HEALTH ASSESSMENT RLE just on a specific illness or

condition.
MODULE 1 HEALTH HISTORY
GUIDELINES Sources of Information

The history provides the client’s Primary Source

perspective of the record and the
● The patient is usually the best
context of beliefs and values in which the
and, therefore, primary source of
client operates. It communicates not only
information for the health history
the client’s words but also the client’s
interview.
nonverbal language and inflections of
● The patient is the only one who
voice. Taking the history offers an
can describe personal symptoms,
opportunity to establish rapport with the
experiences, and factors leading to
client.
the current health or wellness
concern.
Purpose of the Health History
Reasons why a patient may be unable to
Subjective Information
provide information include:

The health history is a detailed record of ● Medical illness

the patient’s past and current health, as ● Infants or young children
well as a record of perceptions about her ● Serious illness
state of wellness. ● Comatose
● Sedated
● The health history is gathered
● Pain
during the initial health
● Developmental, cognitive or
assessment interview which
physical disability
usually occurs during the
patient’s first visit to a healthcare Reasons why a patient may be hesitant to
facility and is updated with each share information:
subsequent visit.
● The purpose of the health history ● Fear of terminal diagnosis
is to document the responses of ● Fear of undergoing further physical
the patient regarding actual and examination
potential health concerns ● Embarrassment
● Fear of legal implications
Information covered in the health history ● Fear of losing a job
includes: ● Lack of trust

