4. Components of Nursing Health History.pptx

Health Hx

1. NURSING HEALTH HISTORY (Chapter 4) NHA INSTRUCTORS 1

2. Components of Nursing Health History Biographic Data Chief Complaint History of Present Illness Past Illness Family History of Illness Lifestyle Social Data Psychological Data Patterns of Health Care 2

3. BIOGRAPHIC DATA 3

4. Biographic Data This includes the following: Complete Name of the Patient Complete Address Age and Birthdate Gender / Sex Marital Status Occupation Religious Affiliation Health Care Financing Usual Source of Medical Care 4

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6. Chief Complaint The answer given to the question: “What is troubling you?” or “What brought you to the hospital or clinic?” Note: The chief complaint should be recorded in the client’s own words. 6

7. HISTORY OF PRESENT ILLNESS 7

8. History of Present Illness The following questions should be considered: When the symptoms started? Whether the onset of the symptoms was sudden or gradual? H ow often the symptoms occur? Exact location of the distress? Character of the complain (e.g. Intensity of pain, quality of sputum, emesis, discharge, etc.) Activity in which the client was involved when the problem occurred. Phenomena or symptoms associated with the chief complaint. Factors that aggravate or alleviate the problem. 8

9. PAST ILLNESS 9

10. Past Illness Childhood Illnesses: Such as chickenpox, mumps, measles, rubella (German Measles), Rubeola (Red Measles), Rheumatic Fever, Streptococcal Infections, and other Significant Illnesses. 2. Childhood Immunization This includes BCG, DPT, Measles, Hep – B, Influenza Shots, Tetanus Shots (last dose taken), OPV, and other vaccines received by the patient. 10

11. Past Illness 3. Allergies to drugs, animals, insects, or other environmental agents and type of reaction that occurs. 4. Accidents and injuries How, where, when the incident occurred, type of injury acquired, treatment received, and any complications 11

12. Past Illness 5. Hospitalization for Serious Illnesses Reason for hospitalization, Dates, Surgery Performed, Course of Recovery, and any complications. 6. Medications All currently used prescriptions and over the counter medications such as aspirin, nasal spray, vitamins, laxatives, maintenance drugs, etc. 12

13. FAMILY HISTORY OF ILLNESSES 13

14. Family History of Illness To ascertain risk factors for certain diseases, the ages of siblings, parents, and grandparents and their current state of health, or if they are deceased, the cause of death are obtained. Particular attention should be given to disorders such as heart disease, cancer, diabetes, hypertension, obesity, allergies, arthritis, tuberculosis, bleeding problems, alcoholism, and any mental health disorders. 14

15. LIFESTYLE 15

16. Lifestyle includes: Personal Habits The amount, frequency, and duration of substance use such as tobacco, alcohol, coffee, cola, tea, and illicit or recreational drugs. 2. Diet Description of a typical diet on a normal day or any special diet, number of meals and snacks per day, who cooks and shops for food, ethnically distinct food patterns, and allergies. 16

17. Lifestyle includes: 3. Sleep / Rest Pattern Usual number of hours of sleep (at night and nap time), Usual time of sleep and usual wake time, sleeping difficulties and the remedies used. 4. Activities of Daily Living A random list, in an hour per hour basis of daily activities. Any difficulties experienced in the basic activities of eating, grooming, dressing, elimination, and locomotion. 17

18. Lifestyle includes: 5. Instrumental Activities of Daily Living Any difficulties experienced in food preparation, shopping, transportation, housekeeping, laundry, ability to use telephone / cellphone, handle finances, and manage medications. 6. Recreation / Hobbies Exercise activity and tolerance, hobbies and other interests, and vacations. 18

19. SOCIAL DATA 19

20. Social Data includes: Family relationships / friendships The client’s support system (who helps in times of need?) What effect the client’s illness has on the family? Any family problems are affecting the client? 2. Ethnic Affiliation Health customs and beliefs Cultural practices that may affect health care and recovery 20

21. Social Data includes: 3. Educational History Data about the client’s highest educational attainment. Any past difficulties with learning. 4. Economic Status Information about how the client is paying for medical care (including what kind of medical or medical coverage the client has), or whether the client’s illness presents financial concern. 21

22. Social Data includes: 5. Occupational History Current employment status? Number of days missed because of illness? Any history of accidents on the job? Any occupational hazards with a potential for future disease or accidents? The client’s need to change job because of past illness? Employment status of the spouse? The way childcare is handled? Client’s overall satisfaction with the work? 22

23. Social Data includes: 6. Home and Neighborhood Conditions Home safety measures and adjustments in physical facilities that may be required to help the client manage a physical disability, activity intolerance, and activities of daily living. Availability of neighborhood and community services to meet the client’s needs. 23

24. PSYCHOLOGICAL DATA 24

25. Psychological Data includes Major stressors experienced and the client’s perception of them. 2. Usual coping pattern with a serious problem or high level of stress. 25

26. Psychological Data includes 3. Communication Style Ability to verbalize appropriate emotions. Non – verbal communication such as eye movement, gestures, use of touch, and posture. Interactions with support persons. Congruence of non – verbal behavior and verbal expression. 26

27. PATTERNS OF HEALTH CARE 27

28. Patterns of Health Care All health care resources the client is currently using and has used in the past. These includes the family physician, specialists (ophthalmologist, Obstetrician, cardiologist, etc.) Use of health clinic or health centers, albulario , herbalist, hilot , faith healers, etc. Is access to health care a problem, and know the reason why. 28

29. End of Chapter 4 29