3. Preparation of the equipment :
• Be sure that’s the equipment is in
good condition working well
• Clean well arranged according to use
• All infection control measures should
be taken under consideration
4. Preparation of physical environment:
• Clean wells furnished place
• Quiet
• Proper temperature
• Proper ventilation
• Proper humidity
• Proper light – natural and artificial
light may used
5. Preparation of Client:
• The nurse identify herself his to the client
• Explain the purpose for examination and
the procedures which may perform
• Explain the need for changing position during
examination asking the client if heshe has the
ability to do so
• Maintain the client privacy
• Provide the client with clean gown
6. Health history is the collection of
data regarding client’s health in a
chronological order.
7. COMPONENTS OF HEALTH HISTORY:
1. Biographical Information/ Base line data
2. Chief complaints
3. Present health history
4. Past health history
5. Family history
6. Personal history
7. Environmental history
8. Socio economic history
9. Psychological history
10.Review of systems
8. Health History
History Tacking
subjective data
Physical
Examination
Objective data
The nurse collects
- Physiological
- Psychological
- Socio-cultural
- Developmental
- Spiritual data
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9. Subjective data what the person says
about himself or herself.
Objective data what you observe through measurement,
inspection, palpation, percussion, and auscultation.
Types of data
10. • It should be performed on:
• All non-emergent
• New patients
• It include:
• all the component of health History.
Comprehensive
• It should be performed on:
• Emergency situation,
• patients under ongoing care.
• It include:
• Identification data
• Chief complaint and any
related family, social history.
• Problem oriented review
system
Focused
Types of health history
13. Use patient’s own words to describe reasons
for seeking care. (signs and symptoms)
Reason for seeking care
(chief complaint)
14. Present illness
Symptoms characteristics:
1. Location
2. Character or Quality
3. Quantity or Severity
4. Timing (Onset, Duration, Frequency)
5. Setting
6. Aggravating or Relieving Factors
7. Associated Factors
8. Patient’s Perception
15. Past history
Childhood Illnesses
Accidents or Injuries
Serious or Chronic Illnesses
Hospitalizations
Operations
Obstetric History (if female patient)
Immunizations
Last Examination Date
Allergies
Current Medications (Medication reconciliation)
16. Family history
An accurate family history highlights diseases and conditions
for which a particular patient may be at increased risk
This information is about,
• type of the family,
• number of members in the family, and
• their health status.
Ask about all disorders such as coronary heart disease, high
blood pressure, stroke, diabetes, obesity, blood disorders,
breast/ovarian cancer, colon cancer and sickle-cell anemia.
17. FAMILY TREE
• This is the diagrammatic representation of family
members.
• Three generation has to be denoted in the family
tree,
• Family tree is also known as genogram.
18.
19. Personal history
It includes client’s personal details such
as
• Dietary pattern
• Sleep pattern
• Elimination pattern
• Habits
• Bathing pattern
• Etc.
20. Environmental history
It includes client’s environmental details such
as,
• Type of the house
• Number of rooms
• Ventilation
• Water supply
• Power supply
• House drainage system
21. Socio economic history
It includes collecting data regarding
client’s
• Lifestyle
• Which class they belong
• What is the monthly or annual income
of the family
22. Psychological history
Here, We must see whether client is co-
operative with her/his
• Family
• Relatives
• Neighbors
• Friends
