Nursing Health Assessment

NURS 201
Obtaining Patient Health History
Things to consider during Patient Interview

C – Cultural consideration
C – Therapeutic Communication
A – Age related changes and adjustments
L – Language barrier
E – Educational background
E – Environmental adjustment
G – Gender (respect)

Different Types of Health History Taking

1. Focused Health History and Assessment

2. Comprehensive Health History and Assessment
3. Emergency Health History and Assessment

Reasons of Obtaining an Accurate Patient Health History

a. To get to know your patient

b. Offers an opportunity to educate your patient
c. Identify potential factors that might affect his/her health
d. Piece together information to better provide the care the patient requires

Challenging Situations

a. Angry and Disruptive Behaviors – validate their feelings, stay calm and avoid being
challenging
b. Talkative Patients – Is the patient anxious? Is there any flight of ideas?; redirect the
patient to the topic
c. Silent Patient – “Is there something bothering you right now?”
d. Seductive Patient – “You are displaying an inappropriate and unacceptable behavior
right now, let’s focus on your health.”

Sensitive Topics: explain why you need to know this information

a. Sexual History: “Because sexual practices put people at risk of certain diseases, I ask all
of my patients the following questions.”
b. ETOH and Illicit Drugs: “Some of the possible medication that will be prescribed to you
by your doctor might interact with alcohol, cigarette, or illicit drugs. I wanted to know if
you are currently using anything.”
 Nursing Health Assessment
NURS 201
Obtaining Patient Health History
1. Patient name
2. Age
3. Gender- what’s your pronoun (transgender)
4. Marital Status
5. Occupation- where?/What do they do
6. Informant- who is reporting
7. Reliability- poor/fair/good historian
8. Chief Complaint (CC)- why they are here? Quotes is okay to put
9. History of Present Illness (HPI)
10. Medication & Allergies- important for prescribing
11. Tobacco use in pack years- know to offer a patch
12. Alcohol & illicit drug use- x3-4
13. Past Health History (PHH)
a. Childhood illnesses
b. Adult illnesses-Medical, Surgical, Obstetric/Gynecologic, Psychiatric- family
member dx?
c. Health maintenance-immunizations, screenings
d. Family History
e. Personal & Social History
f. Review of Systems
 General
Subjective: If the patient has a symptom, problem or concern, use this
 Skin format!
 Head O: Onset (chronological)
 Eyes L: Location
D: Duration
 Ears C: Characteristics
 Nose A: Aggevating and alleviating factors
 Mouth R: Related symptoms (radiation to another area)
T: Treatments tried and pt response
 Throat
 Neck
 Breasts
 Respiratory System
 Cardiovascular System
 Gastrointestinal System
 Genitourinary System
 Musculoskeletal System
 Nervous System
 Psychiatric history
 Neurologic
 Hematologic
 Endocrine
Health Care Maintenance- screening test