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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