Definition:

Health - a state of complete physical, mental, and social well-being and not merely
Key Points:
the absence of disease or infirmity.” (WHO, 1958, p.1.).
Nursing: Scope and
Health Assessment - a plan of care that identifies the specific needs of a person and Standards of Practice,
(ANA, p. 21).
how those needs will be addressed by the healthcare system or
skilled nursing facility. Definition of Terms

Health:
Health assessment - the evaluation of the health status by performing a physical a state of complete
exam after taking a health history. physical, mental, and
social well-being and
not merely the
Health Assessment is a set of questions, answered by patients, that asks about absence of disease or
personal behaviors, risks, life-changing events, health goals and priorities, and infirmity.”
(WHO,1958, p.1.).
overall health.
Health
Nursing - the protection, promotion, and optimization of health and abilities, Assessment:
a plan of care that
prevention of illness and injury, alleviation of suffering through the diagnosis and identifies the specific
treatment of human responses and advocacy in the care of individuals, families, needs of a person and
how these needs will
communities and populations, (ANA, 2010).
be addressed by the
healthcare system or
Emphasis of Nursing (ANA): skilled nursing
facility.
- placed on “diagnosis and treatment of human responses” based on “accurate
client assessments,” including how effective nursing interventions are “to promote
health and prevent illness and injury.”

Nursing: Scope and Standards of Practice states as Standard 1 that

“The registered nurse collects comprehensive data pertinent to the patient’s health
or situation” (ANA, p. 21).
Accomplishing the pertinent and comprehensive data collection: Key Points:
● Nursing: Scope and
1. Collects data in a systematic and ongoing process Standards of Practice
2. Involves the patient, family, other health care providers, and environment, as (ANA, p. 21).
appropriate, in holistic data collection Definition of Terms
3. Prioritizes data collection activities based on the patient’s immediate
Assessment:
condition, or anticipated needs of the patient or situation the first and most critical
step of the nursing process,
4. Uses appropriate evidence-based assessment techniques and instruments in and accuracy of assessment
data affects all other
collecting pertinent data
phases of the nursing
5. Uses analytical models and problem-solving tools process.

6. Synthesizes available data, information, and knowledge relevant to the

situation to identify patterns and variances
7. Documents relevant data in a retrievable format (ANA, 2010, p. 21)

Standard 2 states, “The registered nurse analyzes the assessment data to determine
the diagnoses or issues.
Determining the diagnoses or issues:
1. Derives the diagnosis or issues based on assessment data
2. Validates the diagnoses or issues with the client, family, and other healthcare
providers when possible and appropriate
3. Documents diagnoses or issues in a manner that facilitates the determination
of the expected outcomes and plan (ANA, 2010, p. 22).

Nurse’s Role in Health Assessment (Weber, & Kelly, 2004)

Nursing health assessment differs in purpose, framework, and end result
from all other types of professional health care assessment.
a. from simple observation to a holistic view of the patient that
includes biophysical, psychosocial, developmental,
and cultural assessments (used the senses of sight,
touch, and hearing to assess clients.

Assessment - the first and most critical step of the nursing

process, and accuracy of assessment data affects all other
phases of the nursing process.

The Assessment Process (Dillon, 2007)

 The American Nurses’ Association (ANA) has identified assessment as the
first Standard of Nursing Practice (ANA, 1998).
 The Standard describes assessment as the systematic, continuous collection of
data about the health status of patients.
 Nurses are responsible not only for data collection but also for making sure
that the data are accessible, communicated, and recorded.
 Assessment is an ongoing process.
o Every patient encounter provides you with an opportunity for
assessment.

Purpose of Assessment
 is to collect data pertinent to the patient’s health status,
 to identify deviations from normal,
 to discover the patient’s strengths and coping resources, to pinpoint actual
problems,
 to spot factors that place the patient at risk for health problems.

Skills of Assessment
Assessment requires cognitive, problem-solving, psychomotor,
affective/interpersonal, and ethical skills.
1. Cognitive Skills
 Assessment is a “thinking” process.
 Cognitive skills are needed for:
o critical thinking,
o creative thinking, and
o clinical decision making.
 Your theoretical knowledge-base enables you to assess your patient
holistically.
o The knowledge-base includes:
 biophysical knowledge
 developmental knowledge,
 cultural knowledge,
 psychosocial knowledge, and
 spiritual knowledge.
o This knowledge base enables you to:
 differentiate normal from abnormal findings and
 to identify and prioritize actual and potential problems.
 2. Critical thinking
Key Points:
 is a complex thinking process that has been defined in many ways.
 is reflective, reasonable thinking (Ennis, 1985).  Ways of reasoning
 is not just doing, it is asking “why?”
 involves: inquiry, interpretation, analysis, and synthesis. Definition of Terms
 is the art of thinking about thinking that enables you to think better (Paul, Creativity:
1990). thinking outside of
the box.
 attitudes or “traits of the mind” are needed for critical thinking.
o Think of them as a mindset that enables you to use your cognitive skills Clarification:
to critically think, (Paul, 1990). involves addressing
assumptions,
comparing
Essentials of Critical Thinking (Green, C. (2000). Critical Thinking in Nursing. Upper
and contrasting.
Saddle River, NJ: Prentice Hall).
a. Intellectual Humility (Know what you don’t know).
b. Know your limits (Be aware of your biases and prejudices).
c. Intellectual Courage (Be open and listen to other points of view).
d. Intellectual Empathy (Put yourself in another’s shoes, so that you can
understand his or her perspective).
e. Intellectual Integrity (Maintain high standards; Hold yourself to the same
standards as you do others).
f. Intellectual Perseverance (Persist to find the answer or reach understanding).
g. Faith in Reason (Look out for the best interest for all involved; Consider the
consequences).
h. Intellectual Sense of Justice (Be open to all viewpoints, with a sense of
impartiality and fairness).

Critical Thinking Skills

a. Divergent thinking: involves analyzing various viewpoints, differentiating
relevant/irrelevant data, and making inferences (conclusions).
b. Reasoning: is the ability to differentiate fact (truth) from assumptions
(beliefs).
It can be deductive or inductive. You will use both deductive and
inductive reasoning to assess your patient and interpret the data.
For example, suppose your patient is admitted to the hospital with the
diagnosis of congestive heart failure (CHF).

Knowing this enables you to look for specific signs and

symptoms as you perform the assessment and determine your
patient’s response to this illness.
In this case, you will use deductive reasoning, looking
for specific clues that support the diagnosis of decreased cardiac
output.
Inductive reasoning would be appropriate when
assessing a postoperative patient who states,
“It hurts too much to take deep breaths,” and who
has decreased breath sounds and crackles at the bases,
pulse oximetry of 90 percent on room air, temperature of
 101_F, pulse of 106 BPM, and respirations 26 and shallow.

When you piece together all of the pertinent assessment data,

you formulate diagnoses of Impaired Gas Exchange
and Ineffective Airway Clearance.

c. Reflection: allows you to step back and think, considering

“if . . . then” possibilities.
Experience and new evidence may result in changing
opinions. Integrating what you know from past experience with new
evidence allows for change.

d. Creativity: allows you to “think outside of the box.”

- involves identifying multiple solutions/approaches,
realizing there is more than one way to approach a problem.
- is also listening to your “gut”—intuitive thinking.
- Intuitive thinking develops over time with experience.

e. Clarification:
- involves addressing assumptions, comparing and contrasting.
- Ask yourself, “What is similar?” “What is different?”

f. Basic support:
- is based on sound, credible, known facts.
- Evidence-based practice that is research-based leads to
best practice.

3. Clinical Decision Making

 As you collect data, you will make clinical decisions as to its relevance.
 You will look for cues and make inferences.
 With experience, you will be able to identify patterns and recognize
what differs from the norm and then use the data to make decisions that will
best meet your patient’s needs.
 Use your knowledge, experience, and what the patient says to validate the
data.

4. Problem-Solving Skills
- With experience, you will develop your problem-solving
skills. Do not limit yourself to one method; instead, select the method that best suits
your patient’s needs.
a. Reflexive thinking:
- is automatic, without conscious deliberation, and comes with experience.
For example, if you are working in the ER and a 45-
year-old man is admitted with “crushing chest pain,” you will automatically
take his vital signs and do an electrocardiogram to assess his cardiac status
as you ask him questions.

b. The trial-and-error approach

- is hit-or-miss thinking; random, not systematic and
inefficient.
- This would never be your primary problem-solving
approach, but it may prove helpful at times
because it allows you to “think outside of the box.”
- Trial-and-error thinking fosters creativity and allows
you to formulate new ideas.
- Use it for situations that don’t quite fit the picture,
 look beyond the obvious, and keep looking until you find an answer.

c. The scientific method Key Points:

- is a systematic, critical-thinking approach to problem
 Code for Nurses
solving.
 Four steps of
- It involves identifying a problem and collecting
health assessment
supporting data, formulating a hypothesis,
planning a solution, implementing the plan, and Definition of Terms
then evaluating its effectiveness. Subjective data:
- Assessment corresponds with the “collection of assessment factors
supporting data phase” of the scientific method. that are reported by
the patient

The nursing process is similar to the scientific method, but the nursing Objective data:
process offers nurses the flexibility to practice both the art and the science of nursing. assessment data
includes that which
d. Intuition is observable and
- is a problem-solving method that develops through measurable.
experience, in which theory and practice
are intertwined.
- This is how the “expert” nurse solves problems.
- Through experience, she has a well-established
experiential base of pattern recognition, an
intuitive grasp of the situation, and the ability to
zero in on problem areas.

For example, suppose a patient says, “I just don’t feel right,” even though her
or his vital signs are stable and everything seems fine on the chart.

The objective data may not support it, but the expert nurse senses that something is
not quite right and returns to assess her patient further, only to find her or him in
distress. She intervenes swiftly and saves the patient’s life.

5. Psychomotor Skills
 Assessment is “doing.”
 Psychomotor skills are needed to perform the four techniques of physical
assessment: inspection, palpation, percussion, and auscultation.
 As a beginning practitioner, you may feel unsure of your technique and your
findings, but practice will hone your skills.
 Input from your colleagues will help you perfect your skills and interpret your
findings.
 Through experience, you will become competent at performing the physical
assessment and confident in interpreting your findings.

6. Affective/Interpersonal Skills
 Assessment is also a “feeling” process.
 Affective skills are needed to practice the “art” of nursing.
 Affective skills are essential in developing caring, therapeutic nurse-patient
relationships.

 Interpersonal skills include both verbal and nonverbal communication

skills.
 The quality of your assessment depends on your communication skills and
the relationship that you develop with your patient.
 Establishing trust and mutual respect is essential before you begin the
assessment.
  Seeing your patient as an individual and being sensitive to his or her feelings
conveys a message of caring and promotes human dignity. Key Points:
 Illness often makes a patient very vulnerable, but the power of a caring
relationship can have a major impact on the patient’s sense of worth and  Four types of
well-being. nursing
 Such a relationship can be mutually rewarding, affecting both you and your assessment
patient personally and professionally.
 Your interpersonal skills are also needed to communicate with family Definition of Terms
members and members of the healthcare team. Interval or
 Communicating effectively with the healthcare team is essential in order to abbreviated
successfully meet your patient’s goals. assessment:
assessments are
usually performed at
7. Ethical Skills
subsequent visits in
 Part of assessment is being responsible and accountable. an outpatient setting,
 You are responsible and accountable for your practice. at change of
 You are also an advocate for your patient. shift, when returning
 You must respect your patient’s rights and ensure patient confidentiality. from tests, or upon
transfer to your unit
from another in-
The Code for Nurses describes the ethical standards that guide nursing practice in its.
house unit.
The data collected through assessment are used to plan the patient’s care, but it is important
to remember that the data are the patient’s information. There is established rules to protect
patient privacy.

General Health Assessment (Jarvis, 2012).

A thorough and skilled assessment allows the nurse to:
1. obtain descriptions about the patient’s symptoms
2. how the symptoms developed, and
3. discover any associated physical findings that will aid in the development of
differential diagnoses.

Types of data in assessment:

1. subjective data - assessment factors that are reported by
the patient
2. objective data - assessment data includes that which is
observable and measurable.

(Note: During the assessment period, nurses are given an opportunity

to develop a rapport with the patient and their family. Remember the
saying “first impressions are lasting impressions?” That saying is also
very true in healthcare.
Nurses are often the first person the patient sees when admitted to the unit, returns from
testing, or at the beginning of a new shift. Nurses’ interactions with the patient gives the
patient and family lasting impressions about you, other nurses, the facility you are working
in, and how care will be managed (Jarvis, 2012).

All assessments should consider the patient’s privacy and foster open, honest
patient communications.

Four steps of health assessment

1. collecting subjective data
2. collecting objective data
3. validation of data
4. documentation of data.
Four types of nursing assessment
1. initial comprehensive
2. ongoing or partial
3. focused or problem-oriented
4. emergency

Four fundamental types of assessments that nurses perform: Key Points:

1. comprehensive or complete health assessment
 Special populations
2. interval or abbreviated assessment  Baseline assessment
3. problem-focused assessment
Definition of Terms
4. assessment for special populations

1. Comprehensive or complete health assessment

 usually begins with obtaining a thorough health history and physical exam.
 usually performed in acute care settings upon admission, once your patient
is stable, or when a new patient presents to an outpatient clinic.
o If the patient has been under your care for some time, a complete
health history is usually not indicated.