● Past and present illnesses Secondary Sources

● Family and genetic information
● Wellness assessment
● The nursing health history may
produce information about a
medical diagnosis, but the focus is
on patient-centered care or on
the patient’s response to the health
concern as a whole person, not
● A person or record that provides
additional information about the
patient that is used only if the
patient is unable or unwilling to
communicate.
 ● Secondary sources may also be
used to supplement previously
obtained data.
Most common secondary sources used
are:
● Medical records
● Information obtained from
significant others
The Health Insurance Portability and
Accountability Act (HIPAA) states that
the nurse must obtain the patient’s
permission before requesting information
from another person.
In emergency situations, the HIPAA
regulations permit the use of professional
judgment and experience in solicitation of
information from secondary sources when
the patient is incapacitated and only in an
attempt to protect the patient.
Validate secondary information by
verifying it with the patient, by observation,
or by confirming the information with at
least one other source.
Documenting the Health History
● The last step in the preparation of
a comprehensive database.
● Like all parts of the comprehensive
patient database, the health history
written by the nurse becomes part
of the patient record, forming a
legal document.
Communication Skills
● The principles of effective
communication are used during the
interview to obtain a health history.
● In formulating a message for
transmission during
communication the nurse uses
encoding. During encoding words,
body language, signs, or symbols
are chosen by the sender.
● Decoding occurs during
communication when one is in the
process of searching through one’s
memory, experience, and
knowledge base to determine the
meaning of the intended message.
● To communicate successfully, the
patient must be able to accurately
decode the messages the nurse
sends.
● Communication may also break
down if the nurse fails to decode
the patient’s messages accurately
by not listening actively and
attentively.
Interactional Skills
● Interactional skills are actions that
are used during the encoding and
decoding processes to obtain and
disseminate information, develop
relationships, and promote
understanding of self and others.
● Nurses use a variety of
interactional skills during the
communication process to gather
assessment data from the patient,
family, significant others, and other
healthcare personnel.
Interactional skills that are helpful during
an interview include:
● Listening - the most important
interactional skill and involves
interpretation of what has been
said.
● Attending - involves one giving full
attention to verbal and nonverbal
messages.
● Paraphrasing
● Leading
● Questioning
● Reflecting
● Summarizing
Questioning ● Genuineness: The ability to
present oneself honestly and
● A direct way of speaking with spontaneously. Use of direct eye
patients to obtain subjective contact, facial expressions
data using open- and appropriate to the situation, and
closed-ended questions. open body language conveys
● Open-ended questions are genuineness.
purposefully general and ● Concreteness: Speaking to the
encourage the patient to provide patient in specific terms rather than
additional information. in vague generalities. This implies
● Closed-ended questions limit the that the nurse respects the
patient’s response to “yes,” “no,” or patient’s ability to understand
one-word answers. and recognizes the patient’s
right to know the details of the
Reflecting plan of care.
● Repeating the patient’s verbal or Barriers to Effective Patient–
nonverbal message for the Interaction
patient’s benefit.
● Demonstrates empathy. ● False Reassurance: A nurse
assures the patient of a positive
Summarizing outcome with no basis for
knowledge of this outcome.
● The process of gathering the
● Interrupting or changing the
ideas, feelings, and themes that
subject: Conveys insensitivity to
patients have discussed
the patient’s thoughts and feelings.
throughout the interview and
● Passing Judgment: Nurses must
restating them in several general
carefully reflect on their own beliefs
statements.
and avoid using these to judge
● Demonstrates that the nurse has
their patients’ behaviors or actions.
listened and understood
Judgmental statements imply
concerns.
nonacceptance and discourage
● Allows patients to know that
further interaction.
progress is being made in
● Cross-Examination: Asking
resolving their health concerns and
question after question during an
signals closure of the interview.
assessment interview may cause
Professional Characteristics to the patient to feel threatened,
Enhance the Nurse–Patient Interaction and the patient may seek refuge
by revealing less information.
● Positive Regard: The ability to ● Euphemisms: Using terms that are
appreciate and respect another customarily thought to be less
person’s worth and dignity with harsh. Euphemisms may also
a nonjudgmental attitude. create barriers by misleading or
● Empathy: Showing confusing the patient and family.
understanding and support of ● Unwanted Advice: Unsolicited or
the patient’s experience or unwanted advice is an
feelings through actions and imposition to the patient and is
words. not professional. The nurse’s role
 is to offer expert guidance based
on therapeutic principles and
evidence-based practice that are
intended to promote health and
wellness.
● Technical Terms: The nurse
should use lay language rather
than technical terms and avoid
jargon, slang, or clichés. It is
also best to avoid the use of initials
and acronyms unless they are
commonly accepted as everyday
language.
● Sensitive Issues and
Uncomfortable Situations: Timing
and pacing in the interview
should include starting with the
less sensitive issues and
building up trust and confidence
between the nurse and patient.
Respect the patient’s need for
silence and observe for nonverbal
signs or verbal signs to pause the
interview.
● Cultural Influences and Biases:
The professional nurse must be
prepared to recognize and adapt
the interactional processes to
adjust for cultural differences.
When the nurse’s language is not
the same as the patient’s
language, the nurse must always
employ a professional medical
interpreter.
Phase 1:
a period for data collection prior to
meeting the patient.
Used to plan and guide the direction of the
interview.
The nurse reflects on her own strengths
and limitations and on her personal
biases.
The nurse chooses the setting and time
before the initial interview takes place.
A quiet, private place where few
distractions or interruptions will occur is
most conducive to a successful interview.
The nurse should sit facing the patient at a
comfortable distance without using a
table, a computer, a desk, or any other
barrier that might make communication
difficult.
When possible, the nurse and the patient
should be on the same level.
A distance of approximately 1.5 to 4 ft
between the nurse and the patient is most
likely to make the patient feel at ease.
The interview should be scheduled at a
time that is convenient for the nurse and
the patient.
The interview should be postponed if the
patient is in pain, has been sedated
recently, is upset, or is confused.
Phase 2: The Initial Interview
a planned meeting during which the nurse
interviewer gathers information from the
patient about every facet of the patient’s
health status and state of wellness at this
time.
Begins with the nurse describing the
interviewing process, explaining its
importance, and telling the patient what to
expect.
Nurses will begin to seek information
about the patient’s health status.
Opening questions are purposely broad
and vague to let the patient adjust to the
questioning nature of the interview
a nurse will elicit the best information from
patients by asking carefully thought out
and clearly stated, open-ended questions
throughout the interview.
The nurse continuously assesses the
patient’s anxiety level as the interview
continues. Restlessness, distraction, and
anger are signs that the patient perceives
the interview as threatening.
The nurse indicates that the interview is
almost at an end and gives the patient an
opportunity to express any final questions
or concerns.
Phase 3: The Focused Interview
The purpose of the focus interview
includes:
OLDCART = Onset, Location, Duration,
Characteristics, Aggravating Factors,
Relieving Factors, Treatment.
ICE = Impact on ADLs, Coping Strategies,
Emotional Response.
Components of the Health History

