The Health History

1. The Health History Mrs.Mahdia Samaha Kony

2. Purpose of the Health History • Provide the subjective database. • Identify patient strengths. • Identify patient health problems, both actual and potential. • Identify supports. • Identify teaching needs. • Identify discharge needs. • Identify referral needs. Mrs.Mahdia Samaha Kony

3. Types of Health Histories A complete health history includes • Biographical data • Reason for seeking care • Current health status • Past health status • Family history • A detailed review of systems • A psychosocial profile. A focused health history focuses on an acute problem, so all of your questions will relate to that problem. Mrs.Mahdia Samaha Kony

4. Focused versus Comprehensive History • Deciding which type of health history to do depends on two factors: • Your patient’s condition • The amount of time you have. Mrs.Mahdia Samaha Kony

5. Critical thinking • If you are working in the emergency department and John Harrison, a 49-year-old man, presents with acute chest pain • What questions would you ask him to assess his chest pain? Mrs.Mahdia Samaha Kony

6. Patient’s Condition • First, determine the condition of your patient. This condition may prohibit a detailed health history upon admission. • A comprehensive health history is not indicated. • Instead, you should obtain a focused history while you perform a physical assessment, draw laboratory studies, obtain an electrocardiogram, and connect your patient to a cardiac monitor. • Ask key questions that focus on the acute problem; once your patient’s condition stabilizes, obtain a more detailed health history. Mrs.Mahdia Samaha Kony

7. Critical thinking • What question(s) would you ask Mr. Harrison related to his past health history, family history, review of systems, and psychosocial profile? Mrs.Mahdia Samaha Kony

8. Amount of Time • Allot at least 30 minutes to an hour to obtain a complete health history. • Be sure to let your patient know why you are asking these questions and that it will take time. • If you do not have enough time to complete the history, do not rush. • Instead, perform a focused history first, and then complete the history at later sessions. Mrs.Mahdia Samaha Kony

9. Medical History versusNursing History Remember: • Physicians diagnose and treat illness. • Nurses diagnose and treat the patient’s response to a health problem. • The focus of the medical history is to identify what caused the problem • The history would also try to identify any preexisting medical problems • The physician will use the data that he or she obtains to develop a treatment plan for the fracture. Mrs.Mahdia Samaha Kony

10. Components of the Health History • Biographical Data: The biographical data provide you with: • Direct information related to a current health problem • Alert you to risk factors for health problems • Point out the need for referrals. • Your patient’s ability to provide biographical data accurately reflects his or her mental status. Mrs.Mahdia Samaha Kony

11. Biographical Data include : • the patient’s name • address • phone number • contact person • age/birth date • place of birth • Gender • Race • Religion • marital status • Educational level • occupation, • social security number • health insurance. • They also include the person who provided the history and her or his reliability Mrs.Mahdia Samaha Kony

12. Reason for Seeking Healthcare • Ask your patient why he or she is seeking healthcare; then document his or her direct quote. • The patient’s reason for seeking care is usually related to the level of preventive healthcare —primary, secondary,or tertiary. • If the setting is a primary level of healthcare, there is usually no acute problem. The reason generally relates to health maintenance or promotion. Mrs.Mahdia Samaha Kony

13. Current Health Status • At a primary level of healthcare (no acute problem), the current health status should include the following: ■ Usual state of health. ■ Any major health problems. ■ Usual patterns of healthcare. ■ Any health concerns. • Patients in secondary or tertiary healthcare settings have an existing problem. So you will need to perform a symptom analysis to assess your patient’s presenting symptoms thoroughly Mrs.Mahdia Samaha Kony

14. PQRST for symptom assesment • Precipitating/Palliative Factors • Ask:What were you doing when the problem started? • Does anything make it better, such as medications or certain positions? Does anything make it worse,such as movement or breathing? • ■ Quality/Quantity • Ask: Can you describe the symptom? What does it feel like, look like, or sound like? How often are you experiencing it? To what degree does this problem affect your ability to perform your usual daily activities? Mrs.Mahdia Samaha Kony

15. PQRST for symptom assesment • Region/Radiation/Related Symptoms • Ask: Can you point to where the problem is? Does it occur or spread any where else? (Take care not to lead your patient.) Do you have any other symptoms? • Severity • Ask: Is the symptom mild, moderate, or severe? • Grade it on a scale of 0 to 10, with 0 being no symptom and 10 being the most severe. • Timing • Ask: When did the symptom start? How often does it occur? How long does it last? Mrs.Mahdia Samaha Kony