2. Interval or abbreviated assessment

 assessments are usually performed at subsequent visits in an outpatient
setting, at change of shift, when returning from tests, or upon transfer to
your unit from another in-house unit.
 assessment is not as detailed as the complete assessment that occurs at
admission.
 the advantage of an abbreviated assessment is that it allows nurses to
thoroughly assess the patient in a shorter period of time (Jarvis, 20212).

3. Problem-Focused Assessments
 assessment is usually indicated after a comprehensive assessment has
identified a potential health problem.
 indicated when an interval or abbreviated assessment shows a change in
status from the most current previous assessment or report you received,
when a new symptom emerges, or the patient develops any distress.
 An advantage of the focused assessment is that it directs you to ask about
symptoms and move quickly to conducting a focused physical exam (Jarvis,
2012; Scanlon, 2011).

4. Assessment for special populations, including:

 Pregnant patients
 Infants
 Children
 The elderly

Note: Baseline Assessment

- If there is any indication to perform a problem-focused or special
 population assessment during the comprehensive assessment, the assessment should
occur after obtaining a baseline comprehensive assessment.
Key Points:
- Based upon the results of the problem-focused or special population assessment, you
can decide how often to perform interval assessments to monitor your patient’s  Four basic
techniques of
identified problem (Jarvis, 2012; Scanlon, 2011).
assessment

Definition of Terms
- The special assessment should not replace the comprehensive or interval assessments, Inspection:
but should augment both the complete and interval assessments. Looking for conditions
observed with the eyes,
ears, or nose.
- A systematic physical assessment remains one of the most vital components of patient
care. A thorough physical assessment can be completed within a time frame that is
practical and should never be dismissed due to time constraints (Zambas, 2010).

Assessment Techniques:
- Whether you are performing a comprehensive assessment or a focused assessment, you
will use at least one of the following four basic techniques during your physical exam:
inspection, auscultation, percussion, and palpation. These techniques should be used
in an organized manner from least disturbing or invasive to most invasive to the
patient (Jarvis, 2012).

Four basic techniques of assessment

1. Inspection
 the most frequently used assessment technique.
 When the nurse use inspection, she looks for conditions she can observe with
her eyes, ears, or nose.
o Examples: skin color, location of lesions, bruises or rash, symmetry, size
of body parts and abnormal findings, sounds, and odors.
 Inspection can be an important technique as it leads to further investigation of
findings (Jarvis, 2012).
-
Please note!

Inspection is a critical observation that should always occur first during an

assessment (Jarvis, 2012).

2. Auscultation
 usually performed following inspection, especially with abdominal
assessment.
o The abdomen should be auscultated before percussion or palpation to
prevent production of false bowel sounds.
 When auscultating, ensure the exam room is quiet and auscultate over bare
skin, listening to one sound at a time.
 Auscultation should never be performed over patient clothing or a gown, as it
can produce false sounds or diminish true sounds.
 The bell or diaphragm of your stethoscope should be placed on your patient’s
skin firmly enough to leave a slight ring on the skin when removed.
  Be aware that your patient’s hair may also interfere with true identification
of certain sounds. Key Points:
 Remember to clean your stethoscope between patients.
 Diaphragm
 Light palpation
Note: The diaphragm is used to listen to high pitched sounds and the bell is best  Deep palpation
used to identify low pitched sounds (Jarvis, 2012; Edmunds, Ward & Barnes, 2010).
Definition of Terms
Percussion:
3. Palpation
used to elicit
 requires you to touch your patient with different parts of your hand using
tenderness or sounds
different strength pressures. that may provide
 During light palpation, you press the skin about ½ inch to ¾ inch with the clues to underlying
pads of your fingers. problems.
 When using deep palpation, use your finger pads and compress the skin
approximately 1½ inches to 2 inches.
 Light palpation allows you to assess for texture, tenderness, temperature,
moisture, pulsations, and masses.
 Deep palpation is performed to assess for masses and internal organs (Jarvis,
2012).

4. Percussion
 used to elicit tenderness or sounds that may provide clues to underlying
problems.
 When percussing directly over suspected areas of tenderness, monitor the
patient for signs of discomfort.
 Percussion requires skill and practice.

The method of percussion is described as follows:

1. Press the distal part of the middle finger of your nondominant hand
firmly on the body part.
2. Keep the rest of your hand off the body surface.
3. Flex the wrist, but not the foreman, of your dominant hand.
4. Using the middle finger of your dominant hand, tap quickly and
directly over the point where your other middle finger contacts the
patient’s skin, keeping the fingers perpendicular.
5. Listen to the sounds produced (Jarvis, 2012).
a. These sounds may include:
•Tympany
• Resonance
• Hyper-resonance
• Dullness
• Flatness
Tympany sounds like a drum and is heard over
air pockets.
Resonance is a hollow sound heard over areas
where there is a solid structure and some
air (like the lungs).
Hyper-resonance is a booming sound heard over
air such as in emphysema.
Dullness is heard over solid organs or masses.

Flatness is heard over dense tissues

including muscle and bone (Jarvis, 2012).
Data analysis - the second step of the nursing process and the
end result of nursing assessment.

Purpose of data analysis: to reach conclusions concerning the

client’s health.
Conclusions are in the form of:
1. nursing diagnoses
2. collaborative problems
3. a need for referral (Weber & Kelly, 2004)
Topic 2
Health History Guidelines: Interview (Purpose, Structure, Guidelines of an effective interview)

Introduction
The health history guidelines are important tools to obtain a health history from the patients.
A comprehensive clinical picture of the illness will be provided through clinical interview. It will help
direct the nursing students to gather appropriate information through therapeutic interaction.

Introduction
Interview as an important facet of health history enabling the nurses unveil
important health history from the patient. Understanding the purpose, structure, and the
guidelines will empower the nursing students to extract valuable health information for an
effective high-level care.

Objectives
 Understand and analyze the significance of an effective interview.
 Identify and demonstrate the proper clinical therapeutic interview during the
encounter with the patient.

Lesson Proper
Review
Based on HASS concepts and techniques, what is the significance to the
quality patient care?

Activity
Interactive discussion

Processing of the Activity

Express in a three-sentence writing the significance relationship of health
assessment to patient care.

Brief Lesson
Health History Guidelines
1. Interview
a. Purpose,
b. Structure,
c. Guidelines of an effective interview

HEALTH HISTORY GUIDELINES

Interview
 It is a goal directed purposeful interaction
between two people.
 a therapeutic interaction that has a purpose.
 a conversation between two or more people
(the interviewer and the interviewee) where questions
are asked by the interviewer to obtain information
from the interviewee.
 a nursing health assessment interview of
systemically collecting patient health information to
receive the quality care needed.
 the gateway to building an effective nurse–patient
 relationship that will make patients feel at ease, supported,
and empowered.
(https://www.waldenu.edu/online-bachelors-programs/bachelor-
of-science-in-nursing/resource/effective-nursing-health-
assessment-interview-techniques)

PURPOSE:
 provides information that may reveal a client’s risk for
a problem as well as areas of strengths for the client.

 provides the date base from which all other phases of

the nursing process will flow.

o the physical examination acts to corroborate

information gleaned from the interview.

 designed so that the nurse will begin to understand the

patient's adaptive processes.

 Gathers information to base nursing care

 Establishes a helping relationship
 Identifies health status, concerns, & problems
 For Screening purpose
 For Education

STRUCTURE

Phases of Interview
1. Introductory Phase: After introducing himself to the client,
the nurse:
a. explains the purpose of the interview
b. discusses the types of questions that will be
asked

c. explains the reason for taking notes, and

assures the client that confidential information

will remain confidential.

d. makes sure that the client is comfortable

(physically and emotionally) and has privacy.

e. Develop trust and rapport at this point in the

interview.

 Can begin by conveying a sense of

priority and interest in the client.

 Developing rapport depends heavily on

verbal and nonverbal communication

on the part of the nurse.

2. Working Phase:
a. the nurse elicits the client’s comments about major
biographic data, reasons for seeking care, history of
present health concern, past health history, family history,
 review of body systems for current health problems,
lifestyle and health practices, and developmental
level.
b. The nurse then listens, observes cues, and uses
critical thinking skills to interpret and validate
information received from the client.
c. The nurse and client collaborate to identify the client’s
problems and goals.
d. The facilitating approach may be free-flowing or more
structured with specific questions, depending on the
time available and the type of data needed.

3. Termination Phase/ Summary and Closing Phase

a. the nurse summarizes information obtained validates

problems and goals with the clients.
b. identifies and discusses possible plans to resolve the
problem (nursing diagnoses and collaborative problems)
with the client.
c. the nurse makes sure to ask if anything else concerns
the client and if there are any further questions.

GUIDELINES OF AN EFFECTIVE INTERVIEW

Communication During the Interview
 Involves two types of communication - nonverbal
and verbal.

1. Nonverbal Communication
 It is as important as verbal communication.
 The appearance, demeanor, posture, facial expressions,
and attitude strongly influence how the client perceives
the questions you ask.
o (Note: Never overlook this type of communication or
take it for granted.)

a. APPEARANCE
o First take care to ensure that your appearance is
professional.
o The client is expecting to see a health professional;
therefore, you should look the part.
o Wear comfortable, neat clothes and a
laboratory coat or a uniform.
o Be sure your name tag, including credentials, is
clearly visible.
o Your hair should be neat and not in any extreme style;
some nurses like to wear long hair pulled back.
o Fingernails should be short and neat; jewelry should
be minimal.

b. DEMEANOR (manner)
o Your demeanor should also be professional.
o When you enter a room to interview a client,
display poise.
 o Focus on the client and the upcoming interview
and assessment.
o Do not enter the room laughing loudly, yelling to
a coworker, or muttering under your breath.
o This appears unprofessional to the client and
will have an effect on the entire interview process.
o Greet the client calmly and focus your full attention
on her.
o Do not be overwhelmingly friendly or “touchy”;
many clients are uncomfortable with this type of
behavior.
o It is best to maintain a professional distance.

c. FACIAL EXPRESSION
o Facial expressions are often an overlooked
aspect of communication.
o Because facial expression often shows what
you are truly thinking (regardless of what
you are saying), keep a close check on your
facial expression.
o No matter what you think about a client or
what kind of day you are having, keep your
expression neutral and friendly.
o If your face shows anger or anxiety, the client
will sense it and may think it is directed toward
him or her.
o If you cannot effectively hide your emotions,
you may want to explain that you are angry or
upset about a personal situation.
o Admitting this to the client may also help in
developing a trusting relationship and genuine
rapport.
o Portraying a neutral expression does not mean
that your face lacks expression.
 It means using the right expression at the
right time.
o If the client looks upset, you should appear and be
understanding and concerned.
o Conversely, smiling when the client is on the
o verge of tears will cause the client to believe
o that you do not care about his or her problem.

a. ATTITUDE
o One of the most important nonverbal skills to develop
as a health care professional is a nonjudgmental attitude.
o All clients should be accepted, regardless of beliefs,
ethnicity, lifestyle, and health care practices.
o Do not act superior to the client or appear shocked,
disgusted, or surprised at what you are told.
 These attitudes will cause the client to feel
uncomfortable opening up to you and important
data concerning his or her health status could be
 withheld.
o Being nonjudgmental involves not “preaching”
to the client or imposing your own sense of ethics or
morality on him.
o Focus on health care and how you can best help
the client to achieve the highest possible level
of health.
 E.g., if you are interviewing a client who smokes,
avoid lecturing condescendingly about the
dangers of smoking.
o Also, avoid telling the client he or she is foolish or
portraying an attitude of disgust.
o This will only harm the nurse–client relationship and
will do nothing to improve the client’s health.
o The client is, no doubt, already aware of the dangers of
smoking.
o Forcing guilt on him is unhelpful.
o Accept the client, be understanding of the habit, and
work together to improve the client’s health.
o This does not mean you should not encourage the client
to quit; it means that how you approach the situation
makes a difference.
o Let the client know you understand that it is hard to
quit smoking, support efforts to quit, and offer
suggestions on the latest methods available to help
kick the smoking habit.

b. SILENCE
 Periods of silence allow you and the client to reflect and
organize thoughts, which facilitates more accurate reporting
and data collection.

c. LISTENING (effectively)
 the most important skill to learn and develop fully in order to
collect complete and valid data from your client.
 to maintain good eye contact, smile or display an open,
appropriate facial expression, maintain an open body position
(open arms and hands and lean forward).
 Avoid preconceived ideas or biases about your client.
 you must keep an open mind.
 Avoid crossing your arms, sitting back, tilting your head
away from the client, thinking about other things, or
looking blank or inattentive.
 It takes concentration and practice.

(Note: In addition, several nonverbal affects or attitudes may hinder

effective communication. They may promote discomfort or distrust).

