THESE SLIDES ARE PREPAREED TO UNDERSTAND about HEALTH ASSESSMENT- HISTORY TAKING IN EASY WAY Important links- NOTES- https://mynursingstudents.blogspot.com/ youtube channel https://www.youtube.com/c/MYSTUDENTSU... CHANEL PLAYLIST- ANATOMY AND PHYSIOLOGY-https://www.youtube.com/playlist?list=PL93S13oM2gAPM3VTGVUXIeswKJ3XGaD2p COMMUNITY HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPyslPNdIJoVjiXEDTVEDzs CHILD HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gANcslmv0DXg6BWmWN359Gvg FIRST AID- https://www.youtube.com/playlist?list=PL93S13oM2gAMvGqeqH2ZTklzFAZhOrvgP HCM- https://www.youtube.com/playlist?list=PL93S13oM2gAM7mZ1vZhQBHWbdLnLb-cH9 FUNDAMENTALS OF NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPFxu78NDLpGPaxEmK1fTao COMMUNICABLE DISEASES- https://www.youtube.com/playlist?list=PL93S13oM2gAOWo4IwNjLU_LCuhRN0ZLeb ENVIRONMENTAL HEALTH- https://www.youtube.com/playlist?list=PL93S13oM2gAPkI6LvfS8Zu1nm6mZi9FK6 MSN- https://www.youtube.com/playlist?list=PL93S13oM2gAOdyoHnDLAoR_o8M6ccqYBm HINDI ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAN4L-FJ3s_IEXgZCijGUA1A ENGLISH ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAMYv2a1hFcq4W1nBjTnRkHP facebook profile- https://www.facebook.com/suresh.kr.lrhs/ FACEBOOK PAGE- https://www.facebook.com/My-Student-S... facebook group NURSING NOTES- https://www.facebook.com/groups/24139... FOR MAKING EASY NOTES YOU CAN ALSO VISIT MY BLOG – BLOGGER- https://mynursingstudents.blogspot.com/ Instagram- https://www.instagram.com/mystudentsu... Twitter- https://twitter.com/student_system?s=08 #PEM,#historytaking,#communicablediseases,#ASSESSMENT, #APPEARENCE,#PULSE,#GRIMACE,#REFLEX,#RESPIRATION,#RESUSCITATION,#NEWBORN,#BABY,#VIRGINIA, #CHILD, #OXYGEN,#CYANOSIS,#OPTICNERVE, #SARACHNA,#MYSTUDENTSUPPORTSYSTEM, #rashes,#nursingclasses, #communityhealthnursing,#ANM, #GNM, #BSCNURING,#NURSINGSTUDENTS, #WHO,#NURSINGINSTITUTION,#COLLEGEOFNURSING,#nursingofficer,#COMMUNITYHEALTHOFFICE,#HEALTHPROBLEMS

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2.  A health assessment is a process to identify specific
health needs and level of health status of a person .
Basically health assessment involves two steps-
 History taking and
 Physical examination

3.  History taking is a part of health
assessment which involves asking specific
questions to the patient or the person who
know the patient and can give suitable
information. History taking is also known as
interviewing of patient.

4. • To establish rapport with the patient
• To establish or maintain nurse-patient relationship
for proper nursing care
• To obtain information useful for diagnosis
• To identify or clarify health problems

5. • To give information to the client or to
teach him or Her about health
• To counsel and/or assist the client in
finding solutions to problems

6.  Sit facing the client. Sitting suggests relaxation and
indicates that time will be allowed for the interview.
 Provide privacy, and attend to client’s comfort; for example,
supply pillows for support, a footstool, or a glass of water.

7.  Use simple language at first; increase complexity if
client is able to understand.
 Explain the purpose of the interview, how long it will
last, and how the information will be used.

8.  Use narrow questions to help the client focus, such as “Do
you have nausea with the vomiting?”
 Use open-ended questions such as “How do the headaches
begin?” to explore feelings and perceptions and to identify
areas requiring follow-up.

