= Health Assessment. Definition of Health History health history defined as the systematic collection of subjective data which stated with client, and.

==

Health AssessmentHealth Assessment

Definition of Health HistoryDefinition of Health History

health history defined as the health history defined as the systematic collection of systematic collection of subjective data which stated with subjective data which stated with client, and objective data which client, and objective data which observed by the nurse or observed by the nurse or midwife.midwife.

Phases of taking health historyPhases of taking health history

It takes two phases:-It takes two phases:-

The interview phaseThe interview phase

The recording phase The recording phase

Guidelines for Taking health HistoryGuidelines for Taking health History

Establish private, comfortable, and quiet Establish private, comfortable, and quiet environment.environment.

Allow the client to state problems and expectations Allow the client to state problems and expectations for the interview.for the interview.

Provide the client with an orientation to the structure, Provide the client with an orientation to the structure, purposes, and expectations of the history.purposes, and expectations of the history.

Communicate and allow priorities with the client.Communicate and allow priorities with the client.

Listen more than you talk.Listen more than you talk.

Observe non verbal communications e.g. "body Observe non verbal communications e.g. "body language, voice tone, and appearance".language, voice tone, and appearance".

review information before starting interview.review information before starting interview.

Clarify& rationalize the client condition .Clarify& rationalize the client condition .Avoid questions that can be answered as yes or noAvoid questions that can be answered as yes or noRecord the health history as soon as possible after the Record the health history as soon as possible after the interview. interview.

Types of AssessmentTypes of Assessment • • Initial comprehensive assessmentInitial comprehensive assessment • • Ongoing or partial assessmentOngoing or partial assessment • • Focused or problem-oriented Focused or problem-oriented

assessmentassessment • • Emergency assessmentEmergency assessment • • Time-lapsed assessmentTime-lapsed assessment

Types of Health History Types of Health History

A complete health history : This is taken A complete health history : This is taken on initial visits to health care facilities.on initial visits to health care facilities.

partial :An interval health history used to partial :An interval health history used to collect information in visits following the collect information in visits following the one in which an initial data base is one in which an initial data base is collected.collected.

A problem- focused health history used to A problem- focused health history used to collect data about a specific problem collect data about a specific problem system or region. system or region.

Sources of DataSources of Data • • Primary source:Primary source: – – data directly gathered from the data directly gathered from the

client usingclient using interview and physical examination.interview and physical examination.

Sources of DataSources of Data • • Secondary source:Secondary source: – – data gathered from client’s family data gathered from client’s family

members,members, significant others, client’s medicalsignificant others, client’s medical records/chart, other members of records/chart, other members of

health team,health team, and related care literature/journalsand related care literature/journals

Components of Health HistoryComponents of Health History

1-Biographical Data: This includes1-Biographical Data: This includesFull nameFull nameAddress and telephone numbers (client's permanent Address and telephone numbers (client's permanent contact of client) contact of client) Birth date and birth place. Birth date and birth place. Sex Sex Religion and race.Religion and race.Marital status.Marital status.Social security number.Social security number.Occupation (usual and present)Occupation (usual and present)Source of referral. Source of referral. Usual source of healthcare.Usual source of healthcare.Source and reliability of information.Source and reliability of information.Date of interview.Date of interview.

2- 2- Chief Complaint: “Reason For Chief Complaint: “Reason For Hospitalization”.Hospitalization”.

The following are examples of The following are examples of adequately stated chief complaints:adequately stated chief complaints:

Chest pain for 3 days.Chest pain for 3 days.

Swollen ankles for 2 weeks.Swollen ankles for 2 weeks.

Fever and headache for 24 hours.Fever and headache for 24 hours.

3-History of present illness3-History of present illness

Gathering information relevant Gathering information relevant to the chief complaint, and the to the chief complaint, and the Onset of client's problem,.Onset of client's problem,.

Component of Present IllnessComponent of Present Illness

Introduction: "client's summary and usual Introduction: "client's summary and usual health".health".

Investigation of symptoms: "onset, date, Investigation of symptoms: "onset, date, gradual or sudden, duration, precipitating gradual or sudden, duration, precipitating factors, frequency, location, quality, and factors, frequency, location, quality, and alleviating or aggravating factors".alleviating or aggravating factors".

Relevant family information.Relevant family information.

Disability system "affected the client's total Disability system "affected the client's total life".life".

4- 4- Past Health History:Past Health History:

The purpose of the past history is The purpose of the past history is to identify all major past health to identify all major past health problems of the client. This problems of the client. This includes.includes.Childhood illness e.g. history of Childhood illness e.g. history of rheumatic fever.rheumatic fever.History of accidents and disabling History of accidents and disabling injuries regard less he was injuries regard less he was hospitalized or not.hospitalized or not.

Past Health History. Cont…Past Health History. Cont…

History of hospitalization includes time History of hospitalization includes time of admission and date of it with admitting of admission and date of it with admitting diagnosis and the follow up care.diagnosis and the follow up care.

History of operations "how and why this History of operations "how and why this done"done"

History of immunizations and allergies.History of immunizations and allergies.

Physical examinations and diagnostic Physical examinations and diagnostic tests.tests.

5-Family History5-Family History

The purpose of the family history is to learn The purpose of the family history is to learn about the general health of the client's about the general health of the client's blood relatives, spouse, and children and blood relatives, spouse, and children and to identify any illness of environmental to identify any illness of environmental genetic, or familiar nature that might have genetic, or familiar nature that might have implications for the client's current or implications for the client's current or future health problems and needs or to future health problems and needs or to their solution. their solution.

Family History. Cont…Family History. Cont…

Family history of communicable diseases.Family history of communicable diseases.

Heredity factorsHeredity factors

Strong family history of certain problems.Strong family history of certain problems.