2. Verbal Communication
 Effective verbal communication is essential to a client
interview.
  The goal of the interview process is to elicit as much data
about the client’s health status as possible.

Several types of questions and techniques to use during the

interview.
a. OPEN-ENDED QUESTIONS
 used to elicit the client’s feelings and perceptions.
 typically begin with the words “how” or “what.”
 An example of this type of question is:
“How have you been feeling lately?”
 These types of questions are important because they
require more than a one-word response from the client
and, therefore, encourage description.
 may help to reveal significant data about the client’s
health status.
 The following example shows how open-ended questions
work.

o Imagine yourself interviewing an elderly male client who is

at the physician’s office because of diabetic complications.
He mentions casually to you,
 “Today is the two-month anniversary of my wife’s
death from cancer.”

o Failure to follow up with an open-ended question such as,

 “How does this make you feel?” ……..
o …… may result in the loss of important data that could
provide clues to the client’s current state of health.

b. CLOSED-ENDED QUESTIONS
 Use to obtain facts and to focus on specific information.
 The client can respond with one or two words.
 The questions typically begin with the words “when” or “did.”
o E.g., “When did your headache start?”
 useful in keeping the interview on course.
 used to clarify or obtain more accurate information about
issues disclosed in response to open-ended questions.
o E.g., in response to the open-ended question.…..
“How have you been feeling lately?”
o …… the client says, “Well, I’ve been feeling really sick at
my stomach and I don’t feel like eating because of it.”
o You may be able to follow up and learn more about the
client’s symptom with a closed-ended question such as….
“When did the nausea start?”

ADDITIONAL QUESTION APPROACHES

1. LAUNDRY LIST
 provide the client with a choice of words to choose from in
describing symptoms, conditions, or feelings.
 Helps you to obtain specific answers and reduces the
likelihood of the client’s perceiving or providing an expected
answer.
 o E.g., “Is the pain severe, dull, sharp, mild, cutting, or
piercing?”
o “Does the pain occur once every year, day, month, or
hour?”
 Repeat choices as necessary.

2. REPHRASING
 Rephrasing information the client has provided is an effective
way to communicate during the interview.
 helps to clarify information the client has stated
 it also enables you and the client to reflect on what was said.
o E. g, your client, Mr. G., tells you that he has been really
tired and nauseated for 2 months and that he is scared
because he fears that he has some horrible disease.
o You might rephrase the information by saying ,……
 “You are thinking that you have a serious illness?”

3. WELL-PLACED PHRASES
 Client verbalization can be encouraged by well-placed phrases
from the nurse.
 If the client is in the middle of explaining a symptom or feeling
and believes that you are not paying attention, you may
fail to get all the necessary information.
 Listen closely to the client during his or her description and use
phrases such as “um-hum,” “yes,” or “I agree” to encourage the
client to continue.

4. INFERRING
 Inferring (supposing) information from what the client tells you
and what you observe in the client’s behavior may elicit more data
or verify existing data.
 Be careful not to lead the client to answers that are not true
 An example of inferring information….
o Your client, Mrs. J., tells you that she has bad pain.
o You ask where the pain is, and she says,,,, “My stomach.”
o You notice the client has a hand on the right side of her
lower abdomen and seems to favor her entire right side.
o You say,,,, “It seems you have more difficulty with the right
side of your stomach” (use the word “stomach” because
that is the term the client used to describe the abdomen).
 This technique, if used properly, helps to elicit the most accurate
data possible from the client.

5. PROVIDING INFORMATION
 to provide the client with information as questions and
concerns arise.
 Make sure you answer every question as well as you can.
 If you do not know the answer, explain that you will find out
for the client.
 The more clients know about their own health, the more likely
they are to become equal participants in caring for their health.

Special Considerations during the Interview

  Three variations in communication must be considered as
you interview clients: gerontologic, cultural, and emotional.
o These variations affect the nonverbal and verbal techniques
you use during the interview.
o E.g., you are interviewing an 82-year-old woman and you
ask her to describe how she has been feeling.
 She does not answer you and she looks confused.
 This older client may have some hearing loss.
 In such a case, you may need to modify the verbal
technique of asking open-ended questions by following
the guidelines provided under Gerontologic Variations
in Communication

1. Gerontologic Variations in Communication

(Domarad & Buschmann, 1995).
 Age affects and commonly slows all body systems to varying degrees.
 However, normal aspects of aging do not necessarily equate with a
health problem, so it is important not to approach an interview with
an elderly client assuming that there is a health problem.
 Older clients have the potential to be as healthy as younger clients.
 When interviewing an elderly client, you must first assess hearing acuity.
 Hearing loss occurs normally with age, and undetected hearing loss is
often misinterpreted as mental slowness or confusion.
 If you detect hearing loss, speak slowly, face the client at all times during
the interview, and position yourself so that you are speaking on the side
of the client that has the ear with better acuity.
 Do not yell at the client.
 Older clients may have more health concerns than younger clients and
may seek health care more often.
 Many times, older clients with health problems feel vulnerable and scared.
 They need to believe that they can trust you before they will open up to
you about what is bothering them.
 Thus establishing and maintaining trust, privacy, and partnership
with the older client is particularly important
 It is not unusual for elderly clients to be taken for granted and their
health complaints ignored, causing them to become fearful of
complaining.
 It is often disturbing to the older client that their health problems may
be discussed openly among many health care providers and family
members.
 Assure your elderly clients that you are concerned, that you see
them as equal partners in health care, and that what is discussed
will be between you, their health care provider, and them.
 Speak clearly and use straightforward language during the interview
with the elderly client.
 Ask questions in simple terms.
 Avoid medical jargon and modern slang.
 However, do not talk down to the client.
 Being older physically does not mean the client is slower mentally.
 Showing respect is very important.
 However, if the older client is mentally confused or forgetful, it is
important to have a significant other (e.g., spouse, child, close friend)
present during the interview to provide or clarify the data.
2. Cultural Variations in Communication
 Ethnic/cultural variations in communication and self-disclosure
styles may significantly affect the information obtained
(Andrews & Boyle, 1999; Giger & Davidhizar, 1995; Luckmann, 2000).
 Be aware of possible variations in the communication styles of
yourself and the client.
 If misunderstanding or difficulty in communicating is evident,
seek help from an expert, what some professionals call a
“culture broker.”
o This is someone who is thoroughly familiar not only with
the client’s language, culture, and related health care
practices but also with the health care setting and system
of the dominant culture.

Frequently noted variations in communication styles include:

• Reluctance to reveal personal information to strangers for various
culturally-based reasons
• Variation in willingness to openly express emotional distress or pain
• Variation in ability to receive information (listen)
• Variation in meaning conveyed by language.
o E.g., a client who does not speak the predominant language may
not know what a certain medical term or phrase means and, therefore,
will not know how to answer your question.
o Use of slang with non-native speakers is discouraged as well.
o Keep in mind that it is hard enough to learn proper language,
let alone the idiom vernacular.
o The non-native speaker will likely have no idea what you are trying to convey.
• Variation in use and meaning of nonverbal communication:
eye contact, stance, gestures, demeanor.
o E.g., direct eye contact may be perceived as rude, aggressive, or
immodest by some cultures but lack of eye contact may be
perceived as evasive, insecure, or inattentive by other cultures.
o A slightly bowed stance may indicate respect in some groups;
size of personal space affects one’s comfortable interpersonal distance;
touch may be perceived as comforting or threatening.

• Variation in disease/illness perception:

o Culture-specific syndromes or disorders are accepted by some
groups (e.g., in Latin America, susto is an illness caused by a
sudden shock or fright).

• Variation in past, present, or future time orientation

o e.g., the dominant U.S. culture is future oriented; other cultures
may focus more on the past or present

• Variation in the family’s role in the decision-making process:

o A person other than the client or the client’s parent may be the
major decision maker about appointments, treatments, or follow-up
care for the client.
o You may have to interview a client who does not speak your language.
o To perform the best interview possible, it is necessary to use an interpreter.
o Possibly the best interpreter would be a culture expert (or culture broker).
 o Consider the relationship of the interpreter to the client.
o If the interpreter is the client’s child or a person of a different sex, age, or
social status, interpretation may be impaired.
o Also keep in mind that communication through use of pictures may be
helpful when working with some clients.

3. Emotional Variations in Communication

 Not every client you encounter will be calm, friendly, and eager to
participate in the interview process.
 Clients’ emotions vary for a number of reasons.
o They may be scared or anxious about their health or about
disclosing personal information, angry that they are sick or
about having to have an examination, depressed about their
health or other life events, or they may have an ulterior motive
for having an assessment performed.
 Clients may also have some sensitive issues with which they are
grappling and may turn to you for help.

GUIDELINES OF AN EFFECTIVE INTERVIEW

INTERA INTERACTING WITH CLIENTS WITH VARIOUS EMOTIONAL STATESCTING

WITH CLIENTS WITH VARIOUS EMOTIONAL STATES
1. When Interacting with an Anxious Client
• Provide the client with simple, organized information in a structured format.
• Explain who you are and your role and purpose.
• Ask simple, concise questions.
• Avoid becoming anxious like the client.
• Do not hurry and decrease any external stimuli.
2. When Interacting with an Angry Client
• Approach this client in a calm, reassuring, in-control manner.
• Allow him to ventilate feelings. However, if the client is out of control,
do not argue with or touch the client.
• Obtain help from other health care professionals as needed.
• Avoid arguing and facilitate personal space so the client does not
feel threatened or cornered.
3. When Interacting with a Depressed Client
• Express interest in and understanding of the client and respond in
a neutral manner.
• Do not try to communicate in an upbeat, encouraging manner.
This will not help the depressed client.
4. When Interacting with a Manipulative Client
• Provide structure and set limits.
• Differentiate between manipulation and a reasonable request.
• If you are not sure whether you are being manipulated, obtain an
objective opinion from other nursing colleagues.
5. When Interacting with a Seductive Client
• Set firm limits on overt sexual client behavior and avoid responding
to subtle seductive behaviors.
• Encourage client to use more appropriate methods of coping in
relating to others.
6. When Discussing Sensitive Issues (for example, Sexuality,
Dying, Spirituality)
• First be aware of your own thoughts and feelings regarding dying,
spirituality, and sexuality; then recognize that these factors may
affect the client’s health and may need to be discussed with someone.
• Ask simple questions in a nonjudgmental manner.
• Allow time for ventilation of client’s feelings as needed.
• If you do not feel comfortable or competent discussing personal,
sensitive topics, you may make referrals as appropriate,
for example, to a pastoral counselor for spiritual concerns or
other specialists as needed.

COMMUNICATION TO AVOID
A. Nonverbal Communication to Avoid
a. Excessive or Insufficient Eye Contact:
 Avoid extremes in eye contact. Some clients feel very
uncomfortable with too much eye contact; others believe that
you are hiding something from them if you do not look them
in the eye.
 Therefore, it is best to use a moderate amount of eye contact.
o E.g., establish eye contact when the client is speaking to you
but look down at your notes from time to time.
 A client’s cultural background often determines how he feels
about eye contact

b. Distraction and Distance:

 Avoid being occupied with something else while you are asking
questions during the interview.
o This behavior makes the client believe that the interview
may be unimportant to you
 Avoid appearing mentally distant as well.
o The client will sense your distance and will be less likely
to answer your questions thoroughly.
 Try to avoid physical distance exceeding 2 to 3 feet during the
interview.
o Rapport and trust are established when the client senses
your focus and concern are solely on the client and the
client’s health.
o Physical distance may portray a noncaring attitude or a
desire to avoid close contact with the client.

c. Standing:
 Avoid standing while the client is seated during the interview.
 Standing puts you and the client at different levels.
o You may be perceived as the superior, making the client
feel inferior.
o Care of the client’s health should be an equal partnership
between the health care provider and the client.
o If the client is made to feel inferior, he or she will not feel
empowered to be an equal partner and the potential for
optimal health may be lost.
 vital information may not be revealed if the client believes that the
interviewer is untrustworthy, judgmental, or disinterested.
B. Verbal Communication to Avoid
a. Biased or Leading Questions:
 Avoid using biased or leading questions.
o These cause the client to provide answers that may or
may not be true.
 The way you phrase a question may actually lead the client to
think you want her to answer in a certain way.
o E.g., if you ask “You don’t feel bad, do you?” ……
 the client may conclude that you do not think she
should feel bad and will answer “no” even if this
is not true.

b. Rushing Through the Interview:

 Avoid rushing the client.
 If you ask the client questions on top of questions, several things
may occur.
o First, the client may answer “no” to a series of closed-ended
questions when he or she would have answered “yes” to one
of the questions if it was asked individually.
o This may occur because the client did not hear the individual
question clearly or because the answers to most were “no” and
the client forgot about the “yes” answer in the midst of the others.
o With this type of interview technique, the client may
believe that his individual situation is of little concern
to the nurse.
 Taking time with clients shows that you are concerned about
their health and helps them to open up.
 Finally, rushing someone through the interview process
undoubtedly causes important information to be left out of the
health history.
 A client will usually sense that you are rushed and may try to
help hurry the interview by providing abbreviated or incomplete
answers to questions.

c. Reading the Questions:

 Avoid reading questions from the history form.
o This deflects attention from the client and results in an
impersonal interview process.
 As a result, the client may feel ill at ease opening up to formatted
questions.
Introduction
Health history provides comprehensive information on what the patient tells the nurse and what the nurse
observes on the patient about one’s health and illness patterns.

