Health history.pptx

Health history

1. HEALTH HISTORY Maxim T. Barikder Lecturer , BANC

2. HEALTH ASSESSMENT Health assessment is the collection of data about client’s health status.

3. PURPOSES 🞭 To collect data about physical, mental and social well being of client. 🞭 To get clear picture of the client’s health status and health related problems. 🞭 To determine the cause and extent of disease. 🞭 To determine the nature of treatment required for client. 🞭 To collect data systematically. 🞭 To get a holistic (complete) view of the client. 🞭 To formulate appropriate nursing care plan.

4. PROCESS OF HEALTH ASSESSMENT Health history Physical examination

5. HEALTH HISTORY Health history is the collection of data regarding client’s health in an chronological order.

6. COMPONENTS OF HEALTH HISTORY Biographic data Chief complaints Present health history Past health history Family history Personal history Socio economic history

7. 1. Biographic data This includes information regarding client’s name, age, gender, marital status, occupation, education, I.P no, treating doctor & diagnosis. 2. Chief complaints It is the brief statement of client’s problem for which client needs care. Eg: Client is complaining of cough since 2 weeks, fever since yesterday and headache since today.

8. 3. Present health history Present health history is the expansion of chief complaints. It should include location, quality, quantity, exaggerating and relieving factors. Eg: Client is admitted to the hospital with the complains of cough with mucus secretion since 2 weeks, cough increases during night and decreases with rest, fever with temperature 100⁰F since yesterday and headache at forehead since today which decreases with rest and rates 7 in pain scale.

9. Present medical history Present surgical history

10. 4. Past health history It is the information about client’s previous experience with any disease or surgery. This health history includes the detail of Childhood illness Chronic illness Psychiatric illness Injuries , burns, fractures etc. Hospitalization Surgical & diagnostic procedures Current medications

11. Past medical history Past surgical history

12. 5. Family history This is the information about the client’s family members and their health status. Family tree This is the diagrammatic representation of family members. Three generations has to be denoted in family tree. Family tree is also known as genogram.

13. Male Female Male patient Female patient Male dead -Female dead

14. - Male - female Name, age Name, age Name, age Name, age Name, age Name, age Name, age Name, age Name, age Name, age

15. In d ex Male Female - P a tient - D e ad Name, age N a me , age Name, age Name, age Name, age Name, age Name, age Name, age Name, age Name, age

16. 6. Personal history It includes client’s personal details such as dietary pattern, sleep pattern, activity level, elimination pattern, alcoholism, smoking habits etc 7. Socio economic history Collecting data regarding client’s life style, working environment, personal relationship with other human beings, monthly or annual income, housing facilities.