Cinderella Lanka A.

de Castro April 30, 2010

Ateneo de Zamboanga University NHA 111-D

COLLECTING DATA

EALTH HISTORY:
o Collecting and documenting subjective data through interview process
o is important as a groundwork for identifying nursing problems and
provides a focus for the physical examination.
o Identify areas of strength and limitation in the individual’s lifestyle and
current health status.
o Taking a health history should begin with an explanation to the client of why the
information is being requested

The health history has eight sections:

o Biographic data
o Reasons for seeking health care
o History of present health concern
o Family health history
o Review of body systems for current health problems
o Lifestyle and health practices profile
o Developmental level

Components of nursing health History

A. BIOGRAPHICAL DATA- includes client’s name, address, age, sex, marital status, occupation, religious
preference, health care financing, and usual source of medical care.

B. CHIEF COMPLAINTS- the answer given to the question “what is troubling you?” or “can you tell me
the reason you came to the hospital or clinic today?” The chief complaint should be recorded in the
client’s own words.

C. PRESENT HEALTH HISTORY

o When the symptoms started

o Whether the onset of symptoms was sudden or gradual
o How often the problem occurs
o Exact location of the distress
o Character of the complaint (e.g., intensity of pain or quality of sputum, emesis, or discharge)
o Activity in which the client was involved when the problem occurred
 o Phenomena or symptoms associated with the chief complaint
o Factors that aggravate or alleviate the problem

D. PAST HEALTH HISTORY

o Childhood Illnesses, such as chickenpox, mumps, measles, rubella (German measles), rubeola
(red measles), streptococcal infections, scarlet fever, rheumatic fever, and other significant
illnesses
o Childhood immunizations and the date of the last tetanus shot
o Allergies to drugs, animals, insects, or other environmental agents, the type of reaction that
occurs, and how the reaction is treated
o Accidents and injuries: how, when and where the incident occurred, type of injury, treatment
received, and any complications
o Hospitalization for serious illnesses: reasons for the hospitalization, dates, surgery performed,
course of recovery, and any complications
o Medications: all currently used prescription and over-the-counter medications, such as aspirin,
nasal spray, vitamins, or laxatives.

E. FAMILY HEALTH HISTORY

o To ascertain risk factors for certain diseases, the ages of siblings, parents, and grandparents and
their current state of health, or, if they are deceased, the cause of death are obtained. Particular
attention should be given to disorders such as heart diseases, cancer, diabetes, hypertension,
obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism, and any mental health disorders.

F. SOCIAL HEALTH HISTORY

o Family relationships/friendships: The client’s support system in times of stress ( who helps in
time of need), what effect the client’s illness has on the family, and whether any family
problems are affecting the client.
o Ethnic Affiliation: Health customs and beliefs, cultural practices that may affect health care and
recovery.
o Educational history; Data about the client’s highest level of education attained and any past
difficulties with learning.
o Occupational History: Current employment status, the number of days missed from work
because of illness, any history of accidents on the job, any occupational hazards with a
potential for future disease or accidents, the client’s need to change jobs because of past
illness, the employees status of spouses or partners and the way the child care is handled, and
the client’s overall satisfaction with the work.
o Economic Status: Information about how the client is paying for medical care(including what
kind of medical and hospitalization coverage the client has), and whether the client’s illness
presents financial concerns.
 o Home and neighborhood conditions: Home safety measures and adjustments in physical
facilities that may be required to help the client manage a physical disability, activity
intolerance, and activities of daily living; the availability of neighborhood and community
services to meet the client’s needs.

G. PSYCHOLOGIC DATA

o Major stressors experienced and the client’s perception of them

o Usual coping pattern with a serious problem or a high level of stress
o Communication style: ability to verbalize appropriate emotion, non-verbal communication, such
as eye movements, gestures, use of touch, and posture; interactions with support persons, and
the congruence of nonverbal behavior and verbal expression.

G. ACTIVITIES OF DAILY LIVING AND LIFESTYLE

o Activities of daily living (ADLs): any difficulties experienced in the basic activities of eating,
grooming, dressing, elimination and locomotion.
o Personal habits; the amount, frequency and duration of substance use (tobacco, alcohol, coffee,
sola, tea and illicit or recreational drugs)
o Diet: description of a typical diet on a normal day or any special diet, number of meals and
snacks per day, who cooks and shops for food, ethnically distinct food patterns, and allergies.
o Sleep/rest patters: usual daily sleep/wake times, difficulties sleeping and remedies used for
difficulties.
o Instrumental activities of daily living; any difficulties experienced in food preparation, shopping,
transportation, housekeeping, laundry, and ability to use the telephone, handle finances and
manage medications.
o Recreation/Hobbies: exercise activity and tolerance, hobbies and other interests and vacations.