Objectives
1. To comprehend the importance of health history in the quality
care of patient
2. To comprehensively apply the varied components of health
assessment to achieve high-level patient care
3. To analyze the various results of the comprehensive health
assessment in the application of worthy nursing practice.

Pre-Assessment
One-minute paper and pencil exercise

Lesson Proper
Review
How is the therapeutic interview process interrelates to health history?
Activity
Interactive discussion
Processing of the Activity.
Can you describe importance of health history taking based on the therapeutic communication?

*Lesson proper
HEALTH HISTORY (overview)

 The health history is an excellent way to begin the assessment process because it lays the groundwork for
identifying nursing problems and provides a focus for the physical examination.
 The importance lies in its ability to provide information that will assist the examiner in identifying areas of
strength and limitation in the individual’s lifestyle provide the examiner with specific cues to health problems
that are most apparent to the client.
 obtains data about the patient’s physical status, information about many other factors that impact patient’s
physical status including spiritual needs, cultural idiosyncrasies, and functional living status.
 addresses health and illness patterns, health promotion and protective patterns, and roles and relationships.
 It consists of what the patient tells you, what the patient perceives, and what the patient thinks is important.
 It provides a holistic, qualitative picture of your patient.
 Clues that you obtain from the health history will direct your physical assessment and are essential in developing
a successful plan of care for your patient.

The purpose of the health history

 to provide you with a description of your patient’s symptoms and how they developed.
 to identify not only actual or potential health problems but also your patient’s strengths.
 Identifies discharge needs.
o a successful discharge plan begins on admission with the health history.
 To create a successful plan of care, one must take a holistic view of your patient and all that affects her or him.
Remember: The plan you develop will be successful only if your patient is able to
follow through with it after discharge.
 Provide the subjective database.
 Identify patient strengths.
 Identify patient health problems, both actual and potential.
 Identify supports.
 Identify teaching needs.
 Identify discharge needs.
 Identify referral needs.

The types of the health history

 complete or focused.
 1. complete health history: includes biographical data, reason for seeking care, current health status, past health
status, family history, a detailed review of systems, and a psychosocial profile.
 2. focused health history: focuses on an acute problem, so all of your questions will relate to that problem.

REMINDER: Setting the Scene

1. Before you begin your assessment, look at your surroundings.
 o Do you have a quiet environment that is free of interruptions?
o A private room is preferred, but if one is not available, provide privacy by using
curtains or screens.
2. Prevent interruptions and distractions so that both you and your patient can stay focused on the history.
3. Make sure that the patient is comfortable and that the room is warm and well lit.
4. If the patient uses assistant devices, such as glasses or a hearing aid, be sure that she
or he uses them during the assessment to avoid any misperceptions.
5. Before you begin asking questions, tell your patient what you will be doing and why.
o Inform him or her if you will be taking notes, and reassure the patient that what
he or she says will be confidential.
6. Avoid excessive note taking.
o It sends the message to your patient that the health history form is more
important than he or she is.
o If you are too preoccupied with writing and continually break eye contact,
you may miss valuable nonverbal messages.
 It may inhibit your patient’s responses, especially when discussing personal and sensitive
issues such as sexuality or drug or alcohol use.
7. Be sure to work at the same level as your patient.
o Sit across or next to her or him.
8. Avoid anything that may break the flow of the interview.
9. If the interview is being recorded or videotaped, be sure to get your patient’s permission
before starting.
o Position the equipment as unobtrusively as possible so that it does not distract you or your patient.
10. The approach to your patient depends on his or her cultural background, age, and developmental level.
o Ask yourself, “Are there any cultural considerations that might influence our interaction?” “What
approach is best, considering my patient’s age”.

Key Points to Remember When Obtaining a Health History

■ Listen to what your patient is telling you both verbally and nonverbally.
■ Don’t rush. Allow enough time to obtain the data.
■ Ensure confidentiality.
■ Provide a private, quiet, comfortable environment.
■ Avoid interruptions.
■ Tell your patient how long the interview will take and why you need to ask these questions.
■ Do not be so concerned about completing forms that you neglect the patient.
■ Start with what the patient perceives as the problem.
■ Use open-ended questions to elicit the patient’s perspective.
■ Attend to any acute problems, such as pain, before obtaining a detailed history.
■ Remember that quality is more important than the quantity of information obtained.

Medical History versus Nursing History

Nursing History Medical History

similar areas addressed and the similar

questions

different focus and scope of medical versus different

nursing practice

similar history questions similar

different underlying rationale different

diagnose and treat the patient’s diagnose and treat illness

response to a health problem

A: Complete Health History

1. Biographical data/ Personal profile
  patient’s name, age, gender, birth date, birthplace, marital status, race, religion, address, education, occupation,
contact person, and health insurance/social security number.
 the source of the health history and his or her reliability, who referred the patient, and whether or not the patient
has an advance directive.
 chief complaint: the reason for seeking healthcare, followed by a description of current health status.

Biographical Data
DATA SIGNIFICANCE/CONSIDERATIONS

Name (Full Name and Prevents confusion when patients have similar names. Formats of names
Maiden Name) may differ culturally (e.g., Cambodians put last name first; married
Hispanic women take husband’s surname while retaining both parents’
last names).

Address and Phone May provide socioeconomic information and identify environmental
Number health risks

(e.g., urban vs. suburban or rural neighborhoods).

Contact Person May be a source for further data and support for patient. Essential in case
of medical emergency.

Age/Birth Date/Place of Allows you to compare stated age with apparent age (e.g., chronic illness
Birth can make a person appear older).

Identifies age-related risk factors for health problems (e.g., children more
at risk for accidents; incidence of cardiovascular disease and cancer
increases with age).

Age helps identify patient’s developmental stage.

Place of birth may correlate with environmental risks.

Gender Identifies risk for gender-related health problems (e.g., women have a
much higher incidence of breast cancer than men).

Race/Ethnicity/Nationality Identifies risk for health problems associated with a particular race or
ethnic group (e.g., African American males have high incidence of
hypertension, Native Americans have high incidence of diabetes).

Identifies possible ethnic influences on healthcare practices.

Religion Alerts you to religious beliefs that may influence health practices (e.g.,
Judaism and diet, Jehovah’s Witnesses and blood products). May identify
sources of support for your patient.

Marital Status (Never Identifies possible support people.

Married, Married,
Present health status may affect family relationships, patient’s economic
Widowed, Separated,
status, and ability to support family.
Divorced)
Referral may be necessary.

Number of Dependents Do not assume that unmarried patients live alone.

 Ask if they live with someone.

Educational Level Helps determine teaching approaches. Do not assume that educational
level correlates with knowledge and understanding (e.g., newly diagnosed
diabetic may have a Ph.D. but be totally unfamiliar with disease and its
management).

Do not talk down to patient who has had little formal education.

Ask your patient what teaching method she or he prefers (e.g., videos,
pamphlets, group, one on one).

Occupation Identifies possible occupational risk factors.

Provides clues about socioeconomic status.

Current health status also may affect patient’s occupational status. Referral
may be necessary

Social Security Social Security Number may help in retrieving records.

Number/Health Insurance
Insurance type may influence length of stay.

Referrals may be needed depending on type of health insurance

Source of History/ Ideally, patient is source of history.

Reliability
Secondary source, usually a family member

of friend, is necessary with children or when patient is unable to provide

history.

Establish reliability of person providing history by noting consistency in

responses and willingness to communicate.

Referral Identifies primary care physician/practitioner. If no referral source

identified, may

need to make referral for follow-up.

Advance Directives Allows you to comply with patient’s healthcare wishes if Advance
Directives exist.

CHIEF COMPLAINT - reason(s) for seeking health care; from patient’s own words

 Includes two questions: 1. “What is your major health problem or concerns at this
time?”
2. “How do you feel about having to seek health care?”

 the first question assists the client in focusing on the most significant health concern
and answers the nurse’s question, “Why are you here?” or complaint (CC), but a more holistic approach for phrasing the
question may draw out concerns that reach beyond a physical complaint and may address stress or lifestyle changes.

 The second question, “How do you feel about having to seek health care?” encourages the client to discuss fears or
other feelings about having to see a health care provider.

 E.g., a woman visiting a nurse practitioner states her major health concern:
 “I found a lump in my breast.”
This woman may be able to respond to the second question by voicing fears that she has been reluctant to share
with her significant others. This question may also draw out descriptions of previous experiences—both positive and
negative—with other health care providers.

 Sample questions to be elicited

o So, tell me why you have come here today?
o Tell me what your biggest complaint is right now?
o What is bothering you the most right now?
o If we could fix any of your health problems right now, what would it be?
o What is giving you the most problems right now?
 If your patient has more than one complaint, discuss which one is the most troublesome for them and document
the complaints in order of importance as determined by the patient (Jarvis, 2012).
 Ask your patient why he or she is seeking healthcare;
 Document his or her direct quote.
 The patient’s reason for seeking care is usually related to the level of preventive
healthcare —primary, secondary, or tertiary.
 If the setting is a primary level of healthcare, there is usually no acute problem. The reason generally relates to
health maintenance or promotion.
o For example, the patient states, “I am here for my annual physical examination.”
 If there is an acute problem, ask the patient to state that the problem is and how long it has been going on.
o For example, “I have had chest pain for the last hour.”
 If your patient identifies more than one problem, she or he may be confusing associated symptoms with the
primary problem.
o Help her or him clarify and prioritize the problems by asking questions such as, “Which problems are
giving you the most difficulty?”
o Usually, patients identify problems that affect their ability to do what they usually do.

Hint: perform a symptom analysis for any positive symptom that your patient reports.

HISTORY OF PRESENT ILLNESS - history of present health concern

 This section of the health history takes into account several aspects of the health problem and asks questions whose answers
can provide a detailed description of the concern.

 encourage the client to explain the health problem or symptom in as much detail as possible by focusing on:
o the onset
o progression, and
o duration of the problem
o signs and symptoms and related problems
o what the client perceives as causing the problem.
o ask the client to evaluate:
 what makes the problem worse
 what makes it better,
 which treatments have been tried,
 what effect the problem has had on daily life or lifestyle,
 what expectations are held regarding recovery, and
 what is the client’s ability to provide self-care

 Obtaining information about a patient’s present health status allows the nurse to investigate current complaints.
 The mnemonic, PQRST, utilizes a structured format for information gathering, including evaluation of pain, and
provides an efficient methodology to communicate with other healthcare providers.
 Use PQRST to assess each symptom and after any intervention to evaluate any changes or responses to treatment
(Jarvis, 2012).

PQRST
P = Provocative / Palliative / Precipitating Factors
Ask: What were you doing when the problem started?
Does anything make it better, such as medications or certain positions?
Does anything make it worse, such as movement or breathing?
Q = Quality / Quantity
Ask: Can you describe the symptom?
What does it feel like, look like, or sound like?
How often are you experiencing it?
To what degree does this problem affect your ability to perform your usual daily activities?
R = Region or Radiation / Related Symptoms
Ask: Can you point to where the problem is?
Does it occur or spread anywhere else? (Take care not to lead your patient.)
Do you have any other symptoms?
(Depending on the chief complaint, ask about related symptoms. For example, if the
patient has chest pain, ask if she or he has breathing problems or nausea.)
S = Severity
Ask: Is the symptom mild, moderate, or severe?
Grade it on a scale of 0 to 10, with 0 being no symptom and 10 being the most severe.
(Grading on a scale helps objectify the symptom.)
On a scale of 1-10, (10 being the worst) how bad is the symptom(s)?
Another visual scale may be appropriate for patients that are unable to identify with this
scale.

T = Timing
Ask: When did the symptom start?
How often does it occur?
How long does it last?
Does it occur in association with something else (i.e. eating, exertion, movement)?

The COLDSPA mnemonic adapted to analyze back pain.

Mneumonic Question

Character Describe the sign or symptom (feeling, appearance, sound, smell, or taste if
applicable).

“What does the pain feel like?”

Onset When did it begin?

“When did this pain start?”

Location Where is it? Does it radiate? Does it occur anywhere else?

“Where does it hurt the most? Does it radiate or go to any other part of your
body?”

Duration How long does it last? Does it recur?

“How long does the pain last? Does it come and go or is it constant?”

Severity How bad is it? How much does it bother you?

“How intense is the pain? Rate it on a scale of 1 to 10.”

Pattern What makes it better or worse?

“What makes your back pain worse or better? Are there any treatments
you’ve tried that relieve the pain?”

Associated factors What other symptoms occur with it? How does it affect you?
/How it Affects the
“What do you think caused it to start?
client
 Do you have any other problems that seem related to your back pain? How
does this pain affect your life and daily activities?”

PAST HEALTH HISTORY

It is important to ask questions about your patient’s past health history.

