Bulacan State University

City of Malolos, Bulacan

COLLEGE OF NURSING

NCM 101-A : HEALTH ASSESSMENT

THE NURSING HEALTH HISTORY (NHH)

NURSING HEALTH HISTORY

• Data collected about the client’s current level of wellness
• It is the primary focus of the interview process
• A review of client’s functional health patterns prior to the current contact with the healthcare
agency
• Used in developing plan of care and formulating nursing interventions

BASIC COMPONENTS OF THE NURSING HEALTH HISTORY

A. PERSONAL PROFILE
• Biographic Data
o Factual demographic data about the client
o Includes:
▪ Name
▪ Address
▪ Date of Birth
▪ Gender
▪ Marital Status
▪ Religion
▪ Race
▪ Ethnic origin
▪ Occupation
▪ Source of Health Care
• Reason for Seeking Health Care
o Chief complaint
o The primary reason given by the client as to why he sought consultation or
hospitalization
o To present a more direct and clearer picture of the patient’s condition, it is
recommended that actual verbalization of the patient is documented in a subjective
data format (e.g. “Hirap akong huminga dahil sa matinding sipon at ubo,” as verbalized
by the client)
o Sample Interview Spiels:
✓ “What brought you to the clinic or hospital?”
✓ “What is troubling you?”

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 • History of Present Illness
Includes:
o Usual health status
o Elaboration of the chief complaint in chronological sequence
▪ Essential relevant data about the:
• Nature and Onset of symptoms
• When it began
• Are they always present or they come and go
• Duration of symptoms
• Location, intensity and quality of each symptoms
• Are there any actions which precipitate the symptoms of provides relief
o Additional Interview Spiels
✓ Was help or any medical consultations sought?
✓ What home remedies or medications were taken to relieve these symptoms?
✓ Ask how the health problem and its symptoms have interfered with daily life.
o For clients interviewed during their hospital admission, this portion shall recall the
present condition in succession from symptoms encountered prior to hospitalization up
to the day of interview.

• Past Medical History

o Childhood illnesses
o Childhood immunizations
o Allergies
o Accidents and injuries
o Hospitalizations
✓ This must include any surgical procedures encountered or previous
hospitalization admissions related to the case being presented. Preferably, the
date or year patient was hospitalized should be noted.
o Medications
✓ Medications the patient have been prescribed oftentimes (e.g. maintenance
drugs) and/or any OTC drugs commonly taken for illnesses.
• Family History
o Includes:
o Presented in GENOGRAM
✓ A 3rd level generation outlining is the least/minimum requirement for
presentation.
✓ Reference for the diagram presented has to be cited.
o Ages of siblings, parents and grandparents
o Their current stage of health
o Cause of death
o It reveals risk factors for certain illnesses of a genetic or familial in nature like: DM, HPN,
CA, Obesity, etc.

B. FUNCTIONAL ASSESSMENT
• Gordon’s Functional Health Assessment
o Health Perception-Health Maintenance Pattern
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 o Nutrition-metabolic pattern
o Elimination Pattern
o Activity- Exercise Pattern
o Sleep-Rest Pattern
o Cognitive Perceptual Pattern
o Self Perception Self Concept Pattern
o Role Relationship Pattern
o Sexuality-Reproductive Pattern
o Coping-Stress Tolerance Pattern
o Value-Belief Pattern
• Activities of Daily Living
o the things we normally do in daily living including any daily activity we perform for self-
care
▪ Physical Activities of Daily Living
• The basic activities of daily living consist of these self-care tasks:
• Bathing
• Dressing and undressing
• Eating
• Transferring from bed to chair, and back
• Voluntarily control urinary and fecal discharge
• Using the toilet
• Walking (not bedridden)
▪ Instrumental Activities of Daily Living
• These are not necessary for fundamental functioning, but enable the
individual to live independently within a community
o Light housework
o Preparing meals
o Taking medications
o Shopping for groceries or clothes
o Using the telephone
o Managing money

C. FUNCTIONAL ASSESSMENT TESTS

• Newborns
• Newborn- APGAR SCORING
• Developed by Dr. Virginia Apgar
• A method of assessing the newborn’s adjustment to extrauterine life
• Taken 1 minute and 5 minutes after birth
• 1 minute score indicates need for resuscitation
• 5 minute score is more reliable in predicting mortality and neurologic deficits
• SCORE
• 7- 10
• Good Adjustment, Vigorous
• Normal
• 7-4
• Moderately depressed infant
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 • Needs airway clearance
• 3 & below
• Severely depressed infant
• In need of resuscitation
• Infants and Children
• Metro Manila Developmental Screening Test
• Detection of developmental disabilities
• Children 6 ½ years and below
• Modified and standardized by Dr. Phoebe D. Williams DDST to MMDST
• Not an intelligence test rather it is a screening instrument to determine if child’s
development is within normal
• Adults
• Katz Index of Independence in ADL
• The Index of Independence in Activities of Daily Living is based on an evaluation
of the functional independence or dependence of patients in:
• bathing, dressing, toileting, transferring, continence, and feeding.
Specific definitions of functional independence and dependence appear
below the index.
• Barthel index
• The index should be used as a record of what a patient does, not as a record of
what a patient could do.
• The main aim is to establish degree of independence from any help, physical or
verbal, however minor and for whatever reason.
• The need for supervision renders the patient not independent.
• A patient's performance should be established using the best available
evidence. Asking the patient, friends/relatives and nurses are the usual sources,
but direct observation and common sense are also important. However direct
testing is not needed.
• Usually the patient's performance over the preceding 24-48 hours is important,
but occasionally longer periods will be relevant.
• Middle categories imply that the patient supplies over 50 per cent of the effort.
• Use of aids to be independent is allowed.

D. REVIEW OF SYSTEMS
• Review of all health problems by body systems
• The normal function of each body system are assessed and any noted changes
• Such changes are usually subjective
• Findings in the ROS help the nurse to direct assessment during physical examination

E. ASSESSMENT IN PREGNANCY
• LMP
o Last Menstrual Period; the 1st day of the Last Menstruation
• AOG
o Age of Gestation; the age of the uterus
• EDC
o Expected date of confinement

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 • OB Score
• Pregnancy information; TPAL
• T – full term babies
• P – premature babies
• A – Abortion
• L – Living children

F. PEDIATRIC ADDITIONS TO HEALTH HISTORY

• Anthropometric Measurements
• Head
• Measured at the level of the eye brows
• Range: 33 to 35 cm, average is 35 cm
• Less than 32 cm is indicative of Microcephaly in term infants
• 4cm and more greater than the chest circumference indicates Hydrocephalus
• Chest
• Measured at the level of the nipple
• Ranges from 30-32 cm
• Less than 30 indicates prematurity
• Head and Chest Circumference
• Head > chest at birth
• Head = chest 9-10 mo.
• Head < chest after 1 yr.
• Abdomen
• Measured just below the umbilicus
• Approximately the same as chest circumference
• Weight
• Weight
• Doubles by 5 mo
• Triples by 12 mo
• Ranges from 6 to 8.5 lbs or 2500 to 4000 grams
• Male infant – 7.5 lbs
• Female infant – 7 lbs
• Less than 2,500 gms – Small for Gestational Age (SGA)
• More than 4000 gms – Large for Gestational Age (LGA)
• Length
• Measure newborn length from top of the head to heel
• Length
• Gains 13.75 cm (5.5 in.) by 6 mo
• Additional 7.5 cm (3 in.) by 12 mo
• Average of 45 – 55 cm or 18 to 22 inches
• Male – 20 inches or 50 cm
• Female 19.6 inches or 49 cm
• Immunization

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