Patient History collection

1. HEALTH ASSESSMENT
History Collection
Mrs. Melba Sahaya Sweety. D
M.Sc Nursing
Pediatric Speciality
GIMSAR

2. Health is a state of complete
Physical, Mental and social well
being and not merely the absence
of disease and infirmity.
WHO
DEFINITION OF HEALTH

3. PURPOSE OF HEALTH
ASSESSMENT
To collect data about Physical, Mental,
and Social well-being of client.
To Identify the problem in early stage.
Supplement, confirm, or refute
subjective data obtained in the nursing
history.
Identify and confirm nursing diagnosis.
cont………

4. PURPOSE OF HEALTH
ASSESSMENT
Make Clinical decisions about a
patient’s changing health status and
management.
Evaluate the outcome of care.
To Alleviate the complications.
To Contribute in Medical Research

5. PROCESS OF HEALTH
ASSESSMENT
HEALTH HISTORY

6. Definition of Health History
Systematic collection of
subjective data which stated
with client, and objective data
which observed by the nurse.

7. Purposes of Health History
To gather Subjective Data from clients.
To develop Nursing Diagnosis
To Meet client’s expectation for health.
To plan actions for
 Promoting health
 Preventing disease
 Alleviating Acute problem
 Minimize chronic health problems.

8. Phases of taking health history
Two phases:-
The interview phase
The recording phase

9. Guidelines for Taking Nursing
History
Private, comfortable, and quiet
environment.
Allow the client to state problems
and expectations for the interview.
Orient the client the structure,
purposes, and expectations of the
history.

10. Guidelines for Taking Nursing
History cont..
Communicate and negotiate
priorities with the client
Listen more than talk.
Observe non verbal
communications e.g. "body
language, voice tone, and
appearance".

11. Guidelines for Taking Nursing
History cont..
Review information about past health
history before starting interview.
Balance between allowing a client to
talk in an unstructured manner and the
need to structure requested
information.
Clarify the client's definitions (terms &
descriptors)

12. Types of Nursing Health
History
Complete health history: taken on initial
visits to health care facilities.
Interval health history: collect information
in visits following the initial data base is
collected.
Problem- focused health history: collect
data about a specific problem

13. Components of Health
History
1- Biographical Data: This
includes
Full name :
Age :
Sex :
Religion and race.
Address and telephone number :
Marital Status :
Education :
Occupation :

14. Biographical Data Cont…….
Name of the Ward :
Bed number / IP no :
Source of referral.
Date of Admission :
Provisional Diagnosis :
Confirmatory Diagnosis :
Name of the Surgery :
Date of the Surgery :
Number of Post Operative Days :

15. 2- Chief Complaint: “Reason
For Hospitalization”.
It should be written in client’s statement
Write problem in chronological order
Ask client to indicate the priority of
complaints
Examples of chief complaints:
Chest pain for 3 days.
Swollen ankles for 2 weeks.
Fever and headache for 24 hours.
General Weakness for 30 days

16. 3-History of present illness
Gathering information relevant to the chief
complaint, and the client's problem,
including essential and relevant data, and
self medical treatment.
Elaborate the present chief complaints in
chronological order . It should include
Location, Quality, Chronology, Setting,
Exaggerating and Relieving factors,
Associated symptoms, effect on sleep, daily
activities.

17. Component of Present Illness
Introduction: "client's summary and usual
health".
Investigation of symptoms: "onset, date,
gradual or sudden, duration, frequency,
location, quality, and alleviating or
aggravating factors".
Location : In which area of head ,
Headache occurs.

18. Component of Present Illness
cont….
Quality : Whether the onset is sudden,
gradual. Whether the pain is slabbing, dull ,
throbbing, aching etc…. Is pain intermittent
or continuous ?
Chronology: When these Symptoms
start, how frequently they occur.
Setting : where were you when
symptoms appears eg.. Home, hospital, job
etc…..

19. Component of Present Illness
cont….
Associated Symptoms : Does
symptoms disturb other body area:
Appetite, Sleep pattern, Weakness, Body
ache.
Exaggerating Factors : Does these
symptoms occurrence is linked with
activity such as smoking, speaking loudly,
eating, climbing, change in body position.

20. Component of Present Illness
cont….
Relieving factors : How the
symptoms subside by taking rest
medication eating, home remedies,
meditation etc….

21. 4- Past Health History:
The purpose: (to identify all major past
health problems of the client)
This includes:
Childhood illness e.g. history of
rheumatic fever.
History of accidents and disabling
injuries

22. Past Health History. Cont…
History of hospitalization (time of
admission, date, admitting complaint,
discharge diagnosis and follow up care.
History of operations "how and why this
done"
History of immunizations and allergies.
Physical examinations and diagnostic
tests.

23. 5 -Family History
It includes collecting data about the family
profile .
Name of the family members
Age /Sex of the family members
Education of the family members
Occupation of the family members
Marital Status of the family members
Health status of the family members

24. 6 - Family Medical History
Gather information regarding Family
health history of any Consanguineous
marriage, Congenital anomalies,
Communicable diseases, Hereditary
diseases, and Psychiatric illnesses in
their family.

25. 7-Menstrual History
[ Female ]
Age of Menarche
Regular / irregular menstrual cycle.
LMP, Duration of Menses, Cycle
length
Dysmenorrhea, time, duration of
pain in relation to mensus.

26. 8 -Obstetrical history
[ Female]
Age of Marriages
Gravid, Parity, Abortions
(Spontaneous / induced, Duration
of pregnancy)
Still birth ( Causes of Death )
Live birth

27. 9-Occupational history
Collecting data regarding
client’s occupation, life style in
job, designation, location of
work , exposure to hazardous
material, residing near mines,
farms, factories or shipyard.

28. Collect data regarding
Dietary pattern ( vegetarian or non-
vegetarian), and any restriction in food.
Sleeping hours (any sleeping problem )
Bowel and Bladder habits
Hobbies
Any Bad Habits like substance abuse,
smoking, alcoholism
10- Personal history

29. Personal history cont…..
Relationship with others (
Neighbours, family, schooling,
and working area).
Any allergies ( Food or
Medication )

30. 11-Socio-ecnomic
history
It includes ;-
Bread winner of the family, Monthly income
Types of family ( joint family or nuclear
family)
Types of House ( Pucca or Kacha )
Environmental sanitation
Drainage system
Toilet facility
Water and electricity facility

31. THANK U