PURPOSE:
 to identify any health factors from the past that may have a direct relationship to your
patient’s current health status.
For example, a history of rheumatic fever as a child may explain
mitral valve disease as an adult.
 identifies any chronic preexisting health problems, such as diabetes or hypertension,
which may directly affect the current health problem.
For example, patients with diabetes often have poor wound healing.

Also, even though the chronic disease may be well controlled,

the current health problem may cause an exacerbation.
For instance, a patient with well-controlled diabetes may need
to adjust his or her medication when scheduled for surgery, because the
stress of surgery can elevate blood glucose.
 can identify additional health risks caused by preexisting conditions.
 may also explain your patient’s response to illness, healthcare, and healthcare
workers.
Example, if she or he has a history of multiple medical
problems requiring frequent hospitalizations, these
experiences may affect her or his perception of
healthcare either positively or negatively.

Reminder:
 When obtaining the past health history, be sure to ask for dates, physicians’ names,
names of hospitals, and reasons for hospitalizations or surgeries.
This information is important if past records are needed.
 Also avoid using terms such as “usual,” “general,” or “routine.”
For example, “usual” childhood illnesses vary depending
on the age of your patient and available immunizations.

This portion of the health history focuses on questions related to the client’s personal history, from the earliest beginnings
to the present.
 Ask the client about any childhood illnesses and immunizations to date. Adult illnesses (physical, emotional, and
mental) are then explored.
 Ask the client to recall past surgeries or accidents.
 Ask the client to describe any prolonged episodes of pain or pain patterns he or she has experienced.
 Inquire about any allergies (food, medicine, pollens, other) and use of prescription and over-the-counter (OTC)
medications.

Past Health History Assesses:

 birth
 growth
 development
 childhood illnesses,
 immunizations,
 hospitalizations,
 surgeries,
 serious injuries,
 previous health problems
 adult medical problems (including serious or chronic illnesses),
 allergies,
 chronic illnesses medications,
 recent travel, and
 military service.
 pain experiences
  accidents or traumatic injuries,
 psychiatric or mental illnesses,
 For women - history of menstrual cycle, how many pregnancies and how many births (Jarvis, 2012).

Childhood Illnesses:
 Data related to childhood illnesses is more pertinent to children than adults and the elderly.
 For adults, you want to know if they have ever had rheumatic fever and if their tetanus and hepatitis B
vaccinations are current.
 For the elderly, you may want to ask if they ever had polio, rheumatic fever, or
chicken pox. Pertinent vaccinations for the elderly would include tetanus, pneumonia and influenza (Jarvis, 2012).
Accidents or Traumatic Injuries:
 When assessing pay particular attention to patterns of injury, especially in infants, children, women and the
elderly (Jarvis, 2012).
Hospitalizations:
 Be sure to ask the reason for the hospitalization and the nature of the treatments received while in the hospital
such as blood transfusions, surgeries and any follow-up treatments.
 Remember to include hospitalizations for childbirth (Jarvis, 2012).
Surgeries:
 Many surgical procedures are performed on an outpatient basis.
 Questions regarding surgeries should also be asked in addition to hospitalizations, as patients may not discuss a
surgery if there was no associated hospital stay (Jarvis, 2012).
Psychiatric or Mental Illnesses:
 If your patient has a past history of psychiatric or mental illnesses, ask what
triggered the illness, if anything, and the course and the progression of the illness.
 This includes depression and anxiety, as well as diagnosed mental illness (Jarvis, 2012).
Psychosocial profile
 gives a picture of the patient’s health promotion and preventive patterns.
 includes a description of:
o health practices and health belief
o a typical day
o nutritional patterns
o activity/exercise patterns
o recreational patterns
o sleep/rest patterns
o personal habits
o occupational and environmental risk factors
o socioeconomic status
o developmental level
o roles and relationships
o self-concept
o religious and cultural influences
o supports
o sexuality patterns
o emotional health status
Allergies:
 Identify what your patient is allergic to (both food and medication), as well as the reaction and response to
treatment.
 It is important to ask about any environmental allergies or sensitivities (such as latex)
also (Jarvis, 2012).

The questions elicit data related to the client’s strengths and weaknesses in his or her health history.
The information gained from the questions assists the nurse in identifying risk factors that stem from previous health problems.
Risk factors may be to the client or significant others.

Sample questions:
 Were there any problems?
 As far as you know, did you progress normally as you grew to adulthood?
 Were there any problems that your family told you about or that you experienced?”
 What diseases did you have as a child such as measles or mumps?
 What immunizations did you get and are you up to date now?
 Do you have any chronic illnesses? If so, when was it diagnosed? how is it treated? How satisfied have you been
with the treatment?”
 What illnesses or allergies have you had? How were the illnesses treated?
  What medications have you used in the recent, past and current, both that your doctor prescribed and those you
can buy over the counter at a drug or grocery store? For what purpose did you take the medication? How much
(dose) and how often did you take the medication?”
 Have you ever been pregnant and delivered a baby? How many times have you been pregnant/delivered?
 Have you ever been hospitalized or had surgery? If so when? What were you hospitalized for or what type of
surgery did you have? Were there any complications?
 Have you experienced any accidents or injuries? Please describe them?
 Have you experienced pain in any part of your body? Please describe the pain?
 Have you ever been diagnosed/treated for emotional or mental problems? If so, please describe their nature and
any treatment received? Describe your level of satisfaction with the treatment?

How clients frame their previous health concerns suggests how they feel about themselves and is an indication of their sense of
responsibility for their own health.
For example: a client who has been obese for years may blame himself for
developing diabetes and fail to comply with his diet, whereas
another client may be very willing to share the treatment of
her diabetes and success with an insulin pump in a support group.

Some clients are very forthcoming about their past health status; others are not.
It is helpful to have a series of alternative questions for less responsive clients and for those
who may not understand what is being asked.

FAMILY HISTORY
 identify familial or genetically linked disorders.
 review of systems provides a comprehensive assessment to determine patient’s physiological status.
 Past or current problems may be identified and warrant further investigation.
 Researchers discover an increasing number of health problems seem to run in families and that are genetically
based the family health history assumes greater importance - genetic predisposition

Reminder: Be aware of other health problems that may have affected the client by virtue of having grown up in the
family and being exposed to the problems.
Example 1: a gene predisposing a person to smoking has not yet been discovered but a
family with smoking members can affect other members in at least two ways:
- First, second-hand smoke can compromise the physical health of nonsmoking
members;
- second, the smoker may serve as a negative role model for children, inducing
them to take up the habit as well.
Example 2: obesity; recognizing it in the family history can alert the nurse to a potential risk
factor.

Guides to assessment
 The family history should include as many genetic relatives as the client can recall
 Include maternal and paternal grandparents, aunts and uncles on both sides, parents, siblings, and the client’s
children.
o Such thoroughness usually identifies those diseases that may skip a generation, such as autosomal
recessive disorders.
 Include the client’s spouse but indicate that there is no genetic link.
 Identifying the spouse’s health problems could explain disorders in the client’s children not indicated in the
client’s family history.
 Illustrate the client’s family history.

GENOGRAM - Illustration of the client’s family history

 Use a standard format so that others can easily understand the information.
 Provide a key to the symbols used.
 Usually, female relatives are indicated by a circle and male relatives by a square.
 A deceased relative is noted by marking an X in the circle or square and listing the age at death and cause of
death. Identify all relatives, living or dead, by age and provide a brief list of diseases or conditions.
 If the relative has no problems, the letters “A/W” (alive and well) should be placed next to the age.
 Straight vertical and horizontal lines are used to show relationships.
 A horizontal dotted line can be used to indicate the client’s spouse; a vertical dotted line can be used to indicate
adoption.
 After the diagrammatic family history, prepare a brief summary of the kinds of health problems present in the
family.
o For example:
  the client in the genogram depicted in Figure 2-4 has longevity, obesity,
heart disease, hypertension (HTN), arthritis, thyroid disorders, type 1 or type 2 diabetes, alcoholism,
smoking, myopia, learning disability, hyperactivity disorder, and cancer (one relative) on his maternal side.
 On the client’s paternal side are obesity, heart disease, hypercholesterolemia, back problems, arthritis,
myopia, and cancer.
 The paternal history is not as extensive as the maternal history because the client’s father was adopted.
 In addition, the client’s sister is obese and has Graves’ disease and hypercholesterolemia.
 His wife has arthritis; his children are both A/W.

(cont. genogram)
 provides clues to genetically linked or familial diseases that may be risk factors for
your patient.
 Ask about the health status and ages of your patient’s family members.
 Family members include the patient, spouse, children, parents, siblings, aunts and uncles, and grandparents.
 Ask about genetically linked or common diseases, such as heart disease, high blood pressure, stroke, diabetes,
cancer, obesity, bleeding disorders, tuberculosis, renal disease, seizures, or mental disease.
 If the patient’s family members are deceased, record the age and cause of death.
 may be recorded in one of two ways.
 You can list family members along with their age and health status, or you can use a genogram (family tree).
 A genogram allows you to identify familial risk factors at a glance.
 When developing a genogram, use symbols to represent family members, and include a
key to explain the symbols and abbreviations (Fig. 2.1).
 Another tool that can be effective in taking a patient’s family history is an ecomap

Understanding Ecomapping
ECOMAP
 a family assessment tool that identifies the needs, patterns, and relationships among family members and the
environment, such as school, work, church, healthcare system.
 presents a visual representation as a genogram does for a family history.

Characteristics of an ecomap include:

■ Identifies major systems that are a part of the family’s life.
■ Depicts the nature of the relationships with the external systems.
■ Identifies both positive and negative relationships with the external systems.
■ Identifies the flow of energy and resources between family members and the environment.
■ Allows you to see each member within the whole family unit and the relationship with the environment, identifying
areas of strengths and conflict.

PSYCHOSOCIAL PROFILE
  The last part of health history
 consider the developmental stage of your patient.
 A person’s development crosses the life span.
 Several developmental theories exist and will provide a framework for the psychosocial profile.
 The theories focus on specific areas of development, such as physical, psychosocial, cognitive, and behavioral.
 Identifying the patient’s developmental stage will help determine the relationship between the patient’s health
status and his or her growth and development.
 Because many of these theories do not cross the life span, do not limit to one developmental model.
 Each theorist views development from a different perspective.
 Be open and choose the theory or theories that will best help assess the patient’s development.

Children’s assessment:
 developmental assessments are often performed
 the developmental changes that occur at this age are very observable and measurable.
o For example, when Johnny, age 4, is admitted to the hospital for a hernia repair, he begins wetting the bed during
the night, even though his mother assures you that he has been “potty trained” since age 3.

Adult’s assessment:
 developmental changes need to be considered during the assessment.
 illness and hospitalization can have a major impact on a child’s growth and development, by either halting its
progression or regressing it to an earlier stage.

Summary of Developmental Theories

Knowledge of the various developmental theories provides the nurse with a framework for cultural
and psychosocial assessment. This chart lists selected developmental theorists and summarizes the
focus of their theories.

Theorist Theory Focus

Sigmund Freud Psychosexual: Biological drives influence a person’s psychological and

personality development.

Erik Erikson Psychosocial: The human life cycle is composed of eight developmental stages,
each containing a developmental crisis to be resolved. Psychosocial strengths
emerge with resolution of the crisis.

Abraham Maslow Self-actualization: People are innately motivated toward psychological growth,
self-awareness, and personal freedom. Basic needs must be met before a
person can advance to higher needs.

Jean Piaget Cognitive development: An individual’s knowledge comes from the interaction
between genetic potential and culturally influenced environmental
experiences.

Lawrence Kohlberg Moral development: Cognitive development and emotional growth affect the
individual’s ability to make autonomous decisions.

Carol Gilligan Moral development from a female perspective: Women have moral concern for
others based on their innate nurturing instincts. They maintain social rules
and the expectations of families, social groups, or culture.
Robert Butler Life review: Elderly patients spend time reviewing past events and
concentrating on past conflicts. This life review correlates with the elderly
patient’s good long-term memory.

Robert Peck Psychosocial: This theory emphasizes aspects of development from middle age
through old age by dividing Erikson’s last stage into two parts. There is a
developmental crisis to be resolved in each part.

Robert Havighurst Activity during aging: Elderly patients who stay active and maintain or find
substitutes for activities of middle age are more satisfied with life than elderly
patients who do not. Diminished activity is equated with increased social
isolation and accelerated physical decline.

Elaine Cumming Disengagement during aging: A person naturally gives up roles (a career, for
example) and undergoes losses (through death) as aging occurs. As losses
and William Henry
occur, a person withdraws from the high activity level of middle age. At the
same time, society withdraws from the elderly patient to avoid assigning
crucial roles to a group with a high death rate. This mutual disengagement
helps society and the elderly patient prepare for death.

Evelyn Duvall Family development: Family goes through identifiable stages with tasks to be
mastered.

