NURSING HEALTH HISTORY

 NURSING HEALTH HISTORY

Purpose
• To elicit information about all variables that may affect the client’s health status
• To obtain data that help the nurse understand and appreciate the client’s life experiences
• To initiate a non-judgmental, trusting interpersonal relationship with the client

 BIOGRAOHIC DATA
• Name
• Address
• Age
• Sex
• Race
• Marital status
• Occupation
• Religion
• Health care financing
• User source of medicare

 CHIEF COMPLAINT
• Reason for visit
• “What is troubling you?”
• Recorded in client’s words

 HISTORY OF PRESENT ILLNESS
• Usual health status
• Chronologic story
• Relevant family history
• Disability assessment

 PAST HISTORY
• Childhood illnesses
• Childhood immunizations
• Allergies
• Accident and injuries
• Hospitalization
• Medications

 FAMILY Hx OF ILLNESS
• Ages of siblings, parents, etc.
• Current state of health
• If deceased, cause of death

 REVIEW OF SYSTEMS
• Subjective data
• Checklist

 LIFE-STYLE
• Personal habits
• Diet
• Sleep/rest patterns
• Activities of daily living
• Instrumental activities of daily living
• Recreation/hobbies

 SOCIAL DATA
• Family relationships/friendships
• Ethnic affiliations
• Educational history
• Occupational history
• Economic status
• Home and neighborhood conditions

 PSYCHOLOGIC DATA
• Major stressors
• Usual coping pattern
• Communication style
• Self-concept
• Mood

 PATTERN OF HEALTH CARE
• Note all health care resources

 ABBREVIATIONS

Page 343 and 795 Fundamentals of Nursing – Kozier 7th Edition






Chapter 16 ASSESSING
Page 256 Fundamentals of Nursing – Kozier 7th Edition


 Nursing Process
- Is a systematic, rational method of planning and providing individualized nursing care for individuals, families, groups and communities.
- Originated by Hall(1995), Johnson(1959), Orlando (1961), Wiedenbach (1963)

 Phases of Nursing Process

 Assessing
- Collecting, organizing, validating and documenting client data – client’s personal perceptions
- Involves active participation by the client and nurse in obtaining subjective and objective data about the client’s health status
Subjective data, symptoms, covert data – client’s personal perception
Objective data – detectable by an observer
- Sources of data: primary and secondary
Primary – client
Secondary – family members or other support persons, client records (medical and laboratory), health care professionals, literature
- Data collection methods
Observing
Interviewing
Directive interview – structured
Nondirective interview – rapport building interview
o Types of Interview Questions
- Open-ended questions, neutral question
- Closed questions, leading questions
Examining
 Diagnosing
- analyzing and synthesizing data
 Planning
- determining how to prevent, reduce or resolve the identified client problems; how to support client strengths, and how to implement nursing interventions in an organized, individualized and goal directed manner
 Implementing
- carrying out the planned interventions
 Evaluating
- measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement

 Characteristics of Nursing Process
- Cyclic, dynamic
- Client Centered
- Interpersonal and collaborative
- Universally applicable
- Focus on problem solving and decision making