HISTORY TAKING.pptx and health assessment..

history taking
assessment
education

1. HISTORY TAKING

2. HSTORY COLLECTION It is a systemic collection of information or data obtained from the patient and other relevant sources concerning the patient’s physical status as well as her/his psychological, social and sexual functions. TYPES OF HISTORY: Health history Medical history Nursing history This Photo by Unknown Author is licensed under CC BY-NC

3. STRUCTURE OF HEALTH HISTORY Comprehensive health history Focused health history COMPREHENSIVE HISTORY- It is appropriate for new patient in office or hospital. Provide fundamental and personalised knowledge about the patient. Clinicians patient relationship strengthens. Creates platform for health promotion

4. Cont.… FOCUSED HEALTH HISTORY: Appropriate for established patient especially during urgent or routine visits. Assess symptoms restricted to concerned parts. Address focused concerns or symptoms. Applies examination methods relevant to concerned problem.

5. IMPORTANCE/PURPOSE OF HISTORY TAKING H elps to understand the patient’s health status. Open channel for communication and further care. Gives a baseline information about personal and social life Seeks approval from family members for participation in comprehensive care. Gives the client a sense of trust development. It helps to plan effective nursing care. Help family members who may be in risk for disease.

6. COMPONENTS OF THE ADULT HEALTH HISTORY: 1.Identifying data: such as age,gender,occupation,marital status. Source of history is usually the patient, but can be a family member or friend, letter of referral, or the clinical record. 2. Reliability : varies according to patient’s memory , trust, mood. 3. Chief complaints : The one or more symptoms or concerns causing the patient to seek care. 4.Present illness : Amplifies chief complaints , describe how each symptom developed. May include medications , allergies, habits of smoking and alcohol.

7. Cont.. THE SEVEN ATTRIBUTES OF EVERY SYMPTOMS – Location Quality Quantity or severity Timing including onset, duration and frequency Setting in which it occurs Aggravating and relieving factors Associated manifestations

8. Cont.. 5.Past history- lists childhood illnesses. lists adult illnesses with dates for at least four categories i,e . medical , surgical, obstetrical/gynecologically and psychiatric. Includes health maintenance practices such as immunisation, screening tests, lifestyle issues and home safety. 6. Family history – Outlines or diagrams age and health, or age and cause of death of sibling, parent and grandparents. Document presence and absence of specific illnesses in family such as HTN, coronary artery disease.

9. Cont … 7.Personal and social history- describe educational level, family of origin, current household, personal interests and lifestyle. 8. Review of systems- Documents presence or absence of common symptoms related to each major body system.

10. SUBJECTIVE DATA: What patient tells you The symptoms and history, from chief complaints through review of systems. OBJECTIVE DATA- What you detect during the examination, laboratory information, and test data All physical examination findings or signs.