HEALTH HISTORY

Mr. Binu BabuAsst. professorMSN (N)

Mrs. Jincy BinuLecturerMSN (N)

HEALTH ASSESSMENT Health assessment is the collection of data about client’s health status.

PURPOSES To collect data about physical, mental and social

well being of client. To get clear picture of the client’s health status

and health related problems. To determine the cause and extent of disease. To determine the nature of treatment required for

client. To collect data systematically. To get a holistic (complete) view of the client. To formulate appropriate nursing care plan.

PROCESS OF HEALTH ASSESSMENT

Health history

Physical examination

HEALTH HISTORYHealth history is the collection of

data regarding client’s health in an chronological order.

COMPONENTS OF HEALTH HISTORY1. Biographic data2. Chief complaints3. Present health history4. Past health history5. Family history6. Personal history7. Socio economic history

1. Biographic dataThis includes information regarding client’s name, age, gender, marital status, occupation, education, I.P no, treating doctor & diagnosis.

2. Chief complaintsIt is the brief statement of client’s

problem for which client needs care.Eg: Client is complaining of cough since 2 weeks, fever since yesterday and headache since today.

3. Present health historyPresent health history is the

expansion of chief complaints. It should include location, quality, quantity, exaggerating and relieving factors.Eg: Client is admitted to the hospital with the complains of cough with mucus secretion since 2 weeks, cough increases during night and decreases with rest, fever with temperature 100⁰F since yesterday and headache at forehead since today which decreases with rest and rates 7 in pain scale.

Present medical history

Present surgical history

4. Past health historyIt is the information about client’s previous experience with any disease or surgery. This health history includes the detail of Childhood illness Adult illness Psychiatric illness Injuries, burns, fractures etc. Hospitalization Surgical & diagnostic procedures Current medications

Past medical history

Past surgical history

5. Family historyThis is the information about the client’s family members and their health status. Family treeThis is the diagrammatic representation of family members. Three generations has to be denoted in family tree. Family tree is also known as genogram.

- Male

- Female

- Male patient

- Female patient

- Male dead

-Female dead

Index

- Male

- female

Name, ageName, age

Name, ageName, ageName, ageName, age

Name, ageName, ageName, ageName, age

Index- Male

Female

Patient

Dead

Name, ageName

Name, ageName, ageName, ageName, age

Name, ageName, ageName, ageName, age

6. Personal historyIt includes client’s personal details such as dietary pattern, sleep pattern, activity level, elimination pattern, alcoholism, smoking habits etc

7. Socio economic historyCollecting data regarding client’s life style, working environment, personal relationship with other human beings, monthly or annual income, housing facilities.

Health assessment

Socioeconomic history

Health history

Personal history

Family history

Present health history

Past health history

Chief complaints

Biographic data

Medical

SurgicalMedical

Surgical

Physical examination