Clarification of previously obtained ● The biographical data include:

assessment data. ➔ Name
➔ Address
Gather missing information about specific ➔ Age
health concerns or issues.
➔ Date of birth
Guide the direction of the physical ➔ Birthplace
assessment as it is being conducted. ➔ Marital Status
➔ Sex
Identifying or validating a probable ➔ Gender Identity
nursing diagnosis. ➔ Sexual orientation
➔ Race
Nurses use the focused interview
continuously to update diagnostic cues ➔ Religion
because signs, symptoms, and patient ➔ Occupation
health concerns often change from ➔ Health Insurance
moment to moment or day to day. ➔ Source of Information/Reliability

The process of obtaining subjective data

about patient symptoms is called
symptom analysis.
Many nurses find it helpful to use an
acronym to guide a symptom-focused
interview such as OLDCART & ICE.
OLDCART & ICE Acronym
➔ The focused interview is used to
validate probable or hypothetical
nursing or collaborative diagnoses
formulated after the initial
interview.
➔ These additional data are then
compared with defining
characteristics of the probable
diagnoses to determine the most
appropriate nursing diagnosis for
the patient.
● History of Present Illness
Includes information about the following:
➔ Reason for seeking care and vital
signs
➔ Health beliefs and practices
➔ Health Patterns: Lifestyle,
Nutrition, Activity
➔ Medications; Prescriptions and
Over the Counter
● Family Medical History
Includes information about the following:
➔ Immediate Family
➔ Extended Family
➔ Genogram or Pedigree

● Psychosocial History
Includes information about the following:
● Occupational History
● Education
● Financial Background
● Roles and Relationships
● Family
● Social Structure/Emotional
Concerns
● Self-Concept
Review of Body Systems
Includes information about the following:
● Skin, Hair, and Nails
● Head, Neck, and Lymphatics
● Eyes
● Ears, Nose, Mouth, and Throat
● Respiratory
● Breasts and Axillae
● Cardiovascular
● Peripheral Vascular
• Includes information about the following:
● Abdomen
● Urinary
● Male Reproductive
● Female Reproductive
● Musculoskeletal
● Neurologic
Lifespan Considerations
● The basic components of a health
history are the same whether the
nurse works with children or adults.
● Populations that variations must be
incorporated into the health history
include:
➔ Pregnant Women
➔ Pediatric Patients
➔ Older Adult Patients
The Genogram
● Genetic factors are included in a
comprehensive health
assessment.
● The information is recorded in the
form of a genogram.
● A genogram makes it easy to see
patterns of health and illness
across generations.
● When documenting a family
history, the information from at
least three generations is included.
● It is important to include the age
of the family member or the age at
death and the age at diagnosis of
chronic conditions (e.g., diabetes,
heart disease, cancer,
hypertension) or events such as a
miscarriage or stillbirth.
● At the top of the genogram,
indicate the ancestry (country of
origin) of individuals in the
originating generation. The
genogram should be dated to
facilitate future updates.
● Genograms are most commonly
examined for genetic “red flags,”
which are conditions that indicate
an individual may benefit from
specific genetic information or
services.
● Upon identifying a genetic red flag,
the nurse should discuss the
finding with the patient and explore
options for follow-up or referral
(Patch, 2013).
Key Concepts
1. The health history and the use of
primary and secondary sources of
information.
2. Interactional communication skills:
A. Listening
B. Attending
C. Paraphrasing
D. Leading
 E. Questioning health, address acute health
F. Reflecting problems, and minimize chronic
G. Summarizing health conditions
2. To allow the nurse and the patient
3. Professional characteristics that to establish a therapeutic
enhance nursing communication: relationship.
3. To produce information about the
A. Positive regard client’s diagnosis focusing on the
B. Empathy patient-centered care
C. Genuineness 4. To document the responses of the
D. Concreteness patient to actual and potential
health concerns.
4. Barriers to effective patient
5. To collect data for wellness
communication:
promotion.
A. False reassurance
FUNCTIONAL HEALTH PATTERNS AS
B. Interrupting or changing the
PART OF THE HEALTH HISTORY
subject
TAKING
C. Passing judgment
D. Cross examination The Framework or Nursing Models Used
E. Euphemisms for Health Pattern Assessments
F. Unwanted advice
G. Technical terms Health Pattern is a set of related traits,
H. Sensitive issues and habits, or acts that affect a patient's
uncomfortable situations health. The description of the patient's
health patterns plays a key role in the
5. Phases of the health interview: patient's total health history because it is
the “lifestyle thread” that, woven
A. Phase I: Pre Interaction
throughout the fabric of the health history,
B. Phase II: The initial interview
gives it depth, detail, and definition.
C. Phase III: The focused interview
1. Orem’s Model (Self-Care Deficit)
6. Components of the health history:
1. Universal Self-Care Requisites
A. Biographic data
B. History of present illness Universal self-care requisites are
C. Past medical history associated with life processes and the
D. Family medical history maintenance of the human structure and
E. Psychosocial history functioning integrity.
F. Review of body systems
● Air
Module 2 Nursing Health History ● Water
● Food
Purposes of Health History Taking
● Elimination process and
1. To gather subjective data from the excrements
patient and/or the patient’s family ● Activity and rest
so that the health care team and ● Social interaction
the patient can collaboratively ● Prevention of hazards
create a plan that will promote ● Promotion of normalcy

