement
Joint pain or stiffness
Tendon, ligament, or muscle pains or strains
Muscle weakness
Limitation of motion or activity
Health promotion – prevent or minimize
osteoporosis
Review of Systems
Head and Neck
Headaches
Neck pain and stiffness
Nasal discharge
Nosebleeds
Mouth lesions
Sore throat
Voice changes
Dental problems
Health Promotion – Dental care
Review of Systems
Eyes and Ears
Blurry vision
Changes in vision
Loss of vision
Double vision
Redness of eyes
Eye discharge
Changes in hearing
Loss of hearing
Ear discharge
Health Promotion – Hearing and Vision check,
(glaucoma test)
Review of Systems
Endocrine System
Excessive thirst
Excessive hunger
Excessive urination
Cold tolerance
Heat intolerance
Excessive sweating
Health Promotion – Blood sugar check, healthy
diet, regular exercise
Review of Systems
Neurologic System
Blackouts
Seizures
Loss of memory
Mood swings
Hallucinations
Weakness
Numbness
Tingling
Tremors
Paralysis
Loss of coordination
Involuntary movements
Review of Systems
Cardiovascular System
Chest pain
Heart murmurs
Shortness of breath when lying flat (orthopnea)
DOE (Dyspnea on Exertion)
Palpitations
High blood pressure
Edema
Varicose veins
Past EKG or other heart tests

Health Promotion – BP check, serum cholesterol test,

healthy diet, regular exercise
Review of Systems
Pulmonary System
Cough
Sputum production (color, quantity)
Bloody sputum
Shortness of breath
Painful breathing
Asthma
Wheezing
Emphysema
Review of Systems

Pulmonary System
Tuberculosis
Pneumonia
Bronchitis

Health Promotion – pneumococcal and

influenza vaccines; smoking cessation
Review of Systems
Gastrointestinal System
Changes in stool color, consistency, or frequency
Heartburn
Loss of appetite
Food intolerances
Trouble/Painful swallowing
Abdominal pain
Rectal bleeding
Review of Systems
Gastrointestinal System
Nausea, vomiting
Blood in vomit
Constipation
Diarrhea
Fecal incontinence
Black tarry stools
Hemorrhoids
Liver or GB trouble
Hepatitis
Health Promotion – Colorectal Cancer Screening
Review of Systems
Genitourinary System
Painful urination
Excessive urination
Diminished urination
Hesitancy
Cloudy or darkened urine
Pain in flank
Pain above groin
Urinary incontinence
Blood in urine
Urinary infections
Stones
Health Promotion – Prostate Cancer Screening
Review of Systems
Male Reproductive System
Penile or testicular pain
Penile lesion
Penile discharge
Impotence
Health Promotion – Monthly genital and
testicular self-examination: 15 years and older
Review of Systems
Female Reproductive System
Date of last menstrual period
Possible pregnancy
Breast lumps
Vaginal discharge
Vaginal itching
Labial lesions
Menstrual cramps
Review of Systems
Female Reproductive System
Lack of menstruation
Postmenopausal symptoms
Premenopausal symptoms
Sexual difficulties
Health Promotion – Breast self-exam (BSE),
mammogram, gynecological checkup,
Papanicolaou test
Review of Systems
Psychological Status
Anxiety
Irritability
Apathy
Mood swings
Depression
Sleep disturbances
Suicidal thoughts
Concluding the Health
History
Review findings
Ask more questions (if necessary), to clarify
conflicting or ambiguous information
“What do you think the problem is?”
“What concerns you most right now?”
Thank patient for the time and cooperation
Assessment data are recorded in clear, concise
manner using appropriate terminology.