Health Assesment

The Comprehensive Health History Lecture

Overview

  • Lecture by Boford P. Borres, RN, LPT

  • Focus on collecting subjective data in health assessments.

Learning Objectives

  • Describe components of a comprehensive health history.

  • Identify medical terms from layman’s definitions.

  • Formulate relevant questions for information gathering.

  • Complete a health history based on case scenarios.

Comprehensive Health History Components

Main Components

  1. Biographic Data

    Source of History

    • Record who furnishes the information (e.g. the patient, relative or friend)

    • Judge how reliable the information seems and how willing he or she is to communicate.

    • Note any special circumstances, such as the use of an interpreter

  2. Reason for Seeking Care (Chief Complaint)

  3. Present Health/History of Present Illness

  4. Current Medications (Medication Reconciliation)

  5. Family History

  6. Review of Systems (ROS)

  7. Functional Assessment (Activities of Daily Living - ADLs)

Purpose of Health History

  • Collects subjective information—what the patient reports about themselves.

  • Combines subjective with objective data from physical exams and lab tests for a comprehensive database.

  • Provides a detailed overview of the patient's health history.

Detailed Components of Health History

Biographic Data

  • Patient's Name, Address, Phone, Email, Age, Birthdate, and Birthplace.

  • Gender, Marital Status, Race, Ethnic Origin, Occupation.

  • Language and Communication Needs (e.g., interpreter usage for non-English speaking patients).

Information Source

  • Identify who provides information (reliable sources and any use of interpreters).

  • Judge the reliability of the informant.

Reason for Seeking Care

  • Patient’s brief statement in their own words indicating the reason for the visit, e.g., "Chest pain for 2 hours."

  • Differentiate between signs (detectable by exam) and symptoms (subjective sensations by the patient).

Present Health or History of Present Illness

  • For well patients, a brief state of health.

  • For ill patients, a chronological account of events leading to care.

  • Summarize symptoms using critical characteristics:

    • Location

    • Quality/Character

    • Quantity/Severity

    • Timing (Onset, Duration, Frequency)

    • Setting

    • Aggravating/Relieving Factors

    • Associated Factors

    • Patient’s Perception

PQRSTU Approach

  1. P - Provocative/Palliative

  2. Q - Quality/Quantity

  3. R - Region/Radiation

  4. S - Severity Scale

  5. T - Timing

  6. U - Understanding Patient’s Perspective

Past Health History

  • Record all past health events including:

    • Childhood Illness (Measles, Mumps, Rubella, etc)

    • Accidents/Injuries

    • Serious/Chronic Illnesses

    • Hospitalizations

    • Operations

    • Obstetric History

    • Last Examination Date

    • Allergies

Current Medications

  • Document all medications (prescription and OTC) along with herbal remedies.

  • Note any potential interactions and ensure reconciliation against previous lists.

Family History

  • Explore family health info to identify genetic risks.

  • Use a pedigree or genogram to document family conditions such as heart diseases, diabetes, cancer, etc.


Review of Systems (ROS)

  • Conduct a head-to-toe assessment focusing on patient statements.

  • Document overall health (weight changes, fatigue, etc.) and specific systems (skin, respiratory, cardiovascular, etc.).

Specific Systems to Review:

  1. Skin

  2. Eyes

  3. Ears

  4. Respiratory

  5. Cardiovascular

  6. Gastrointestinal

  7. Musculoskeletal

  8. Neurologic

  9. Endocrine

Functional Assessment

Key Areas

  • Activities of Daily Living (ADLs)

  • Instrumental ADLs (IADLs)

  • Nutrition and Eating Habits

  • Social Relationships

  • Coping Mechanisms

  • Home Environment

Additional Considerations

Adolescent Health Assessment

  • Conduct interviews privately. Address sleep patterns, relationships, education, physical safety, substance use, and sexual health.

Pregnancy Health History

  • Include considerations related to age, prenatal status, labor and delivery, and maternal medical history.

Conclusion

  • A thorough health history is critical for accurate assessment and diagnosis in nursing practice. It requires sensitivity, attentiveness, and a structured approach.