2. Developmental self-care requisites
3. Health deviation self-care requisites
2. Doenges’s Model (13 Diagnostic
Divisions)
1. Activity/rest—Ability to engage in
necessary or desired activities of
life (work and leisure) and to obtain
adequate sleep or rest
2. Circulation—Ability to transport
oxygen and nutrients necessary to
meet cellular needs
3. Ego integrity—Ability to develop
and use skills and behaviors to
integrate and manage
experiences
4. Elimination—Ability to excrete
waste products
5. Food/fluid—Ability to maintain
intake of and utilize nutrients and
liquids to meet physiological needs
6. Hygiene—Ability to perform
activities of daily living
7. Neurosensory—Ability
perceive, integrate, and respond to
internal and external cues
8. Pain/discomfort—Ability to control
internal and external environment
to maintain comfort
9. Respiration—Ability to provide
and use oxygen to meet
physiological needs
10. Safety—Ability to provide safe,
growth-promoting environment
11. Sexuality - [Component of Ego
Integrity and Social Interaction]
Ability to meet
requirements/characteristics
male/female roles
12. Social interaction—Ability
establish and maintain
relationships
13. Teaching/learning—Ability
incorporate and use information to
achieve healthy lifestyle/optimal
wellness
3. Gordon’s Model (11 Patterns of
Functioning)- ADULT Health Patterns
of Functioning
● Health Perception and Health
Management Pattern
● Nutritional and Metabolic Pattern
● Elimination Pattern
● Activity-Exercise Pattern
● Sleep-rest Pattern
● Cognitive-perceptual Pattern
● Self-perception and self-control
Pattern
● Role-relationship Pattern
● Sexuality-reproductive Pattern
life
● Coping-stress Tolerance Pattern
● Value-belief Pattern
● Emotional Pattern
● Cultural Pattern
● Recreation Pattern
● Environment
● Hygiene
● Substance Use/Abuse
to Head, Eyes, Ears, Nose, Throat
(HEENT)
Nursing Considerations
1. Consider the client’s ability to
participate in the interview
process.
2. Culture and language are
important considerations in
establishing a positive
relationship.
3. Consider the factors that can
affect the interview process are
of
alterations in the senses, such as
blindness or hearing deficits,
to
developmental level, and pain.
Functional Assessment is an objective
to
review of an individual’s mobility,
transfer skills and activities of daily
living, including self-care, mobility, to measure the client’s ability to perform
locomotion and communication (Farlex, activities of daily living independently.
2021).

APGAR SCORE

The Apgar score is an assessment of

the newborn immediately after birth.

The Barthel Scale/Index (BI) is a scale

used to measure performance in
activities of daily living (ADL). Ten
variables describing the activities and
ADOLESCENT - HEADSS Assessment mobility are scored, a higher number
being a reflection of greater ability to
The HEADSSS assessment is an function independently following hospital
internationally recognized tool used to discharge.
structure the assessment of an
adolescent patient, encompassing
Home, Education/Employment,
Activities, Drugs, Sex and relationships,
Self-harm and depression, Safety and
abuse.

