L1_ Health History

The primary purpose of taking a health history is to provide a subjective database for assessment, identify patient strengths and health problems (both actual and potential), and establish a foundation for the nurse-patient relationship.

The two main types of health history are Complete Health History and Focused Health History.

A Complete Health History includes:

1. Biographical Data: Patient's name, age, birthdate, gender, birthplace, race/nationality, marital status, religion, address, educational attainment, occupation, contact person, health insurance/SSS.
2. Source of Health History: Reliability and referral information.
3. Past Health History: Childhood illnesses, surgeries, injuries, hospitalizations, adult medical problems, medications, allergies, immunizations, travel history.
4. Family History: Familial or genetically linked disorders.
5. Review of Systems: Comprehensive assessment of psychological status.
6. Psychological Profile: Health promotion, preventive patterns, and various lifestyle factors.

A health history contributes to patient care by:

• Providing a holistic, qualitative picture of the patient.
• Directing the physical assessment based on gathered information.
• Identifying teaching needs and discharge needs for effective patient management.

Factors assessed in a patient's psychological profile include:

• Health practices
• Health beliefs
• Nutritional pattern
• Activity or exercise pattern
• Recreational pattern
• Sleep or rest pattern
• Personal habits
• Occupational and environmental risk factors
• Socioeconomic status
• Developmental level
• Roles and relationships
• Self-concept
• Religious and cultural influences
• Support systems
• Sexuality patterns
• Emotional health status

A focused health history includes:

1. Biographical Data: Patient's name, age, birthdate, gender, birthplace, race/nationality, marital status, religion, address, educational attainment, occupation, contact person, health insurance/SSS.

2. Source of Health History: Reliability of the source and referral information.

3. Past Health History: Relevant diseases such as heart disease, hypertension, cancer, and alcoholism.

4. Review of Systems: Questions about each system related to the presenting health problem.

5. Psychological Profile: Impact of the presenting problem on the patient's life.

Key points include:

1. Listen: Pay attention to verbal and nonverbal cues.
2. Take Your Time: Don't rush the process.
3. Ensure Confidentiality: Maintain patient privacy.
4. Create a Comfortable Environment: Provide a private and quiet space.
5. Avoid Interruptions: Minimize distractions during the interview.
6. Set Expectations: Inform the patient about the duration and purpose of the interview.
7. Prioritize Patient Concerns: Start with what the patient perceives as a problem.
8. Use Open-Ended Questions: Encourage the patient to share their perspective.

Biographical data is significant because it:

• Provides direct information related to the patient's current health problem.
• Alerts the nurse to potential risk factors for health issues.
• Indicates the need for referrals.
• Reflects the patient's mental status.
• Includes essential details such as name, address, age, gender, race, religion, marital status, educational level, occupation, and health insurance information.

Reasons for seeking health care can be categorized as:

The current health status assessment includes:

• Usual state of health
• Any major health problem
• Usual pattern of healthcare
• Any health concerns

Additionally, it utilizes the PQRST method:

• P: Precipitating/Palliative Factors
• Q: Quality/Quantity
• R: Region/Radiation/Related Symptoms
• S: Severity
• T: Timing

The past health history should identify:

• Any health factors from the past that may relate to the patient's current health status
• Chronic preexisting health problems
• Additional health risks caused by preexisting conditions
• Patient's responses to illness, healthcare, and healthcare workers

Specific items to include are:

• Childhood Illness
• Hospitalization
• Surgeries
• Serious Injuries
• Serious Chronic Illness
• Immunizations
• Allergies
• Medications
• Recent Travel

Family history provides clues to genetically linked or familial diseases that may be risk factors for the patient. It includes:

• Family members such as patient, spouse, children, parents, siblings, aunts, uncles, and grandparents.
• It can be recorded by listing family members along with their age and health status or using a genogram.

The review of systems serves to:

• Gather a litany of questions specific to each body system.
• Identify the current and past health status of each system.
• Detect problems that the patient may have failed to mention previously.

It includes assessments of various systems such as:

• General Health Survey
• Integumentary
• Head and Neck
• Eyes
• Ears
• Nose and Sinuses
• Mouth and Throat
• Respiratory
• Cardiovascular
• Breasts
• Gastrointestinal
• Genitourinary
• Female Reproductive
• Male Reproductive
• Musculoskeletal
• Neurological
• Endocrine
• Immune/Hematologic

Developmental considerations in health assessments recognize that:

• A person's development crosses the life span.
• Developmental assessments are often performed on children, as changes are observable and measurable.
• Illness and hospitalization can significantly impact a child's growth and development, potentially halting progression or causing regression.

Key developmental theories include:

• Sigmund Freud's Psychosexual Theory
• Erik Erikson's Psychosocial Theory
• Jean Piaget's Cognitive Theory
• Lawrence Kohlberg's Moral Development Theory

The psychosocial profile focuses on:

• Health promotion, protective patterns, and roles and relationships.
• Identifying how the patient incorporates health practices into various aspects of life.

It includes:

• Health Practices and Beliefs
• Typical Day
• Nutritional Patterns
• Activity and Exercise Patterns

• Recreation, Hobbies, and Pets
• Sleep/rest Patterns
• Personal Habits
• Occupational Health Patterns
• Socioeconomic Status
• Environmental Health Patterns
• Roles, Relationships, Self-Concept
• Cultural Influences
• Religious/Spiritual Influences
• Family Roles and Relationships
• Sexuality Patterns
• Social Supports
• Stress and Coping Patterns

• Be accurate and objective; avoid bias.
• Use brief notes instead of complete sentences.
• Utilize standard medical abbreviations.
• Avoid the term 'normal' to prevent misinterpretation.
• Record pertinent negatives.
• Ensure documentation is dated and signed.