H. REVIEW OF SYSTEMS

The following list illustrates the content of a complete review of systems.

General/Constitutional

Average weight, weight loss or gain, general state of health, sense of well-being, strength, ability
to conduct usual activities, exercise tolerance

Skin/Breast

Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growth or loss, nail
changes

Breast lumps, tenderness, swelling, nipple discharge

Eyes/Ears/Nose/Mouth/Throat

Headaches (location, time of onset, duration, precipitating factors), vertigo, lightheadedness,

injury

Vision, double vision, tearing, blind spots, pain

Nose bleeding, colds, obstruction, discharge

Dental difficulties, gingival bleeding, dentures

Neck stiffness, pain, tenderness, masses in thyroid or other areas

Cardiovascular

Precordial pain, substernal distress, palpitations, syncope, dyspnea on exertion, orthopnea,

nocturnal paroxysmal dyspnea, edema, cyanosis, hypertension, heart murmurs, varicosities,
phlebitis, claudication

Respiratory

Pain (location, quality, relation to respiration), shortness of breath, wheezing, stridor, cough
(time of day, of productive, amount in tablespoons or cups per day and color of sputum),
hemoptysis, respiratory infections, tuberculosis (or exposure to tuberculosis), fever or night
sweats

Gastrointestinal

Appetite, dysphagia, indigestion, food idiosyncrasy, abdominal pain, heartburn, eructation,

nausea, vomiting, hematemesis, jaundice, constipation, or diarrhea, abnormal stools (clay-
colored, tarry, bloody, greasy, foul smelling), flatulence, hemorrhoids, recent changes in bowel
habits

Genitourinary

Urgency, frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or change in) color
of urine, stones, infections, nephritis, hesitancy, change in size of stream, dribbling, acute
retention or incontinence, libido, potency, genital stores, discharge, venereal disease

(Female) Age of onset of menses, regularity, last period, dysmenorrhea, menorrhagia, or

metrorrhagia, vaginal discharge, post-menopausal bleeding, dyspareunia, number and results of
pregnancies (gravida, para)

Musculoskeletal

Pain, swelling, redness or heat of muscles or joints, l;imitation, of motion, muscular weakness,
atrophy, cramps
Neurologic/Psychiatric

Convulsions, paralyses, tremor, incoordination, parathesias, difficulties with memory of speech,

sensory or motor disturbances, or muscular coordination (ataxia, tremor)

Predominant mood "nervousness" (define), emotional problems, anxiety, depression, previous

psychiatric care, unusual perceptions, hallucinations

Allergic/Immunologic/Lymphatic/Endocrine

Reactions to drugs, food, insects, skin rashs, trouble breathing

Anemia, bleeding tendency, previous transfusions and reactions, Rh incompatibility

Local or general lymph node enlargement or tenderness. -Polydipsia, polyuria, asthenia,

hormone therapy, growth, secondary sexual development, intolerance to heat or cold

Additional research:

A. PADC

B. ADL-

Activities of daily living (ADLs) is a term used in medicine and nursing, especially in the care of
the elderly.

ADLs are "the things we normally do in daily living, including any daily activity we perform for
self-care (such as feeding ourselves, bathing, dressing, grooming), work, homemaking, and
leisure." A number of national surveys collect data on the ADL status of the U.S. population.

Health professionals routinely refer to the ability or inability to perform ADLs as a measurement
of the functional status of a person. This measurement is useful for assessing the elderly, the
mentally ill, those with chronic diseases, and others, to evaluate what type of health care
services an individual may need. There are several evaluation tools, such as the Katz ADL scale
and the Lawton IADL scale.

Most models of health care service use ADL evaluations in their practice, including the medical
(or institutional) models, such as the Roper-Logan-Tierney model of nursing, and the resident-
centered models, such as the Program of All-Inclusive Care for the Elderly (PACE).

In the US, most medical insurance policies will not cover assistance with performing ADLs,
whereas such assistance is often covered by policies specific to long-term care.

Basic ADLs
The basic activities of daily living consist of these self-care tasks: [4]

 Personal hygiene
 Dressing and undressing
 Eating
 Transferring from bed to chair, and back
 Voluntarily controlling urinary and fecal discharge
 Elimination
 Moving around (as opposed to being bedridden)

Instrumental ADLs
Instrumental activities of daily living (IADLs) are not necessary for fundamental functioning, but
they let an individual live independently in a community:

 Doing light housework

 Preparing meals
 Taking medications
 Shopping for groceries or clothes
 Using the telephone
 Managing money
 Using technology (older generations may not be that technologically savvy since they
were not as exposed to it during their lifetime.)

