Chapter 3: The Health History

Chapter 3: The Health History · The purposes of the health history are to establish a trusting and supportive relationship, gather information, and offer information. It is critical to obtain comprehensive, accurate information about the patient's physical and mental health to develop a plan for care ↳ during history-taking and interviewing, a therapeutic relationship built on trust and rapport is established Subjective and Objective Data · Subjective data: the information that the patient reports. They include data about signs and symptoms that the patient describes and cannot be observed ↳ additionally, the nurse collects demographic data, individual and family histories, surgeries, personal and social history, review of systems, and risk for illness (all are subjective) · Objective data: information gathered from the physical examination that can be seen, felt, or heard by the observer · Signs: actions or physical manifestations that are observable by others ↳ objective data, observable, usually collected during physical exam · Symptoms: sensations, feelings, or emotions that are perceived or experienced by a patient ↳ subjective data, not observable, usually collected during interview - - Primary and Secondary Data Sources · primary data: the individual patient · Secondary data: charts, significant others, family members, and medical alert information · primary data (from the patient) is always more ideal, and its important to fact-check Components of the Health History · 3 types of health assessments: 1) Emergency/urgent 2) Focused 3) Comprehensive · Gather demographic data, (the patient's name, address, and other contact information) environmental data (travel history, allergies, medications), the patients living situation, and people brought with the patient to the ED ↳ it is important to note the date and time of the health history · the reason for seeking care is a brief statement, usually in the patient's own words, about why they are seeking medical help. It is often called their "chief concern" ↳ try to quote the patient's own words when documenting this, as well as their symptoms ↳ LATER SNAPS, OLDCARTS, and PQRSTU L - location A - associated symptoms O - onset P - provoke/palliative T - timing L - location Q - quality E - environmental/exposure D - duration R - region R - relieving factors C - character S - severity S - severity A - associated or aggravating factors T - timing N - nature/quality R - relieving factors U - understanding patient A - aggravating factors T - timing perception P - perspective from patient S - severity S - significance to patient PAST HEALTH HISTORY · the past health history covers the assessment of 4 health areas: ↳ medical, surgical, obstetric, mental health · the past health history includes an assessment of medical and surgical conditions along with the treatment and course · For females, note the last menstrual period (LMP) and whether the patient may be pregnant · Ask the patient about mental health issues (depression, anxiety, eating disorders and sleep disturbances) · The record should also include childhood illnesses (with lasting effects) and immunizations · Ask patients about current medications including name, dose, route, and reason for taking each medication · Verify allergies with patients and check the health care record for accuracy ↳ note the type of response such as rash, throat swelling, difficulty breathing, or anaphylactic shock FAMILY HISTORY · Ask the patient about the health of close family members to help identify disorders at risk and to provide health education ↳ eg. high blood pressure, high cholesterol, stroke, cancer etc. · genogram: a map used to identify family structures and info visually FUNCTIONAL HEALTH ASSESSMENT · functional health patterns are especially important to nursing because they focus on the effects of health or illness on the patient's quality of life ↳ address more personal questions near the end so they are more comfortable initially · Activities of daily living (ADLs) help determine whether patients are totally independent, need assistance, or are dependent on others GROWTH AND DEVELOPMENT · with pediatric patients, observe growth to determine how children compare to peers ↳ consider genetic background ↳ assess physical activities, fine and gross motor skills, and speech · For all patients, carefully evaluate the cognitive stage (for young and old) · When working with younger patients, assess their development of abstract thinking skills, with older patients assess for memory decline Review of Systems: · General health state REVIEW OF SYSTEMS · Nutrition & hydration · The review of systems is a series of questions about all · Skin, hair, and nails body systems as part of a comprehensive assessment · Head and Neck ↳ ask patients about any symptoms related to each body system, such as a cough in the respiratory system · Eyes · Obtain information about health promotion practices and · Ears · Nose, mouth, and throat provide education about areas of interest or concern · Explain to patients that although the review is lengthly, it · Thorax, lungs, respiratory · Cardiovascular is an opportunity to double check for completeness and · Peripheral vascular accuracy - · Breasts · Abdominal-gastrointestinal · Abdominal-urinary · Musculoskeletal · Neurological · Male/femal genitalia · Anus, rectum, prostate · Endocrine and hematological PSYCHOSOCIAL AND LIFESTYLE FACTORS · These types of questions are saved until the end of the interview because they are often personal and aren't easily fit into body systems questions ↳ examples of sensitive questions are sexual orientation, risk for domestic violence, and drugs/alcohol · Information about exercise regimens, employment, sedentary lifestyle, stress and coping mechanisms, and economic factors are essential to collect to develop a plan of care · Social, cultural, and spiritual assessment ↳ Assess the overall psychosocial well-being as part of the screening for functional health patterns, including self-perception, self-concept, role/relationships, and coping/stress tolerance ↳ also assess cultural beliefs and health practices that may influence care (spiritual beliefs, religious preferences, rituals and practices, etc. ) ↳ The 3 dimensions of cultural encounters: ① self-awareness ② respectful communication ③ collaborative relationships · Mental health ↳ if a patient reports feeling anxious or depressed, or they sound illogical, or if an association exists between current physical status and psychiatric concerns, a more focused assessment is required ↳ When the primary concern is psychiatric, the nurse performs a complete mental health assessment · Alcohol and substance use ↳ ask patients about smoking, alcohol, cannabis, recreational drug use, and illegal substance use. Assess use with direct questioning and observation of behaviours that indicate impairment, such as slurred speech, nodding off, and an unstable gait ↳ CAGE questionnaire (cutting down, annoyance if criticized, guilty feelings, and eye-openers) · Human violence ↳ because of the sensitive nature of the topic, the nurse poses questions so that the patient feels comfortable ↳ abuse is suspected if injuries are inconsistent with explanations, the story changes over time, the patient has delayed getting treatment, there is a past history of injuries or accidents, there is associated drug or alcohol abuse, or there is a history of mental illness · Sexual history and orientation ↳ the comprehensive history includes sexual history and sexual orientation to establish a baseline for health behaviours and identify the need for education ↳ the nurse avoids bias about sexual orientation, culture, age, or marital status Lifespan Considerations · women who are pregnant ↳ a comprehensive health history is done at the first prenatal visit, especially info on current pregnancy, previous pregnancies, obstetrical and gynecological history, family, significant others, and psychosocial profile · Newborns, children, and adolescents ↳ collect the health history for infants and children from parents ↳ the relationship between the child and the parent determines how to collect data, such as asking questions about sexual history when the adult isn't present · Aging adults ↳ When interviewing aging adults, consider the increased risk for sensory deficits that might alter the historytaking such as loss of vision or hearing (do not assume they have deficits! )