Developmental Stages and Theories

STAGE FREUD ERIKSON PIAGET KOHLBERG

Infancy: Birth Oral- Trust vs. mistrust Sensorimotor

to 1yr. sensory

Toddler: 1–3yr. Anal Autonomy vs. Preoperational Preconventional

shame level—punishment
thought— preconceptual
and obedience
phase

Preschool: 3– Phallic Initiative vs. guilt Preoperational— Preconventional level

6yr. intuitive phase

School Age: Latency Industry vs. Concrete operations— Conventional level—

inferiority inductive reasoning and
6–12yr. conformity and
beginning to
loyalty; responds to
think logically authority

Adolescence: Genital Identity vs. role Formal operation— Postconventional—

12–18 Yr diffusion deductive and Behavior corresponds

with society
abstract reasoning
Young Adult: Intimacy vs.
isolation
18–40yr.

Middle Adult: Generativity vs.

40–64yr. stagnation

Older Adult: Integrity vs.

despair
64yr. to Death

Developmental Tasks

STAGE FREUD ERIKSON PIAGET KOHLBERG HAVIGHURST

Adolescent Attains Realizes a Able to Stage 4: Law Acceptance and

sexual stable sense combine and order. development
maturity of identity. systems.
Behavior of gender role.
Develops Develops
and becomes guided by law Develops
devotion hypothetical
interested in deductive and order, the more mature
and fidelity.
sex. rules of relationships.
thinking.
society. Attains
Adjusts to
emotional,
physical
financial
changes,
independence
retirement,
from parents.
reduced
Begins to think
income, loss of
of choosing
spouse, family
members, and a career and a
friends. partner for

marriage.
Intellectual
skills

and socially
acceptable

behavior
develop further.

Young Develops Stage 5: Social Selects mate.

personal and contract. Learns to live
adult
professional Respects together with
relationships. individual partner.
 Attains differences. Starts career and
affiliation Realizes that family.
and love.
social laws may Rears family.
Manages
contradict
moral career, family,
and home.
principles.
Tries to better Assumes civic
responsibility.
the social
condition. Has social
group of friends.

Middle Productive Stage 6: Assumes more

and creative Universal- civic and social
adult
in ethical. responsibility.

both work Universal- Maintains career

and ethical and family.
relationships. Develops leisure
principles
Develops guide moral activities.
productivity Strengthens
judgment with
and
spousal
underlying
caring for relationship.
good of
family,
Accepts midlife
friends, and humanity as
changes.
community. driving force
even at expense Cares for aging
of the parents.

individual.
This stage is
rarely met by
most
individuals
over the course
of a lifetime.

Older adult Has had Adjusts to Develops

purpose in physical explicit identity
life and with own age
changes,
group.
fulfillment. retirement,
Achieves Modifies living
reduced
sense
income, loss of
 of fulfillment spouse, family arrangements.
and wisdom. members, Meets social and
civic obligations.
and friends.

Psychosocial Profile

DATA SIGNIFICANCE/CONSIDERATIONS

Health Practices Your patient’s overall health is affected by her or his values, beliefs, financial
and Beliefs status, expectations of healthcare, and other factors.

How does the patient perceive her or his role in maintaining health? Does she or
he get a yearly physical examination or seek healthcare only when ill?

Does she or he perform self-examinations and other self-care measures?

Health is a component of every aspect of life.

Determine whether your patient’s life positively or negatively affects her or his
health.

Typical Day Describing a typical day may identify health risk factors.

Or, if the patient has a health problem, it helps determine what effect this
problem has on his or her everyday life.

Nutritional Eating habits can positively or negatively affect your patient’s health. Religious
Patterns beliefs or culture may influence eating habits.

Financial problems, such as being on a fixed income, may limit food purchases.

Ask about special diets, food preferences, food allergies, weight changes,
happiness with weight, and history of eating disorders.

Ask who does the cooking, who does the shopping, and who dines with the
patient.

All of these factors have an effect on nutrition.

Screen for nutritional deficits by doing a 24-hour recall.

Ask the patient, “What did you eat yesterday?”.

Do the recall on a weekday rather than a weekend because it is more reflective of

the usual diet.

After you complete the 24-hour recall, compare the diet with the food groups
(meat, poultry, and fish; grains; dairy; vegetables and fruits) and note any
deficits.

Take note of number and size of servings.

Also note if your patient is taking vitamins, mineral or herbal supplements.

 Make nutritional referrals as indicated.

Activity and Activity and routine exercise can help maintain both physical and mental health.
Exercise Patterns
Ask about type and amount of activity or exercise.

If your patient participates in contact sports, assess use of protective equipment

and provide instruction as needed.

If she or he has a health problem, determine its effect on her or his ability to
maintain usual activity and exercise patterns.

Recreation, Recreational activities, hobbies, and pets usually enhance health by reducing
Hobbies, Pets stress.

But they can also pose health risks.

For example, stained glass work exposes one to lead, and pets may trigger
allergies or carry diseases such as toxoplasmosis.

Sleep/Rest Many physical and psychological problems can affect sleep or are affected by
Patterns lack of sleep.

Ask your patient how many hours of sleep she or he gets, if sleep is interrupted,
how many hours she or he needs to feel rested, any medication taken to aid
sleep, or if patient has any sleeping disorders such as narcolepsy or sleep apnea.

Personal Habits Unhealthy personal habits, such as use of tobacco, alcohol, caffeine, and drugs,
can adversely affect health.

Ask for specific information about the amount and length of use.

Tobacco: Ask about cigarettes (filtered/unfiltered), pipe, cigars, or chewing

tobacco.

Alcohol: Ask what kinds (wine, beer, mixed drinks), when patient drinks, if he or
she drinks to help deal with stress, and whether patient notices a change in his
or her drinking patterns (more or less).

The CAGE questionnaire can be used to screen for alcohol abuse.

Caffeine: Ask what kinds (coffee, tea, chocolate) and if patient has trouble
sleeping, nervousness, or palpitations.

Drugs: Ask what kinds (prescription, over-the-counter, recreational, or street

drugs), when patient last took drug, and method of use (e.g., inhalation,
intravenous, oral).

A L E R T: IV drug users are at risk for hepatitis B and HIV.

Occupational Certain occupations pose health risks.

Health Patterns
Ask your patient if her or his job requires exposure to toxins such as asbestos,
pesticides, plastics, anesthetics, radiation, or solvents; protective gear (e.g.,
 construction workers, welders, landscapers, and tree trimmers), or heavy
physical activity, such as nursing.

Job satisfaction can also affect health.

Ask your patient if she or he is satisfied with the job, what she or he likes best
and least, how many hours a week she or he works, how far she or he travels to
and from work, if there are occupational health programs, if she or he gets work
breaks, how much vacation she or he gets, if she or he considers the job stressful,
and if she or he is satisfied with the salary received.

Socioeconomic Socioeconomic status can have a major impact on your patient’s health and
Status healthcare.

Ask your patient if he or she has health insurance, dental insurance, or a

prescription plan.

Limited financial resources may limit available healthcare services or prevent

your patient from following through with a treatment plan. You may need to
make referrals to social service agencies for assistance.

Environmental The patient’s home and type of community can have an impact on her or his
Health Patterns health.

Ask if the patient’s community is urban, suburban, or rural.

Urban dwellers are exposed to more noise and air pollution, whereas rural
dwellers are exposed to more polluted water sources, septic systems, and greater
contact with allergens and toxins associated with farming.

Determine type of neighborhood.

Ask the patient if she or he feels safe; are there adequate sidewalks and lighting;
with police and fire departments and ambulance nearby; public transportation;
accessibility to food and drug stores; easy access to churches, schools, healthcare
facilities, and community supports, such as senior citizen centers?

Determine type of home patient lives in.

Ask if it is a single home or apartment; if she or he rents or owns it; if living

space, heating, water, and plumbing are adequate; if it is one story, two stories,
or more; if there are smoke detectors, fire extinguishers, carbon monoxide
detectors, and a burglar alarm system; and what type of heating is used.

Also ask if medications and cleaning supplies are kept out of the reach of
children and if the family uses seat belts, car seats, and bike helmets.

Identify teaching needs or areas that warrant referrals or further follow-up.

Roles, Your patient’s feelings, attitudes, past experiences, and relationships

Relationships,
contribute to his or her sense of value and worth and affect his or her overall
Self-Concept
health.
 A person with a positive self-concept and an internal locus of control

takes charge and assumes responsibility for his or her life and for achieving
health goals.

Find out if your patient has a positive or negative self-image by

asking what he or she feels are his or her strengths and weaknesses; what he or
she likes best and least about himself or herself; and if he or she considers
himself or herself outgoing or shy.

Find out if his or her locus of control is internal or external by asking if he or she
feels in control of what happens to him or her or believes that “whatever will be
will be.”

Does he or she assume responsibility or place the responsibility on others?

Illness or changes in body image can pose a threat to self-concept.

Be alert for risk factors such as serious illness, loss of function, or surgery that
threaten your patient’s self-image.

Use the supports and resources necessary to help him or her maintain

the integrity of his or her self-concept.

Cultural Culture can influence communication patterns, health beliefs and practices,
Influences dietary habits, family roles, and life-and-death issues.

Ask yourself: Is there a language barrier? Cultural practices that conflict with the
prescribed treatment plan? Dietary preferences that need to be considered?
Cultural practices that can be included in the patient’s plan of care?

As long as cultural beliefs will not harm the patient’s health, accepting them and
incorporating them into the plan of care can only help ensure compliance.

Individualizing the plan of care gives the patient a feeling of ownership and
makes her or him more likely to follow through.

Religious/Spiritual Religion and spirituality influence health beliefs and practices, dietary
Influences
preferences, family roles, and life-and-death issues.

Ask about religious beliefs that conflict with prescribed treatment plan. For
example, a Jehovah’s Witness may refuse a blood transfusion even in a life-
threatening situation.

Ask about dietary preferences, such as kosher food for Jewish patients. Ask
about religious rites that should be incorporated into the plan of care, such as
receiving the sacrament of the sick for Catholic patients. As long as religious
beliefs will not harm the patient’s health, accepting them and incorporating
them into the plan of care will only help ensure its success.
Family Roles and The family is an important support system for most ill people.
Relationships
Also, when people become ill, their role in the family changes and the family
unit may need to reorganize to sustain itself.

Determine what effect this change has on your patient and his or her family;
then plan how to meet their needs.

You may need to rely on outside supports.

Ask your patient about his or her role within the family and other social groups.
Is he or she head of the household, responsible for parenting and housekeeping,
or are the roles shared?

Today’s family structure varies greatly, from traditional nuclear

family, to single-parent family, to restructured family through divorce or

remarriage, to alternative families, to the extended family of the past. But all
families share common functions.

Sexuality Patterns Illness can have both physical and psychological effects on your patient’s
sexuality.

Changes in body image or self-concept, changes in ability to perform sexually,

prescribed medications, and depression can all have

adverse effects on sexuality.

Developmental, cultural, and religious factors influence your patient’s

perspective and expression of sexuality and her or his willingness to discuss
sexuality with you.

Sexuality concerns also vary according to your patient’s age and developmental
stage.

Sexuality is a sensitive topic that both you and your patient may feel
uncomfortable discussing.

Pick up on clues from your patient and address sexuality issues when most
appropriate, either during the review of systems (ROS) or the

psychosocial history. Be open and nonjudgmental.

Ask if your patient is sexually active and, if so, whether she or he is satisfied
with her or his sexual role, performance, and relationship. Find out the source of
her or his knowledge of sexuality, reproduction, birth control, and safe sex
practices.

Social Supports Support systems outside the family are important during illness.

Ask your patient if there is anyone aside from family that he or she can call on
for help—for example, friends, coworkers, community agencies, or clergy.
 Ask if he or she belongs to a church or to community organizations or clubs and
if he or she attends on a regular basis.

If your patient’s social supports are limited, tell him or her about resources
available within the community and church, and help him or her access those
that meet his or her needs.

Stress and Coping The amount of stress in your patient’s life and how she or he copes with it can
Patterns affect her or his health. Illness only adds stress and anxiety. Ask your patient
how she or he deals with everyday stress, what she or he does when feeling
upset, if she or he has ever felt sad or depressed, and whom she or he talks to
when upset.

Keep in mind that normal developmental changes and changes associated with
illness can threaten a person’s ability to cope.

If you determine that your patient’s coping skills are ineffective, develop a plan
of care, including sources of support, to help her or him deal with stress more
effectively.

Documenting the Findings

 Once you have completed the health history, summarize pertinent findings and share them with patient to
confirm their accuracy.
 Then document the findings and begin to formulate a plan of care.
 Documentation of history findings varies from one healthcare facility to another.
 Many acute-care facilities use computerized programs that enable you to enter the history directly into the
computer.
 Standardized nursing admission assessment forms that combine both history and physical assessments are also
commonly used.

Helpful Hints for Documenting a Health History (regardless of the system)

■ Be accurate and objective. Avoid stating opinions that might bias the reader.
■ Do not write in complete sentences. Be brief and to the point.
■ Use standard medical abbreviations.
■ Don’t use the word “normal.” It leaves too much room for interpretation.
■ Record pertinent negatives.
■ Be sure to date and sign your documentation.

“Dear future registered nurses again let me refresh you again with these simple PRACTICE EXERCISES AND
REMINDERS.”