Occupational therapists also evaluate IADLs when completing patient assessments. These
include 11 areas of IADLs that are generally optional in nature and can be delegated to others:

 Care of others (including selecting and supervising caregivers)

 Care of pets
 Child rearing
 Use of communication devices
 Community mobility
 Financial management
 Health management and maintenance
 Meal preparation and cleanup
 Safety procedures and emergency responses
 Shopping

C. KATS INDEX OF INDEPENDENCE

ACTIVITIES INDEPENDENCE:
Points (1 or 0) (1 POINT)

NO supervision, direction or personal

assistance

BATHING (1 POINT) Bathes self completely or

needs help in bathing only a single part
of the body such as the back, genital area
Points: -- or disabled extremity.

DRESSING (1 POINT) Gets clothes from closets and

drawers and puts on clothes and outer
garments complete with fasteners. May
Points: -- have help tying shoes.

TOILETING (1 POINT) Goes to toilet, gets on and off,

arranges clothes, cleans genital area
Points: -- without help.

TRANSFERRING (1 POINT) Moves in and out of bed or

chair unassisted. Mechanical transfer-
Points: -- ring aides are acceptable.

CONTINENCE (1 POINT) Exercises complete self con-

Points: -- trol over urination and defecation.

FEEDING (1 POINT) Gets food from plate into

mouth without help. Preparation of food
Points: -- may be done by another person.

ACTIVITIES DEPENDENCE:
Points (1 or 0) (0 POINTS)

WITH supervision, direction, personal

assistance or total care

BATHING (0 POINTS) Needs help with bathing

more than one part of the body, getting
in or out of the tub or shower. Requires
Points: -- total bathing.

DRESSING (0 POINTS) Needs help with dressing self

Points: -- or needs to be completely dressed.

TOILETING (0 POINTS) Needs help transferring to

the toilet, cleaning self or uses bedpan or
Points: -- commode.

TRANSFERRING (0 POINTS) Needs help in moving from

bed to chair or requires a complete
Points: -- transfer.

CONTINENCE (0 POINTS) Is partially or totally inconti-

Points: -- nent of bowel or bladder.

FEEDING (0 POINTS) Needs partial or total help

 with feeding or requires parenteral feed-
Points: -- ing.

TOTAL POINTS = -- 6 = High (patient independent)

0 = Low (patient very dependent)

Slightly adapted from Katz S., Down, T.D., Cash, H.R. et al. (1970)
Progress in the Development of the Index of ADL. Gerontologist
10:20-30. Copyright The Gerontological Society of America. Reproduced
by permission of the publisher.

D. BARTHEL INDEX

arthel Index serves as a measure of daily living activities in relation to personal care and mobility of the
patient. The instrument was developed for chronic patients and long-term hospital patients with
paralytic conditions, examining their performance before and after treatment. Barthel Index has been
used for such tasks as predicting time needed for rehabilitation and amount of nursing aid required. It
consists of 10 items that measure a person's daily functioning specifically the activities of daily
living and mobility. The items include feeding, moving from wheelchair to bed and return,
grooming, transferring to and from a toilet, bathing, walking on level surface, going up and
down stairs, dressing, continence of bowels and bladder.

How is the Barthel Index used?

The assessment can be used to determine a baseline level of functioning and can be used to
monitor improvement in activities of daily living over time. The items are weighted according to
a scheme developed by the authors. The person receives a score based on whether they have
received help while doing the task. The scores for each of the items are summed to create a
total score. The higher the score the more "independent" the person is. Independence means
that the person needs no assistance at any part of the task.   If a person does about 50%
independently then the "middle" score would apply.

In the United Kingdom quite frequently the 5, 10 and 15 scores are substituted by 1, 2, and 3. 
This gives a potential maximum of 20 rather than 100.

Example form:

Patient Name:  __________________   Rater: ____________________  Date:      /     /              :      

Activity Score

Feeding 0     5    10

 0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent

Bathing
0 = dependent 0        5
5 = independent (or in shower)

Grooming
0 = needs to help with personal care 0     5
5 = independent face/hair/teeth/shaving (implements provided)

Dressing
0 = dependent
0     5     10
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)

Bowels
0 = incontinent (or needs to be given enemas)
0     5    10
5 = occasional accident
10 = continent

Bladder
0 = incontinent, or catheterized and unable to manage alone
0     5    10
5 = occasional accident
10 = continent

Toilet Use
0 = dependent
0     5    10
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)

Transfers (bed to chair and back)

0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit 0      5    10    15
10 = minor help (verbal or physical)
15 = independent

Mobility (on level surfaces)

0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards 0      5    10    15
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards

Stairs
0 = unable
0     5     10
5 = needs help (verbal, physical, carrying aid)
10 = independent

TOTAL  (0 - 100) ________