Assessment Components and Taking a Health History NSG 2106 Health Assessment I 02 Sept 2014

Agenda: from Content Presentation (lecture): Review components of assessment and health histories 5 min break Health History Taking Skills: Practice Final questions Close

Goals for today To identify 1. Types assessment data 2. Types of health history 3. Components of a health istory To discuss and apply tools used in the patient health history (TAKE NOTES TO USE for...) To practice performing a health history with peers

What is a health history The health history is a detailed account of the patient’s perception of his/her current and past health, provided in his/her own words. The nursing health history focuses on what effect the patient’s current health status has on being able to function independently.

What types of health histories do nurses take Comprehensive Focused

What are the components of a each type of health hx

What are the types of data gathered in health histories and physical assessments  Subjective  Objective

Subjective data:  “patient reports....”  good for describing  points to what objective data you shoud gather  May be difficult to observe

Objective data:  measurable  reproducible  seeks to quantify and verify  can be more observable

Is this objective or subjective data  “ My baby is sick.”

Is this objective or subjective data  “ His lung sounds are clear to auscultate bilaterally in all fields”

Is this objective or subjective data  “He is starting to improve with the use of metered dosed inhaler medication”

Is this objective or subjective data  “His white blood cell count was 7,000/mm3 this morning”

Back to the components of Health Hx:  Biographical data 1. Name, address, village 2. Age, DOB 3. Gender 4. Birthplace and geography 5. Marital status 6. Religion 7. Tribe, race 8. Occupation/ Job 9. Source of data

Back to the components of Health Hx: Present Health/ Illness 1. What is your chief complain? Is anything bothering you? Why are you seeking care? The following questions and statements will assist the nurse in learning more about the patient’s health care beliefs: 1. What do you think it means to be healthy? 2. Tell me about your own health. 3. Do members of your family have the same beliefs about health as you do? 4. What do you do to remain healthy? 5. Do you have any behaviors that you believe are unhealthy? 6. Where do you get your health information? 7. Do you have a regular health care provider? 8. How often do you have a complete physical examination? 9. Do you have any home remedies that you use regularly?

Back to the components of Health Hx: Past Medical and Medication Hx 1. Are you currently under the supervision of a health care provider for a medical condition? 2. What diseases have you experienced, beginning with childhood? 3. Have you ever been hospitalized? why, when, and for how long? 4. Have you experienced any complications (sequelae) from diseases or injuries? 5. Have you ever been involved in an accident in which you were injured? 6. Have you ever had a blood transfusion? when and where? 7. Has any disease or injury affected your ability to lead a normal life? 8. Have you ever suffered from any mental illnesses, such as depression? 1. What herbs and medications do you take regularly 2. How long do you save unused drugs and are you aware of discard dates? 3. Where do you keep or store your medications? 4. Do you take the entire prescription of antibiotics when prescribed? 5. Do you share medications with anyone ?

Back to the components of Health Hx: Family Hx 1. Please tell me about your family members’ health, including your spouse, children, siblings, parents, aunts, uncles, and grandparents. 2. Do any of these individuals have medical illnesses or diseases? 3. Have there been any deaths in the immediate family? The cause? 4. How old were your parents/siblings when they died and what was the cause?

Back to the components of Health Hx: Psychosocial Hx 1. What the highest level of education you have? 2. Do you own a home? 3. Do you have many roles in your household or people who depend on you? 4. What are the different jobs that you’ve had?

What about a focused Health Hx? Problem based hx use the following mnemonics: PQRSTU 1. Provokes 2. Quality 3. Radiate 4. Severity 5. Timing (onset) 6. yoU (what do you think?) SAMPLE 1. Signs and sx 2. Allergies 3. Medications 4. Pertinent medical hx 5. Last oral intake 6. Events leading to illness/injury

Skills Practice: Instruction Take 10 minutes to reconsturct your notes into a brief health history tool Choose a classmate that you do not know very well Start by choosing one person to perform a health history with that partner using the tool you created. Remember to interview use the 3 phases of communication (intro with AIDET, working with closed ended questions, and a closing or summary). Facilitate the conversation, and drive the interview Share only the information you feel comfortable with Switch roles with your partner and begin again

Regroup

Today we: identified 1. 2 Types of assessment data 2. 2 Types of health history 3. 5 Components of a health istory discussed and applied tools used for the patient health history practiced performing a health history with peers

Follow up items Class Materials 1. LMS 2. Hard Copy 3. Soft Copy Thank you for your attention!