Scenario: Patient’s Condition

 First, determine the condition of the patient.
 This condition may prohibit a detailed health history upon admission.

For example, if you are working in the emergency department and J.H., a 49-year-old man, presents with acute chest pain, a
comprehensive health history is not indicated. Instead, you should obtain a focused history while you perform a physical assessment,
draw laboratory studies, obtain an electrocardiogram, and connect your patient to a cardiac monitor. When a patient is in acute
distress, trying to obtain a complete health history not only is detrimental but also provides little valuable or accurate information. So,
ask key questions that focus on the acute problem; once your patient’s condition stabilizes, obtain a more detailed health history.

CRITICALTHINKINGACTIVITY#1
Suppose you were caring for Mr. H. What questions would you ask him to assess his chest pain?

CRITICALTHINKINGACTIVITY#2
What question(s) would you ask Mr. H related to his past health history, family history, review of systems, and
psychosocial profile?
Amount of Time
 Allot at least 30 minutes to an hour to obtain a complete health history.
 Be sure to let your patient know why you are asking these questions and that it will take time.
 If you do not have enough time to complete the history, do not rush.
 Instead, perform a focused history first, and then complete the history at later sessions.

HELPFULHINT
To save time:
 Ask the patient to fill out a standard history form; then review it with him or her.
 If necessary, use secondary sources, such as family members, to obtain data.
 Ask questions while you’re bathing the patient or performing other care.
 Some information may already have been provided; for example, biographical data from the admission
sheet.
 Do not repeat questions unless you need your patient’s perspective.
 If the patient is asked the same questions several times by different members of the healthcare team, she
or he may become frustrated.
 So, if you need to repeat questions, be sure to tell her or him the reason why.

Medical History versus Nursing History

Nursing History Medical History

similar areas addressed and the similar

questions

different focus and scope of medical versus different

nursing practice

similar history questions similar

different underlying rationale different

diagnose and treat the patient’s diagnose and treat illness

response to a health problem

 For example, M.J., an 81-year-old woman, is admitted to the hospital with a fractured right hip.
 The focus of the medical history would be to identify what caused the fracture in order to determine the extent of
injury.
 The history would also try to identify any preexisting medical problems that might make her a poor surgical risk.
 The physician will use the data that he or she obtains to develop a treatment plan for the fracture.
 Although the nursing health history also focuses on the cause of the injury, the purpose is to determine M.J.’s
response to the injury, or what effect it has on her.
 You will look at much more than the fractured hip.
 You will consider how the injury affects every aspect of her health and life.
 Your history will provide clues about the impact of the injury on her ability to perform her everyday activities
and help you identify strengths she has that can be incorporated into her plan of care.
 You will also identify supports and begin your discharge plan.
 Then you will use the data to develop a care plan with M.J. that includes not only her perioperative phase but
also her discharge rehabilitative planning.

Setting the Scene

 Before you begin your assessment, look at your surroundings.
 Do you have a quiet environment that is free of interruptions?
 A private room is preferred, but if one is not available, provide privacy by using curtains or screens.
 Prevent interruptions and distractions so that both you and your patient can stay focused on the history.
 Make sure that the patient is comfortable and that the room is warm and well lit.
 If the patient uses assistant devices, such as glasses or a hearing aid, be sure that she
or he uses them during the assessment to avoid any misperceptions
 Before you begin asking questions, tell your patient what you will be doing and why. Inform him or her if you
will be taking notes, and reassure the patient that what he or she says will be confidential.
  avoid excessive note taking—it sends the message to your patient that the health history form is more important
than he or she is.
 if you are too preoccupied with writing and continually break eye contact, you may miss valuable nonverbal
messages.
 Excessive note taking may also inhibit your patient’s responses, especially when discussing personal and
sensitive issues such as sexuality or drug or alcohol use.
 Be sure to work at the same level as your patient.
 Sit across or next to her or him.
 Avoid anything that may break the flow of the interview.
 If the interview is being recorded or videotaped, be sure to get your patient’s permission
before starting.
 Position the equipment as unobtrusively as possible so that it does not distract you or your patient.
 Your approach to your patient depends on his or her cultural background, age, and developmental level.
 Ask yourself, “Are there any cultural considerations that might influence our interaction?” “What approach is
best, considering my patient’s age?”

Key Points to Remember When Obtaining a Health History

 Listen to what your patient is telling you both verbally and nonverbally.
 Don’t rush. Allow enough time to obtain the data.
 Ensure confidentiality.
 Provide a private, quiet, comfortable environment. Avoid interruptions.
 Tell your patient how long the interview will take and why you need to ask these questions.
 Do not be so concerned about completing forms that you neglect the patient.
 Start with what the patient perceives as the problem.
 Use open-ended questions to elicit the patient’s perspective.
 Attend to any acute problems, such as pain, before obtaining a detailed history.
 Remember that quality is more important than the quantity of information obtained.

Components of the Health History

 A complete health history addresses health and illness patterns, health promotion and protective patterns, and
roles and relationships.
 The parts of the health history that focus on health and illness patterns include the:
o Biographical data
o reason for seeking healthcare,
o current health status,
o past health history,
o family history, and
o review of systems.
 Assessed through psychosocial component of the health history the:
o past health problems and any familial factors that place your patient at risk for health problems.
o health promotion activities, protective patterns, and role and relationship patterns
o assess for risk factors that pose a threat to your patient’s health in every aspect of her or his life.
o You need to consider your patient’s cultural and developmental status as it affects her or his health
status.

Biographical Data
 provide you with direct information related to a current health problem, alert you to
risk factors for health problems, and point out the need for referrals.
 Your patient’s ability to provide biographical data accurately reflects his or her mental status.
 include the patient’s name, address, phone number, contact person, age/birth date,
place of birth, gender, race, religion, marital status, educational level, occupation, and social security
number/health insurance.
 include the person who provided the history and her or his reliability as well as the
person who referred the patient.
 Information on advance directives may also be obtained for hospital admissions.
 note any special considerations, such as the use of an interpreter.

Biographical Data
DATA SIGNIFICANCE/CONSIDERATIONS
Name (Full Name and Prevents confusion when patients have similar names. Formats of names may
Maiden Name) differ culturally (e.g., Cambodians put last name first; married Hispanic women
take husband’s surname while retaining both parents’ last names).

Address and Phone Number May provide socioeconomic information and identify environmental health risks

(e.g., urban vs. suburban or rural neighborhoods).

Contact Person May be a source for further data and support for patient. Essential in case of
medical emergency.

Age/Birth Date/Place of Allows you to compare stated age with apparent age (e.g., chronic illness can make
Birth a person appear older).

Identifies age-related risk factors for health problems (e.g., children more at risk
for accidents; incidence of cardiovascular disease and cancer increases with age).

Age helps identify patient’s developmental stage.

Place of birth may correlate with environmental risks.

Gender Identifies risk for gender-related health problems (e.g., women have a much higher
incidence of breast cancer than men).

Race/Ethnicity/Nationality Identifies risk for health problems associated with a particular race or ethnic group
(e.g., African American males have high incidence of hypertension, Native
Americans have high incidence of diabetes).

Identifies possible ethnic influences on healthcare practices.

Religion Alerts you to religious beliefs that may influence health practices (e.g., Judaism
and diet, Jehovah’s Witnesses and blood products). May identify sources of
support for your patient.

Marital Status (Never Identifies possible support people.

Married, Married,
Present health status may affect family relationships, patient’s economic status,
Widowed, Separated,
and ability to support family.
Divorced)

Referral may be necessary.

Number of Dependents Do not assume that unmarried patients live alone.

Ask if they live with someone.

Educational Level Helps determine teaching approaches. Do not assume that educational level
correlates with knowledge and understanding (e.g., newly diagnosed diabetic may
have a Ph.D. but be totally unfamiliar with disease and its management).

Do not talk down to patient who has had little formal education.

Ask your patient what teaching method she or he prefers (e.g., videos, pamphlets,
group, one on one).

Occupation Identifies possible occupational risk factors.

Provides clues about socioeconomic status.

Current health status also may affect patient’s occupational status. Referral may be
necessary
 Social Security Social Security Number may help in retrieving records.
Number/Health Insurance
Insurance type may influence length of stay.

Referrals may be needed depending on type of health insurance

Source of History/ Ideally, patient is source of history.

Reliability
Secondary source, usually a family member

of friend, is necessary with children or when patient is unable to provide history.

Establish reliability of person providing history by noting consistency in responses

and willingness to communicate.

Referral Identifies primary care physician/practitioner. If no referral source identified, may

need to make referral for follow-up.

Advance Directives Allows you to comply with patient’s healthcare wishes if Advance Directives exist.

Reason for Seeking Healthcare

 Ask your patient why he or she is seeking healthcare; then document his or her direct quote.
 The patient’s reason for seeking care is usually related to the level of preventive
healthcare —primary, secondary, or tertiary.
 If the setting is a primary level of healthcare, there is usually no acute problem.
 The reason generally relates to health maintenance or promotion.

For example, the patient states, “I am here for my annual physical examination.”
If there is an acute problem, ask the patient to state what the problem is and how long it has been going on.

For example, “I have had chest pain for the last hour.” If your patient identifies more than one
problem, she or he may be confusing associated symptoms with the primary problem. Help her or him clarify and prioritize the
problems by asking questions such as, “Which problems are giving you the most difficulty?”

 Usually, patients identify problems that affect their ability to do what they usually do.
 In an acute-care setting, the reason for seeking care is called the chief complaint.
 The CHIEF COMPLAINT gives you the patient’s perspective on the problem, a view of the problem through his
or her eyes.
 At the tertiary level, the problem may be well defined, a chronic problem, or an acute problem that is resolving.
 In this case, the problem does not have the acuity or life-threatening urgency of an acute problem.

Current Health Status

 Once you have identified the patient’s reason for seeking healthcare, assess her or his current health status.
 At a primary level of healthcare (no acute problem), the current health status should include the following:
o Usual state of health.
o Any major health problems.
o Usual patterns of healthcare.
o Any health concerns.

For example: Patient is M.W. age 42, married, mother of three, full-time teacher. Usual state of
health good. Has yearly physical with pelvic examination and dental examination. Last eye examination 1 year ago.

FUNCTIONAL ASSESSMENT
ADULTS
 older adults may not present in the same way as younger people when they are ill.
 Three (3) factors to remember when performing assessment:
o Older adults may minimize or ignore symptoms.
o They often have several concurrent medical problems.
o They often present with atypical signs and symptoms of disease.
Symptom Reporting
 Some older adults are “health pessimists” who exaggerate their symptoms, the opposite is more often true.
 Many older adults are “health optimists” who downplay symptoms and give a more positive evaluation of their
overall health status in the face of disease and disability.
o Failing to report symptoms or explaining them away can lead to late recognition of serious medical
problems.
 Older adults are the least likely of all patients to take action in response to symptoms of serious illness.
o they may attribute symptoms to normal aging and then simply wait and watch what happens, accept the
changes they are experiencing, deny any danger associated with the symptoms, and delay seeking help.
 Many older adults worry that if they report symptoms to their healthcare provider, they may end up in a nursing
home or in a more restrictive level of care.
 The cost of healthcare is also a major concern for many older adults.
 When older adults do complain of a particular problem, they are more likely to identify a specific disease than are
younger patients.

Functional Assessment (Determining Functional Status)

 an evaluation of the person’s ability to carry out the basic self-care activities of daily living (ADLs), such as
bathing, eating, grooming, and toileting.
 functional ability is determined by the dynamic interplay of the frail elder’s physiologic status; emotional and
cognitive statuses; and the physical, interpersonal, and social environments.
 a major purpose of assessing the frail older adult is to correctly identify and describe the client’s ability to
perform ADLs.
 Katz Index - a basic measure that describes the patient as dependent, semi-dependent,
or independent in ADLs but does not identify small changes over time.
 Barthel Index - gives weighted scores for each ADL, and allows the nurse to recognize
small changes over time. a score of less than 60 on this index indicates that the patient needs assistance
with ADLs.
 tools most appropriate for assessing functional status in older adults (Wallace
& Shelkey, 2007)
o Katz Activities of Daily Living
o includes those activities necessary for well-being as an individual in a society known as
Instrumental Activities of Daily Living
o Focus of IADL
1. household chores - cooking, cleaning, laundry)
2. mobility-related activities - shopping and transportation
3. cognitive abilities - money management, using the telephone, and
making decisions affecting basic safety and social needs).

 Reviewing the assessment items with the patient allows the nurse to determine his or her level of functioning and
make appropriate referrals for care.

