Chapter 4

Health History

comprehensive health assessment

assessing a patients full health history and status; including past and current health issues, history of present illness, family history, a review of body systems, and health patterns, identifying data, and date and time

health patterns

assess self perception, values and beliefs, activity and exercise, sleep and rest, role and relationship, and coping with stress

past history

allergies, medications (note route, time, frequency, dose), childhood and adult illnesses, health maintenance

adult illnesses

medical (chronic or genetic illnesses such as diabetes, hypertension, etc.)

surgical (type of operation and date)

accidents (type, date, treatment, residual disability)

psychiatric (illness and time frame, hospitalizations, treatments)

health maitenance

immunizations, screening tests, safety measures, risk factors (tobacco, environmental hazards, substance abuse, alcohol)

identifying data

age, DOB, gender, occupation, marital/relationship status, education level, primary language

review of systems

presence or absence of common symptoms related to each body system

systems to review during history taking

general (weight, fatigue, fever)

skin (rashes, lumps, sores, itching, dryness, moles)

H - head → headache, dizziness

E - eyes → vision, glasses, redness, specks, flashing, double vision, tearing

E - ears → hearing, tinnitus, infection, discharge, hearing aids

N - nose → frequent colds, stuffiness, nosebleeds

T - throat → condition of teeth and gums, dentures, sore tongue or throat

neck (glands, lumps)

breasts ( lumps, pain)

respiratory (cough, sputum, wheezing, asthma, bronchitis)

cardio (HTN, dyspnea, edema, EEGs)

gastro (trouble swallowing, nausea, bowel movements, hemorrhoids, abd pain, jaundice)

peripheral vascular (muscle pain, varicose veins, swelling in calves)

urinary ( frequency of urination, polyuria, nocturia, incontinence)

reproductive (sexual habits, menopause, pregnancies, HIV infection)

history of present illness

seven attributes of each principal symptom (OLDCART)

self treatment for the symptom by patient or family (any meds taken and results)

past occurrence of the symptom

pertinent positives/negatives from the review of systems (symptoms related to the system)

risk factors or other pertinent information related to the symptom (ex. coronary heart disease in patient with chest pain)

focused assessment

assessing a particular concern or symptom; assesses symptoms restricted to a certain body system

follow-up history

a form of focused assessment where the patient is returning after treatment and the nurse is evaluating if treatment was successful

emergency history

assessment is based on patients emergent problem with systematic prioritization of need based on patients presentation (ex. ABCs)

alcohol and drugs

misuse of these often contributes to symptoms; may go undiagnosed, should routinely ask about use and family history, assess adults and adolescents

illicit drugs

ask about drugs used for purposes other than medical; ask about patterns and modes of consumption that correlate with substance abuse

sensitive topics

sexual history, mental health history, family violence