1. The document provides an overview of the nursing process and how it is used to assess patients. It describes the nursing process as dynamic, patient-centered, goal-directed, and holistic. 2. It discusses different types of health assessments including comprehensive assessments, focused assessments, and levels of preventive healthcare like primary, secondary, and tertiary prevention. 3. The document provides guidance on conducting health histories, including obtaining subjective and objective data, asking open and closed-ended questions, ensuring confidentiality, and documenting findings in an accurate and objective manner.

1. Health History
NUR 221; Fundamental (2) COURSE
Dr/ Magda Bayoumi

2. Introduction to the Health
Assessment
 How do you assess the patient?

3. Nursing process:

4. Characteristics of the Nursing
Process
 Dynamic and cyclic
■ Patient centered
■ Goal directed
■ Flexible
■ Problem oriented
■ Cognitive
■ Action oriented
■ Interpersonal
■ Holistic
■ Systematic

5. Communication
 is
a process of sharing information
and meaning, of sending and
receiving messages.

6. Collecting Data
 Subjective findings
 Objective data

7. Levels of Preventive
Healthcare
 Primary preventive care focuses on
health promotion and guards against
health problems.
 Secondary preventive care focuses on
early detection, prompt intervention, and
health maintenance for patients with
health problems.
 Tertiary preventive care deals with
rehabilitative or extended care.

8. Types of Assessment
 A comprehensive assessment
examines the patient’s overall health
status.
 A focused assessment is frequently
performed on an ongoing basis to
monitor and evaluate the patient’s
progress, interventions, and response to
treatments.

9. How You Communicate:
 Genuineness: Be open, honest,
and sincere with your patient.
 Respect: Everyone should be
respected as a person of worth
and value.
 Empathy: Empathy is knowing
what your patient means and
understanding how she or he
feels. Showing empathy

10. Interviews
When you use your interpersonal
skills in a healing way to help your
patient, this is known as
Therapeutic use of self.

11. Types of Interviews
 Directive interviews :
Are controlled by the nurse.
 Nondirective interviews :
Are controlled by the patient &
Nondirective interviews help you to
identify what is important to the patient.

12. Types of Questions
 Closed questions
Are often those that elicit a “yes” or “no”
.
 Open questions
Elicit the patient’s perceptions.

13. Interviewing Techniques
Introduce yourself.
■ Don’t rush. Allow enough time for the
interview.
■ Avoid interruptions.
■ Explain that information from the
interview is confidential.
■ Actively listen to what your patient is
saying.
■ Maintain eye contact.

14. Work at the same level as your patient.
Pull up a chair and sit next to her or
him.
■ Don’t invade your patient’s personal
space. Two to 4 feet away is a
comfortable distance for most
patients.
■ Explain what you are doing and why.
If the patient presents with a
problem, begin by asking questions
about that.
■ Begin with nonsensitive issues.
Leave more sensitive topics until

15. Consider your patient’s cultural
background. How does it affect the
interview and your interpretation of the
data?
■ Consider your patient’s developmental
level. How does it affect the interview
and your interpretation of the data?
■ Don’t become preoccupied with writing.
You may convey to the patient that the
forms you are completing are more
important than he or she is.
■ Be nonjudgmental.
■ Avoid “why?” questions; they tend to
put patients on the defensive.

16. Nonverbal behavior is more accurate than
verbal. Take a look at yours—What is
it telling your patient?
■ Take a good look at your patient’s
nonverbal behavior. Is it consistent with
what
she or he is telling you?
■ Now look at your patient’s nonverbal
behavior another way. Does it indicate
health problems?
■ Never pass up an opportunity to teach.
■ Present reality.
■ Be honest.
■ Provide reassurance and
encouragement.

17. Phases of the Interview
 IntroductoryPhase
 Working Phase
 Termination Phase

18. Documentation Methods
 problem-oriented medical records
(POMR.
 SOAPIE Method
 DAR Method
 PIE Method
 Narrative Method

19. The purpose of the health
history is to:
■ 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.

20. Types of Health Histories
 A CompleteHealth History
 Focused Health History

21. Critical Thinking activity
 Suppose you were caring for Mr.
H. What questions would you ask
him to assess his chest pain?

22. Critical Thinking activity
 What question(s) would you ask
Mr. H; related to his past health
history, family history, review of
systems, and psychosocial
profile?

23. Amount of Time
 Allow at least 30 minutes to an
hour to obtain a complete
health history

24. Medical History versus
Nursing History
 Physicians diagnose and treat
illness.
 Nurses diagnose and treat the
patient’s response to a health
problem.

25. Key Points to Remember
When Obtaining a Health
History
■ Listen to what your patient is telling you
both verbally and nonverbally.
■ Don’t rush. Allow enough time to obtain
the data.
■ Ensure confidentiality.
■ Provide a private, quiet, comfortable
environment.
■ Avoid interruptions.
■ Tell your patient how long the interview
will take and why you need to ask these
questions.

26. Do not be so concerned about
completing forms that you neglect the
patient.
■ Start with what the patient perceives
as the problem.
■ Use open-ended questions to elicit
the patient’s perspective.
■ Attend to any acute problems, such
as pain, before obtaining a detailed
history.
■ Remember that quality is more
important than the quantity of
information obtained.

27. Components of the Health
History
 Biographical Data.
 Reason for Seeking Healthcare.
 Current Health Status (PQRST).
 Past Health History
 Family History
 Review of Systems
 Developmental Considerations
 Psychosocial Profile

28. Documenting Your Findings
Be accurate and objective. Avoid stating
opinions that might bias the reader.
■ Do not write in complete sentences.
Be brief and to the point.
■ Use standard medical abbreviations.
■ Don’t use the word “normal.” It leaves
too much room for interpretation.
■ Record pertinent negatives.
■ Be sure to date and sign your
documentation

29. THANK YOU

30. Mrs Hesa at inpatient cardiac department, vital
signs taken early morning at 6 am and reported
client rates pain 7, substernal sharp chest pain
like electrical thrill along to neck, shoulder to
left arm increase with activity even
moving, immediately the nurse give her
nitroglycerin sublingual 3 tables through 15
min and then the pain relived and reported 2

31.  P: Precipitating factor: pain increase with
activity.
 P: Palliative factor: pain decreased with
medication (nitroglycerin).

 Q: Quality: sharp chest pain. like electrical
thrill
 R: Region & Radiation: chest; radiated to
neck, shoulder to left arm.
 S: Severity: 7 and decrease to 2 after
medication.
 T: Timing: 15 min