NEWBORNS
 Each newborn (birth to 30 days) arrives as a unique person with the energetic desire to grow and learn.
 For approximately 40 weeks, the fetus has enjoyed a warm, comfortable uterine environment with all needs met.
At birth, he or she is totally dependent on the caretaker.
 Because the newborn is unable to directly communicate his or her needs, the nurse must learn assessment skills to
identify abnormal findings and promote a healthy environment.
 General Health Survey/Anthropometric Measurements
o Flexed head and extremities.
o Head, 33 cm; chest, 31 cm; abdomen, 32 cm.
o Length head to heel, 50 cm.
o Weight, 7 lb., 6 oz.
 Vital Signs
o Axillary temperature, 98oF/36.7C
o Pulse, 144 beats per minute (BPM).
o Respirations, 44 and irregular.
o Blood pressure (BP), 64/38.
 APGAR
o 8 and 10

APGAR scoring
o Assess the newborn’s physiological and cardiopulmonary status immediately after birth.
o A quick test performed on a baby at 1 and 5 minutes after birth.
 The 1-minute score determines how well the baby tolerated the birthing process.
 The 5-minute score tells the health care provider how well the baby is doing outside the mother's
womb.
 In rare cases - event of a difficult resuscitation, the test will be done 10 minutes after birth; 15, and
20 minutes.
o Assesses five vital areas: heart rate, respiration, color, muscle tone, and reflex irritability.
o A score from 0 to 2 is assigned to each category, for a score range of 0 to 10.
o The score is obtained at 1 and 5 minutes after birth.
o A score of 8 to 10 is excellent, 4 to 7 is guarded, and 0 to 3 is critical.
o What does a persistently low Apgar score mean?
 The persistence of low (0-3) Apgar scores at 20 minutes of age is predictive of high rates of
morbidity (disease) and mortality (death).
o In term infants, the five-minute Apgar score is predictive of mortality but is not as precise a predictor for
neurologic and developmental disabilities.

INFANTS & CHILDREN

 The subsequent history and physical examination are performed when the infant visits
the clinic or pediatrician’s office for well-baby checkups.
 Infants (1–11 months) have few communication skills.
 As they grow, they can smile, frown, point, and even say “no,” but it will be several years before they can
communicate well enough to provide information during a
patient history
 Until then, parents, siblings, and extended family are fine sources of information.
 Healthy families usually raise healthy babies, so take every opportunity to offer education and support during
your assessment.

FUNCTIONAL ASSESSMENT TESTS

a. Newborns
APGAR scoring

APGAR Scoring

Indicator 0 point 1 point 2 points

A Activity (muscle absent Flexed arms and legs Active

tone)

P Pulse Absent bpm Below 100 Over 100 bpm

G Grimace (reflex Floppy Minimal response to Prompt response to

irritability) stimulation stimulation

A Appearance (skin Blue; pale Pink body, blue Totally pink

color) extremities

R Respiration Absent Slow & irregular; 1 ≤ 30 2 = vigorous, strong cry,

bpm regular

b. Infants & Children

Metro Manila Developmental Screening Test (MMDST)
Romero, B., (2011). Metro Manila Developmental Screening Test (MMDST).
https://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/metro-manila-developmental-screening-test-
mmdst/

Sample MMDST video: https://www.youtube.com/watch?v=OP-eX8Oltg4

 The care of pediatric clients, growth and development are not in isolation.
 MMDST is:
o a screening test to note for normalcy of the child’s development and
o determines any delays as well in children 6 ½ years old and below.
 o modified and standardized by Dr. Phoebe Williams from the original Denver Developmental
Screening Test (DDST) by Dr. William K. Frankenburg, MMDST evaluates
o 4 Sectors of Development:
 Personal-Social – tasks which indicate the child’s ability to get along with people and to take care of himself
 Fine-Motor Adaptive – tasks which indicate the child’s ability to see and use his hands to pick up objects
and to draw
 Language – tasks which indicate the child’s ability to hear, follow directions and to speak
 Gross-Motor – tasks which indicate the child’s ability to sit, walk and jump

MMDST KIT. Preparation for test administration involves the nurse ensuring the
completeness of the test materials contained in the MMDST Kit.

Specified materials:
 MMDST manual
 test Form
 bright red yarn pom-pom
 rattle with narrow handle
 eight 1-inch colored wooden blocks (red, yellow, blue green)
 small clear glass/bottle with 5/8inch opening
 small bell with 2 ½ inch-diameter mouth
 rubber ball 12 ½ inches in circumference
 cheese curls
 pencil

Explaining the procedure.

 Once the materials are ready emphasized that this is not a diagnostic test but rather a screening test only.
 When conducting the test, the parents or caregivers of the child under study should be informed that it is not an
IQ test as it may be misinterpreted by them.
 The nurse should also establish rapport with the parent and the child to ensure cooperation.

Age & the Age Line.

 the nurse is to compute for the exact age of the child (meaning the age of the child during the test date itself)
 the age is the most crucial component of the test because it determines the test items that will be applicable/
administered to the child.
 the exact age is computing by subtracting the child’s birth date with the test date.
 After computing, draw the age line in the test form.

Test items.
 There are 105 test items in MMDST but not all are administered.
 The examiner prioritizes items that the age line passes through.
 Explain to the parent or caregiver that the child is not expected to perform all the tasks correctly.
 If the sequence were to be followed, the examiner should start with personal-social then progressing to the other
sectors. Items that are footnoted with “R” can be passed by report.

Scoring.
 The test items are scored as either Passed (P), Failed (F), Refused (R), or Nor Opportunity (NO).
 Failure of an item that is completely to the left of the child’s age is considered a developmental delay.
 Failure of an item that is completely to the right of the child’s age line is acceptable and not a delay.

Considerations:
 Manner in which each test is administered must be exactly the same as stated in the manual, words or
direction may not be changed
 If the child is premature, subtract the number of weeks of prematurity.
 If the child is more than 2 years of age during the test, subtracting may not be necessary
 If the child is shy or uncooperative, the caregiver may be asked to administer the test provided that the
examiner instructs the caregiver to administer it exactly as directed in the manual
 If the child is very shy or uncooperative, the test may be deferred

c. Adults Functional Assessment Tools

Katz Index of Independence in ADL

Katz Index of ADL (Source: Adapted from Katz, S., Ford, A., and Moskowitz, R. (1963). Studies of illness in the aged: The
index of ADL. Journal of the American Medical Association 185:914–919.)

Abbreviations: I = independent; A = assistance; D = dependent

1. Bathing (sponge, I: Receives no assistance (gets in and out of the tub)

shower, or tub)
A: Receives assistance in bathing only one part of the body

D: Receives assistance in bathing more than one part of the body

2. Dressing I: Gets clothes and gets completely dressed without assistance

A: Gets clothes and gets dressed without assistance except in tying shoes

D: Receives assistance in getting clothes or in getting dressed or stays partly

or completely undressed

3. Toileting I: Goes to bathroom, cleans self, and manages clothes without assistance
(may use an assistive device)

A: Receives assistance in going to bathroom or in cleaning self, managing

clothes, or emptying a bedpan

D: Doesn’t go to bathroom for elimination

4. Transfer I: Moves in and out of bed or chair without assistance (may use assistive
device)

A: Moves in and out of bed or chair with assistance

D: Doesn’t get out of bed

5. Continence I: Controls urination and bowel movements independently

A: Has occasional accidents

D: Urine or bowel control maintained with supervision; patient is incontinent or

has catheter

6. Feeding I: Feeds self without assistance

A: Feeds self except for cutting meat or buttering bread

D: Receives assistance in feeding or is fed partly or completely by tubes or

intravenous fluids

Barthel Index

(Source: Adapted from Barthel DW et al., (1965) Functional Evaluation: The Barthel Index. Maryland
State Medical Journal 14:61–65.)

LEVEL OF CARE INTACT LIMITED HELPER NULL

Self-Care

1. Feed 10 5 3 3

2. Dress (upper 5 5 3 0

extremities)
3. Dress (lower 5 5 2 0

extremities)

4. Don brace 0 0 -2 0

5. Grooming 4 4 0 0

Cleanse

Perineum

Sphincters Completely Urgency/ Some help Frequent

voluntary appliance needed accidents

6. Bladder 10 10 5 0

7. Bowel 10 10 5 0

Mobility/Transfer Easy/no device With difficulty Some help needed Dependent

or uses device

1. Chair 15 15 7 0

2. Toilet 6 5 3 0

3. Tub 1 1 0 0

4. Walk 50 yd 15 15 10 0

5. Stairs 10 10 5 0

6. Wheelchair 50 15 5 0 0
yd

Instrumental Activities of Daily (IADL)

Source: Duke University Center for the Study of Aging and Human Development, pp. 169–170, with permission.

Abbreviations: I = independent; A = assistance; and D = dependent.

1. Telephone I: Able to look up numbers, dial, receive, and make calls without help

A: Able to answer phone or dial operator in an emergency, but needs special phone
or help in getting number or dialing

D: Unable to use the telephone

2. Traveling I: Able to drive own car or travel alone on bus or taxi

A: Able to travel but not alone

D: Unable to travel
 3. Shopping I: Able to take care of all shopping with transportation provided

A: Able to shop but not alone

D: Unable to shop

4. Preparing I: Able to plan and cook full meals

meals
A: Able to prepare light foods, but unable to cook full meals alone

D: Unable to prepare any meals

5. Housework I: Able to do heavy housework (e.g., scrubbing floors)

A: Able to do light housework, but needs help with heavy tasks

D: Unable to do any housework

6. Medication I: Able to take medications in the right dose at the right time

A: Able to take medications, but needs reminding or someone to prepare it

D: Unable to take medications

7. Money I: Able to manage buying needs, write checks, pay bills

A: Able to manage daily buying needs, but needs help managing checkbook and
paying bills

D: Unable to manage money

Roles and Activities of Community Health Nurse

Community health nursing: involves several basic concepts, including the promotion of healthy living, prevention
of disease and health problems, medical treatment, rehabilitation, evaluation of community health nursing care delivery
and prevention systems, and research to further community health nursing and wellness.
A community nurse can serve direct care, educate individuals or the public, advocate for health improvements,
and perform research in community health. It is the job of a community health nurse to help and keep the community
health problems under control.

Characteristics of Community Health Nursing:

 It is a specialty field of nursing.
 Its practice combines public health with nursing.
 It is population-based.
 It emphasizes wellness and other than disease or Illness.
 It includes interdisciplinary collaboration.
 It amplifies the client’s responsibility and self-care.

Functions of Community Health Nursing:

The four core functions of community health nursing practices are described below:
1. Identification of community culture and resources that lead as a key factor in the community health care
delivery system.
2. Evaluate community health conditions, health risks, and problems to identify the health-care demands of
the people.
3. Plan and implementation of comprehensive community health interventions, care, services, and programs.
4. Develop health policy at the local community level to drive policies/agreements at the state and national
levels for collaborative endeavors and actions.

Seven major roles/functions of a community health nurse:

 1. Clinician,
2. Educator,
3. Advocate,
4. Managerial,
5. Collaborator,
6. Leader,
7. Researcher.

1. Clinician Role or Direct care provider:

 the nurse ensures health care services, not just to individuals and families but also to groups and
populations of the community.
 the clinician role involves certain emphasis different from basic nursing, i.e. – Holism, health promotion,
and skill expansion
2. Educator Role:
 It is widely recognized that health teaching is a part of good nursing practice and one of the major
functions of a community health nurse (Brown, 1988).
 Assesses the knowledge, attitudes, values, beliefs, behaviors, practices, stage of change, and skills of the
community people and provides health education according to knowledge level.
3. Advocate Role:
 The issue of clients’ rights is important in health care today.
 Every patient or client has the right to receive just equal and humane treatment.
 A community health nurse is an advocate of patient’s rights about their care.
 They encourage the individuals to take the;
o right food for maintaining health,
o the right drugs for the treatment, and
o the right services at the right place where ever needed.
o Responsibility to provide sufficient information to make necessary health care decisions, promote
community awareness of significant health problems.
4. Managerial Role:
 exercises administrative direction towards the accomplishment of specified goals by:
o assessing clients’ needs,
o planning and organizing to meet those needs,
o directing and controlling and
o evaluating the progress to assure that goal are met.
5. Collaborator Role:
 must work with many people including:
 clients,
 other nurses,
 physicians,
 social workers, and
 community leaders,
 therapists,
 nutritionists,
 occupational therapists,
 psychologists,
 epidemiologists,
 biostatisticians,
 legislators, etc. as a member of the health team (Fairly 1993, Williams, 1986).
6. Leader Role:
 instructs influences or persuades others to effect change that will positively affect people’s health.
 The leadership role’s primary function is to use a change of health policy based on community people’s
health; thus, the community health nurse becomes an agent of change.
7. Research Role:
 engage in systematic investigation, collection, and analysis of data to solve problems and enhance
community health nursing practice.
 Based on the research result community nurse improve their service quality and improve community
people’s health.

Activities:
  Administering well-baby assessments and vaccinations/immunizations.
 Directing expectant and new mothers to healthcare resources so they can receive proper care for themselves
and their...
 Conducting education programs or handing out information about lead poisoning, substance abuse, dangers
of smoking, teenage pregnancies.

(REMINDER)
Helpful Hints for Documenting a Health History (regardless of the system)
■ Be accurate and objective. Avoid stating opinions that might bias the reader.
■ Do not write in complete sentences. Be brief and to the point.
■ Use standard medical abbreviations.
■ Don’t use the word “normal.” It leaves too much room for interpretation.
■ Record pertinent negatives.
■ Be sure to date and sign your documentation.