9.  look and listen carefully for clues,
both verbal and nonverbal.
Establish eye contact, avoid
answering for the client, and
explore clues in a nonthreatening
manner.

10.  Avoid interruptions and the appearance of being
distracted or bored, such as looking at the clock or
flipping pages in the record. Wait for answers. Silence
encourages thinking and often produces verbal
responses.

11.  Start history taking by collecting personal data such as
 Date of interview
 Name
 Gender
 Date of birth
 Place of birth
 Age

12.  Address
 Person to be contacted in an emergency (name,
relationship, address, phone number)
 Education
 Occupation (presently or before retirement)

13.  In this section we collect information about-
 Present problems
 Onset of problem
 Location of symptoms
 Chronology
 Precipitating factors

14.  Alleviating factors
 Aggravating factors
 Associated symptoms
 Treatments
 Client’s view of cause

15.  In this section we collect information about-
 Client’s perception of level of health in general
 Childhood illnesses (dates and types)
 Genogram (family history of diseases)
 Immunizations
 Allergies

16.  Serious accidents and/or injuries (dates)
 Major adult illnesses (types and dates)
 Behavioral problems
 Surgical procedures (types and dates)
 Other hospitalizations (types and dates)
 Environmental hazards

17.  Work: Type, length of time employed, stresses
 Rest and/or sleep: How much, when, aids
 Exercise and/or ambulation: How much, when
 Recreation, leisure, hobbies: Type, amount
 Nutrition: Time, foods, fluids, and amounts for all meals and
snacks; recent changes in appetite; special diet

18.  Alcohol and/or other drugs: Type, number of years used,
amount, perceived problems with level of use
 Tobacco: Type, number of years used, amount per day
 Urinary and bowel activity: Frequency, amount, problems
related to urinary and bowel activity

19.  Ambulating
 Dressing
 Grooming
 Bathing
 Toileting
 Eating
 Using the telephone
 Doing laundry
 Housekeeping
 Preparing food
 Driving
 Purchasing food

20.  The psychosocial history is important in any assessment that
considers a holistic view of the client, especially in a community
or long-term care setting. The psychosocial history involves the
client’s relationship to others such as family members, friends,
neighbors, colleagues at workplace and friends in social and
civic organizations in the community

21.  The psychosocial history includes-
 Significant stressors
 Coping ability
 Feelings about self: Self-concept, functional status,
adaptations, independence, body image, marital status etc.

22.  History of interpersonal trauma: Rape, incest, abuse as child
or spouse, other personal tragedies. Note ability to discuss,
current stage in resolution
 • Periods of grief and current status
 • Understanding of and feelings about current illness(es)

23.  The review of systems (sometimes called the review of
symptoms) helps the nurse to focus on each major system
major system of the body, noting from the health history
which systems may have special problems. This systematic
process prevents the omission of important assessment
information.

24.  It includes inquiry about
 General symptoms
 Integument (skin, hair, nails)
 Head
 Eyes
 Ears
 Nose and sinuses
 Mouth and throat
 Neck
 Lungs and thorax
 Breasts and axillae
 Cardiovascular system
 Abdomen

25.  • Musculoskeletal system
 • Male genitourinary system and rectum
 • Female genitourinary system and rectum
 • Neurologic
 • Adaptations in pregnancy

26.  This section includes history about-
 Interview all family members at the same time to observe
communication and decision-making patterns.
 Assess each family member’s health.
 Assess family’s health history


27.  family health history also includes family member’s ages at
death and causes of death.
 Note patterns of illness distribution across generations(for
example, cancer and heart disease).
 • Assess family structure: Single, nuclear, joint

28.  Ask whether there is anything else that the client
would like to tell or ask you. Assure the client that
information provided by him ill be kept confidential
and ill be used only for health care plan of him/her.

29. By – SURESH KUMAR ( Nursing Tutor )