11 Jan 2023

Learning Objectives:

At the end of this topic, students should be

able to:
STEPS OF HEALTH 1. State reasons for performing a health history
2. Discuss techniques for communicating
ASSESSMENT effectively during a health history assessment
3. Discuss essential steps in a complete health
history

DEFINITION Two Components of

the Health Assessment
HEALTH HISTORY
Health is a state of wellbeing. (WHO) • It is a collection of subjective data in detail
regarding client’s health in a chronological order.
Assessment is defined as a systematic ,
dynamic process by which the nurse PHYSICAL ASSESSMENT
through interaction with client, significant • A structured physical examination allows the
others and health care providers, collects nurse to obtain a complete assessment of the
and analyze data about the client. (ANA). patient. Observation/inspection, palpation,
percussion and auscultation are techniques used
to gather information.

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STEPS OF HEALTH Guidelines for Taking

ASSESSMENT Nursing History
A. COLLECTION OF SUBJECTIVE DATA – Private, comfortable, and quiet
THROUGH INTERVIEW AND HEALTH HISTORY environment.
– Allow the client to state problems and
B. COLLECTION OF OBJECTIVE DATA expectations for the interview.
– Orient the client the structure,
C. VALIDATION of DATA purposes, and expectations of the
history.
D. DOCUMENTATION of DATA

Guidelines for Taking Guidelines for Taking

Nursing History Nursing History
– Review information about past health
– Communicate and negotiate priorities
history before starting interview.
with the client
– Balance between allowing a client to
– Listen more than talk.
talk in an unstructured manner and
– Observe non verbal communications
the need to structure requested
e.g. "body language, voice tone, and
information.
appearance".
– Clarify the client's definitions (terms &
– Observe cues
descriptors)

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Guidelines for Taking Types of Nursing

Nursing History Health History
Complete health history: taken on
– Avoid yes or no question (when initial visits to health care facilities.
detailed information is desired).
– Write adequate notes for recording Interval health history: collect
– Record nursing health history soon information in visits following the
after interview. initial data base is collected.

Problem- focused health history:

collect data about a specific problem

COLLECTION OF SUBJECTIVE DATA THROUGH Biographical Data:

INTERVIEW AND HEALTH HISTORY This includes
 Full name
 Address and telephone numbers (permanent contact
of client)
 Birth date and birth place
6. Environmental History  Sex
1. Biographic Data
7. Current Health Information  Religion and race
2. Chief Complaint
8. Developmental Level  Marital status.
3. History of Present Illness
9. Psychosocial History  Social security number
4. Past Health History  Occupation (usual and present)
10. Current Living
5. Family Health History  Source of referral
Circumstances
 Usual source of healthcare
 Source and reliability of information
 Date of interview

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Chief Complaint:
 “Reason for Hospitalization”.
 It is a brief assessment of client’s problem
for which clients seeks medical care.
 It should be written in clients statement.

Examples of chief complaints:

- Chest pain for 3 days
- Swollen ankles for 2 weeks
- Fever and headache for 24 hours
- Pap smear needed
- Physical examination needed for camp

ANALYSIS OF SYMPTOMS PQRSTU

SYMPTOM ANALYSIS
PROVOCATIVE or PALLIATIVE
Use the PQRSTU
mnemonic device to fully
– First occurrence :What were you doing when you
explore your patient’s first experienced or noticed the symptom?
chief complaint. When – What to trigger it ? stress? Position?, activity?
you ask the questions, – What seems to cause it or make it worse? For a
you’ll encourage him to psychological symptom .
describe his symptoms – What relieves the symptom : change diet? Change
in greater detail.
position ? Take medication ? Being active?
– Aggravation: what makes the symptom worse?

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PQRSTU PQRSTU
SYMPTOM ANALYSIS SYMPTOM ANALYSIS
QUALITY Or QUANTITY REGION Or RADIATION
Quality:
How would you describe the symptom- how it Region :
feels, looks, or sounds? – Where does the symptom occur?

Quantity: Radiation :
– How much are you experiencing now? – Does it travel down your back or arm, up
– Is it so much that it prevents you from your neck or down your legs?
performing any activity?

P Q R S T SYMPTOM PQRSTU
ANALYSIS TIMING SYMPTOM ANALYSIS
SEVERITY SCALE Onset :
– On what date did the symptom first occur
Severity Type of onset :
– How bad is symptom at its worst? On a – How did the symptom start sudden? Gradually?
scale of 1-10, (10 being the worst). Frequency :
– How often do you experience the symptom ; hourly
Course ? Daily ? Weekly? monthly
– Does the symptom seem to be getting better, Duration :
getting worse? – How long does an episode of the symptom last

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PQRSTU History of Present Illness

SYMPTOM ANALYSIS
Gathering information relevant to the chief
complaint, and the client's problem, including
UNDERSTANDING
essential and relevant data, and self-medical
– How do you feel about the symptom?
treatment.
Do you have fears associated with it?
Begin with an open-ended question, e.g. “Tell me
more about your chest discomfort.”

Component of Present Illness Past Health History:

Purpose: to identify all major past health problems of the
• Introduction: "client's summary and usual client.
health". This includes:
• Investigation of symptoms: "onset, date, • Childhood illness e.g. history of rheumatic fever.
gradual or sudden, duration, frequency, • History of accidents and disabling injuries
location, quality, and alleviating or aggravating • History of hospitalization (time of admission, date,
admitting complaint, discharge diagnosis and follow up
factors".
care).
• Negative information. • History of operations "how and why this done“
• Relevant family information. • History of immunizations and allergies.
• Disability "affected the client's total life". • Physical examinations and diagnostic tests.

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Family Health History Environmental History

Purpose: to learn about the general health of the client's blood
relatives, spouse, and children and to identify any illness of Purpose:
environmental genetic, or familiar nature that might have
“To gather information about surroundings of
implications for the client's health problems.
• Family history of communicable diseases.
the client", including physical, psychological,
• Heredity factors associated with causes of some diseases. social environment, and presence of hazards,
• Strong family history of certain problems. pollutants and safety measures."
• Health of family members "maternal, parents, siblings, aunts,
uncles…etc.".
• Cause of death of the family members "immediate and
extended family".

Current Health Information Developmental Level

Purpose: to record major, current, health An account of how and when a person met
related information. developmental milestones, such as walking
• Allergies: environmental, ingestion, drug, and talking.
other.
• Habits "alcohol, tobacco, drug, caffeine“ For adults, information on social-emotional
• Medications taken regularly "by doctor or development may be included.
self-prescription
• Exercise patterns. Used primarily in the diagnosis of
• Sleep patterns (daily routine). developmental disorders.
• The pattern life (sedentary or active)

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Psychosocial History Current Living

Circumstances.
Includes:
How client and his family cope with disease These circumstances include marital
or stress, and how they responses to illness status, number of children, occupation,
and health. financial resources, and hobbies.

You can assess if there is psychological or

social problem and if it affects general health
of the client.

Factors Affecting The Collection of

REFERENCES
Subjective Data
Dillon, P.M. (2015). Nursing Health Assessment A
- Physical setting CRITICAL THINKING, CASE STUDIES
APPROACH. 2nd edition. F. A. Davis Company,
- Client’s Personality and Behavior Philadelphia, PA 19103

- Nurses Personality and Behavior Weber, Janet R (2017). Health Assessment in

Nursing, 6th Edition. Lippincott Williams &
- Communication Skill Wilkins
- Patient’s Problem

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