The instrument is most effectively used

among adolescents aged 10-19 years
old in a variety of care settings.

The Katz Index of Independence in

Activities of Daily Living (Katz ADL) is
an instrument to assess functional status
The CAGE Substance Abuse
Screening Tool assesses for alcohol
problems and has an adapted version
for drug problems- the CAGE-AID
Substance Abuse Screening Tool A
five-question tool used to screen for
drug and alcohol use; answering yes to
two or more questions indicates a
complete assessment.

Intimate Partner Violence Screening

Tests

It includes physical violence, sexual

violence, stalking, and psychological
aggression that is perpetrated by a
current or past intimate partner (CDC,
2017).

• Screening tools

● HARK – Humiliation, Afraid,

Rape, Kick
● HITS – Hurts, Insult, Threaten,
Scream
● WAST – Woman Abuse
Screening tool
Pediatric Health Assessment
Purposes:
1. Direct appropriate investigation
and examination.
2. Reach the correct diagnosis.
3. Establish the context of a child’s
illness.
4. Establish and maintain a good
relationship with the child and
parents.
5. Use the interaction with the
child/parent(s) as part of the
therapeutic process.
6. Use the understanding and
knowledge of context and
background to tailor pragmatic,
appropriate treatment strategies.
7. Take an overview of the child's
previous and current state of
health to anticipate or identify any
problems which may not be
immediately apparent.
MMDST
MMDST- Metro Manila Developmental
Screening Test
devised by Dr. Phoebe Dauz Williams,
RN, PhD in the 1980
DDST- Denver Developmental Screening
Test
By Dr. William K. Frankenburg
Screening- presumptive identification of
an unrecognized disease or defect by the
application of tests that can be applied
rapidly.
- Not an absolute diagnostic tool.
MMDST- an early detection model that
applies to the detection of developmental
disabilities in children ages six and a half
years old and younger.
- A simple, clinically useful tool used
in the early detection of children
with serious developmental delays.
- Not an intelligence test (IQ Test)
- Determine whether a child’s
development is within normal
range.
- Used in children aged 2 weeks to 6
½ years old. (because 7 and above
is school-aged)
- Only for Metro Manila children.
- Made up of 105 items.
Four Aspect of Child’s Development:
Personal-Social- tasks indicate the child’s
ability to get along with people and to take
care of himself.
Fine Motor-Adaptive- tasks indicate the
child’s ability to see and use his hands to
pick up objects and to draw. (controlling of
fingers)
Language- tasks indicate the child’s Four kinds of Scores:
ability to hear, follow directions and to
speak. P- Pass

Gross Motor Behavior- tasks indicate the F- Fail

child’s ability to sit, walk, and jump. (using
of hands and feet in a large movement) NO- No Opportunity

R- Refused

Materials/Equipments needed for *Failure of an item that is completely to the

MMDST: left of the child’s age line is considered a
developmental delay and is therefore
MMDST Kit Composed of: referred to in the MMDST as a delay.

-MMDST Manual (for guide) Calculating the Child’s Age

-MMDST Test Form (to input the results) - crucial, initial step in test administration.
The test items that will be administered
MMDST bag composed of: will depend on the calculated age of the
child.
- Bright red yarn pom-pom (because
infants can only see black, white and red - subsequent interpretation of results.
color)
Example:
- Rattle with narrow handle (for easy grip)
Date of Test: Feb 20, 2023
- Eight 1 inch colored wooden blocks (red,
blue, yellow, green) (colors are primary & Child’s Birthday: June 24, 2020
secondary color)
Solution: Subtraction
- Small clear glass bottle with ⅝ inch
opening (not too big, not too small to test
the ability of the child)

- Small bell with 2 ½ inch diameter mouth

(big mouth tends to be louder)

- Rubber ball 12 ½ inch in circumference Conversion for borrowing:

(to fit the hand of a filipino child)
1 Year = 12 Months
- Cheese curls
1 Month = 30 Days
- Pencil
* For Premature 2 years old below, it
- Bond paper should be adjusted. If they are born 2 or
more weeks earlier than the expected
date, Subtract the no. of weeks of
prematurity from the actual age.
*After knowing the actual age, mark the The MMDST Form:
age line on the test form and write the
date of the test and the actual age.