16. Past Health History • It assesses childhood illnesses • Hospitalizations • Surgeries • serious injuries • adult medical problems (including serious or chronic illnesses) • Immunizations • Allergies • Medications • recent travel • and military service. Mrs.Mahdia Samaha Kony

17. The purpose of Past Health History • to identify any health factors from the past that may have a direct relationship to your patient’s current health status. • to identify any chronic preexisting health problems, such as diabetes or hypertension, which may directly affect the current health problem. • explain your patient’s response to illness, healthcare, and healthcare workers. Mrs.Mahdia Samaha Kony

18. Family History • It provide clues to genetically linked or familial diseases • Ask about the health status and ages of your patient’s family members. • Family members include: • the patient • Spouse • Children • Parents • Siblings aunts and uncles • grandparents. Mrs.Mahdia Samaha Kony

19. Family History Ask about: Genetically linked or common diseases, such as • heart disease • high blood pressure • Stroke • Diabetes • Cancer • Obesity bleeding disorders • Renal disease • Seizures • Mental disease. If the patient’s family members are deceased, record the age and cause of death. Mrs.Mahdia Samaha Kony

20. Mrs.Mahdia Samaha Kony

21. Review of Systems: purpose: • Obtain the current and past health status of each system • Identify health problems that your patient may have failed to mention previously. • Provides clues to health promotion activities for each particular system. • Identify health promotion activities and provide instruction as needed. Mrs.Mahdia Samaha Kony

22. Developmental Considerations • The last part of your health history is taking a psychosocial profile, but before you do this, consider the developmental stage of your patient. • Developmental assessments are often performed on children because the developmental changes that occur at this age are very observable and measurable. Yet adults also go through developmental changes that you need to consider during the assessment. • Illness and hospitalization can have a major impact on a child’s growth and development, by either halting its progression or regressing it to an earlier stage. Mrs.Mahdia Samaha Kony

23. Psychosocial Profile • This section focuses on: • health promotion • protective patterns • Roles • relationships. It includes questions about: • healthcare practices and beliefs • a description of a typical day • a nutritional assessment • activity and exercise patterns • recreational activities • sleep/rest patterns • personal habits • occupationalrisks • environmentalrisks, • family roles and relationships • stress and coping mechanisms. Mrs.Mahdia Samaha Kony

24. MEDICATION HISTORY • Do they take any prescription medicines? Dose and frequency? • Medication non-compliance/confusion • Side effect that they are experiencing, a reasonable fear that can be addressed Mrs.Mahdia Samaha Kony

25. ALLERGIES/ REACTIONS • Adverse reactions to medications? The exact nature of the reaction should be clearly identified as it can have important clinical implications. • Anaphylaxis, for example, is a life threatening reaction Mrs.Mahdia Samaha Kony

26. SMOKING HISTORY • Have they ever smoked cigarettes? • How many packs per day & for how many years? • If they quit, when did this occur? • Pipe, cigar and chewing tobacco use Mrs.Mahdia Samaha Kony

27. SEXUAL HISTORY • Your ability to determine on sight who is sexually active (and in what type of activity) is rather limited. • Do they participate in intercourse? With persons of the same or opposite sex? • Are they involved in a stable relationship? • Do they use condoms or other means of birth control? • Married? • Health of spouse? • Divorced? • Past sexually transmitted diseases? • Do they have children? If so, are they healthy? • Do they live with the patient? Mrs.Mahdia Samaha Kony

28. WORK/ HOBBIES • What sort of work does the patient do? • Have they always done the same thing? • Do they enjoy it? • If retired, what do they do to stay busy? • Any hobbies? • Participation in sports or other physical activity? Mrs.Mahdia Samaha Kony

29. SOCIAL HISTORY • Occupation and the last year of schooling • Home situation and significant others • Sources of stress • Important life experiences, such as military service, job history, financial situation, and retirement • Leisure activities; religious affiliation and spiritual beliefs; & (ADLs). • Lifestyle habits that promote health or create risk such as exercise and diet, usual daily food intake, dietary supplements or restrictions, and use of coffee, tea Mrs.Mahdia Samaha Kony