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    Health History

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    Raissa Chan
    This document outlines guidelines for taking a patient's health history. It discusses gathering subjective data from the patient's past and current health conditions. Key areas of information include the patient's level of wellness, life patterns, socio-cultural role, and mental/emotional reactions to illness. The purpose is to identify patterns of health/illness, risk factors, and available resources by collecting data from the patient, their family, and health records. Effective interviews establish rapport, clarify health concerns, and guide further physical assessment and nursing diagnoses.

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    Health History

    Uploaded by

    Raissa Chan
    249 views2 pages
    This document outlines guidelines for taking a patient's health history. It discusses gathering subjective data from the patient's past and current health conditions. Key areas of information include the patient's level of wellness, life patterns, socio-cultural role, and mental/emotional reactions to illness. The purpose is to identify patterns of health/illness, risk factors, and available resources by collecting data from the patient, their family, and health records. Effective interviews establish rapport, clarify health concerns, and guide further physical assessment and nursing diagnoses.

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    This document outlines guidelines for taking a patient's health history. It discusses gathering subjective data from the patient's past and current health conditions. Key areas of information include the patient's level of wellness, life patterns, socio-cultural role, and mental/emotional reactions to illness. The purpose is to identify patterns of health/illness, risk factors, and available resources by collecting data from the patient, their family, and health records. Effective interviews establish rapport, clarify health concerns, and guide further physical assessment and nursing diagnoses.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    249 views2 pages

    Health History

    Uploaded by

    Raissa Chan
    This document outlines guidelines for taking a patient's health history. It discusses gathering subjective data from the patient's past and current health conditions. Key areas of information include the patient's level of wellness, life patterns, socio-cultural role, and mental/emotional reactions to illness. The purpose is to identify patterns of health/illness, risk factors, and available resources by collecting data from the patient, their family, and health records. Effective interviews establish rapport, clarify health concerns, and guide further physical assessment and nursing diagnoses.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    HEALTH HISTORY

     Comprehensive record of the patient’s past and current health


     Gives subjective information on how a health condition came about
     Data Information to be gathered:
    o Level of Wellness
    o Changes in Life Patterns
    o Socio-cultural Role
    o Mental and Emotional Reactions to Illness
    o Other Health Condition

    Database Sources:
    1. Health History
    2. Physical Assessment
    3. Laboratory and Diagnostic Tests
    4. Materials Contributed by Other Health Personnel

    Purpose:
     Identify:
    o Patterns of Health and Illness
    o Risks Factors for Health Problems
    o Deviations from Normal
    o Available Resources for Adaptation

    Guidelines in History Taking


    1. Sources of Information
    Primary Source – Client
    Secondary Source – Family or Significant Others, Health Team Members and Client’s Health Record
    2. Most of the Data are Subjective
    3. Focus on data or information from all the client’s dimension
    4. Record data using clear, concise and appropriate terminology

    Interview (Health Hx)


     Means of collecting subjective data
     A formal, planned interaction to inquire about:
     Patient’s health problem/pattern
     ADLs
     Past Health Hx
     Current Health Issues
     Self-care Activities
     Wellness Concerns

    Focus of Interview
    1. Establishing rapport and trusting relationship with the client
    2. Gathering information on the client’s developmental, psychological, physiologic, socio-cultural and
    spiritual statuses.
    Phases of the Health Assessment Interview
    1. Pre-interaction
     Collection of data from medical record, previous health risk appraisal, health screenings,
    therapists and other health care professionals.
     Information obtained during the phase plan and guide the direction of initial interview
     Nurse reflects on his or her own strengths and limitations
    2. Initial Interview
     Gathering information from the patient
     Use of Health History Form
     Establishing NPR
     Explaining the importance of the interview, telling what to expect
    3. Focused Interview
     Clarify previously obtained assessment data
     Gather missing information about a specific health concern
     Update and identify new diagnostic cues as they occur
     Guide the direction of physical assessment
     Identify or validate probable nursing diagnosis

    Guidelines of an Effective Interview


    1. Start by using icebreakers
    2. Be observant
    3. Ask questions in a non-threatening way
    4. Let the interview flow naturally
    5. Obtain cues about which part of the data collected requires in-depth investigation
    6. Control the interview

    Approaches to Interview
    1. Directive (Closed)
     Highly structured
     Elicits specific information
     Nurse controls subject matter
     Used when time is limited
    2. Non-Directive (Open-Ended)
     Nurse allow the patient to control the purpose, subject matter and pacing of the interview

    Types of Interview Questions


    1. Closed
     Generally require yes or no or short factual answers giving specific information
    2. Open-Ended
     Specific broad topics to be discussed and invite longer answers
    3. Neutral
     Can be answered by the client without direction or pressure from the nurse
    4. Leading
     Direct the client’s answer

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