Example:

At the back:
*The location of the age line must be
accurate. The space between age marks
represents 2 weeks until age 14 months
and 1 month from 14 to 24 months. From
24 months to 5 years, spaces represents 3
months, and thereafter, 6 months to the
end scale.

*Whatever the age line passes, that will be

the initial tasks that will be tested on the
child.

*If failure occurs, proceed to administer

items to the left of the age line until the
child obtains 3 passes, then stop.

*Normally, a child is tested on only 20

simple tasks or items. The child may
accomplish some task without being
asked which is therefore will be written as
passed.

- the numbers on the edges will be the

age scales marking ages from months
from 1 to 24, and ages in years from 2 ½
to 6.
- Each task is represented in the test form *Avoid testing the child when he/she is ill,
by a bar. sleepy, tired, hungry, or upset.

Administering the Test

*test should be sequenced in personal

social, fine motor adaptive, language, anf
gross motor behavior. However, there are
some instances when you may vary the
- The percentage indicates that the
sequence of some items in order to take
normal children passed this item.
advantage of the child’s interest.

*words or directions must not be changed.

Otherwise, test administration will not be
standard.
*Some items have footnote numbers and
*Avoid asking questions in such a way that
an R on the edge. The footnote indicates
you suggest the answer.
a corresponding instruction found at the
back of the Test Form.
*Each sector, start with items that the child
is able to perform easily in order to
Passed By Report (R)- this means that
motivate the child to perform more difficult
the item can be asked to the guardian of
tasks and provide parents with
the child rather than performed by the
satisfaction.
child during the test.
*CHILD IS ALLOWED TO HAVE 3
asterisk(*)- equal movements- located at
TRIALS TO PERFORM EACH ITEM
the fine motor adaptive sector of the Test
BEFORE A SCORE OF FAILURE IS
form.
GIVEN.
Arrows (->)- nine items have it at the right
*Read page 15-65 in the manual for
end of the bars. This indicates that normal
scoring directions
children may pass these items even
beyond 6 ½ years of age.
*If the child refuses to do such a task that
cannot be passed by report even though
Preliminary Phase
the parent reported that the child can do it,
- establish rapport with the score the item by R (refusal).
mother/caregiver. State that you are
*After completing the test administration,
interested in observing what babies and
note pertinent behaviors on the child’s
children can do at certain ages. State also
cooperation, attention span, verbal
that it is a screening test, not an
behavior, self-confidence, nervous habits,
intelligence (IQ) Test. Reassure that the
parent-child relationship, and your own
child is not expected to do or pass all the
overall feeling about the test.
items administered.

- make the child as comfortable as

possible. (sit on the lap of guardian) (kneel
position)
Interpreting the Test Result
The MMDST result is interpreted as
NORMAL, QUESTIONABLE, ABNORMAL
or UNTESTABLE depending on the
number of delays. Remember that a delay
is any failure that falls completely to the
left of the age line.
Steps:
1. Mark each delay by heavily shading the
right end of the bar.
2. Count the number of sectors that have
2 or more delays.
3. Count the number of sectors that have
1 delay with the passes intersection the
age line in the same sector.
4. Interpret the result using the following
criteria.
* At the bottom of the age line, indicate the
result and interpretation.
Example:
Abnormal, Reason: 2 sectors have 2
delays.
Discussing the Test Result
*Ask parents/caregiver whether the child’s
performance is typical of his/her ability and
behavior.
*Interpretation or result should be given to
the parent/caregiver in general rather than
abnormal, questionable, or normal.
*Do not use the label or term ABNORMAL
when talking to the parent/caregiver.
*If the child has done well, praise the child
and reassure the parent/caregiver that the
child is developing as he/she should be.
*Retest the child for approximately 2
weeks if necessary. In retesting, draw a
new age line and score with a new
different color of pencil. Write the date of
the new retest at the top of the age line.
*A child who is still resulted as abnormal,
questionable, or untestable should be
referred to a pediatrician or an appropriate
health professional for further evaluation
and possible developmental stimulation
program.
Difficult Test Situations (pg 69-72)
*Before the test, ask the parent if the child
has always been shy, inattentive,
overactive, or exhibit other similar
behaviors for which it is considered
difficult.
The Shy Child
The Uncooperative Child
The Overactive Child
The Child with many siblings
The Interfering Parent