Health of family members "maternal, parents, Health of family members "maternal, parents, siblings, aunts, uncles, spouse and children".siblings, aunts, uncles, spouse and children".

Cause of death of the family membersCause of death of the family members

6-Environmental History:6-Environmental History:

purposepurpose

"to gather information about "to gather information about surroundings of the client", surroundings of the client", including physical, psychological, including physical, psychological, social environment, and presence of social environment, and presence of hazards, pollutants and safety hazards, pollutants and safety measures."measures."

7- Current Health Information 7- Current Health Information

Allergies: environmental, ingestion, drug, other.Allergies: environmental, ingestion, drug, other.Habits "alcohol, tobacco, drug, caffeine"Habits "alcohol, tobacco, drug, caffeine"Medications taken regularly "by doctor or self Medications taken regularly "by doctor or self prescriptionprescriptionExercise patterns.Exercise patterns.Sleep patterns.Sleep patterns.The pattern of sedentary and active activities in the The pattern of sedentary and active activities in the client'sclient'sUsual routine is explored. A weekly pattern of Usual routine is explored. A weekly pattern of activity is recorded. The client's sleep pattern is activity is recorded. The client's sleep pattern is explored and usual daily routine is recorded.explored and usual daily routine is recorded.

8- Psychosocial History8- Psychosocial History::

Which includes :Which includes :

How client and his family cope with How client and his family cope with disease or stress, and how they responses disease or stress, and how they responses to illness and health.to illness and health.

The nurse or midwife can assess if there The nurse or midwife can assess if there is psychological or social problem and if is psychological or social problem and if it affects general health of the client.it affects general health of the client.

9- Review of Systems (ROS)9- Review of Systems (ROS)

This includes a collection of data about This includes a collection of data about the past and the present of each of the the past and the present of each of the client systems. This review of the client systems. This review of the client’s physical, sociologic, and client’s physical, sociologic, and psychological health status may psychological health status may identify hidden problems and identify hidden problems and provides an opportunity to indicate provides an opportunity to indicate client strengthclient strength

Physical SPhysical SystemsystemsWhich includes assessment of:-Which includes assessment of:-

General review of skin, hair, head, face, eyes, ears, General review of skin, hair, head, face, eyes, ears, noise, sinuses, mouth, throat, neck nodes and breasts.noise, sinuses, mouth, throat, neck nodes and breasts.Assessment of respiratory and cardiovascular system.Assessment of respiratory and cardiovascular system.Assessment of gastrointestinal system.Assessment of gastrointestinal system.Assessment of urinary system.Assessment of urinary system.Assessment of genital system.Assessment of genital system.Assessment of extremities and musculoskeletal Assessment of extremities and musculoskeletal system.system.Assessment of endocrine system.Assessment of endocrine system.Assessment of heamatoboitic system.Assessment of heamatoboitic system.Assessment of social system.Assessment of social system.Assessment of psychological systemAssessment of psychological system..

11- Assessment of Interpersonal Factors.11- Assessment of Interpersonal Factors.

This includes :-This includes :-

Ethnic and cultural backgroundEthnic and cultural backgroundLife style e.g. rest and sleep patternLife style e.g. rest and sleep patternSelf concept perception of strengthSelf concept perception of strengthSexuality developmental level and concernsSexuality developmental level and concernsStress response copping pattern, support Stress response copping pattern, support system.system.

Subjective Data:Subjective Data:

Describe your illness or current health Describe your illness or current health problem.problem.How has this affected your normal daily How has this affected your normal daily activities?activities?How do you feel your current daily How do you feel your current daily activities have affected your Health What activities have affected your Health What do you feel caused your illness?do you feel caused your illness?How do you feel your illness should be How do you feel your illness should be treated?treated?

Pain AssessmentPain AssessmentDescribe any pain you have now.Describe any pain you have now.What brings it on? What relieves it?What brings it on? What relieves it?When does it occur? How often? How long When does it occur? How often? How long does it last?does it last?What else do you feel when you have this What else do you feel when you have this pain?pain?Rate your pain on a scale of 1 to 10, with 10 Rate your pain on a scale of 1 to 10, with 10 being the most severe Pain.being the most severe Pain.How has your pain affected your activities of How has your pain affected your activities of daily living?daily living?

Exam of the SkinExam of the Skin

Examine the patient in good lighting Examine the patient in good lighting Inspect and palpate skin for the following: Inspect and palpate skin for the following:

• ColorColor• Texture Texture • TurgorTurgor• Moisture Moisture

Abnormal FindingsAbnormal Findings

ColorColor • Pallor:Pallor:

Iron def. anemiaIron def. anemia• Yellow:Yellow:

JaundiceJaundice CarotenemiaCarotenemia HemolysisHemolysis

• Red:Red: ErythrodermaErythroderma

TextureTexture

• Soft: Soft: (Thyrotoxicosis) (Thyrotoxicosis) • Tight:Tight: (Scleroderma) (Scleroderma) • RoughRough: (Hypothyroidism) : (Hypothyroidism)

MoistureMoisture

• Dry:Dry: (Vitamin A def, Myxedema) (Vitamin A def, Myxedema) • Oily:Oily: (Acne) (Acne)

TurgorTurgor

• Decreased:Decreased: (Dehydration) (Dehydration) Warmth:Warmth:

• Generalized warmthGeneralized warmth: (Fever, : (Fever, Hyperthyroidism) Hyperthyroidism)

• Localized warmthLocalized warmth: (Inflammation) : (Inflammation) • Coolness:Coolness: (Hypothyroidism, Frostbite, (Hypothyroidism, Frostbite,

Hypothermia, Shock, Low cardiac outputHypothermia, Shock, Low cardiac output