NURS 356 Foundations of Nursing
Week 1 and 2 (Exam 1)
What is the Purpose of a Health History Assessment?
- provides a subjective data base
- identified a patients’ strengths
- identifies patients’ actual and potential health problems
-directs the physical assessment - it is essential for successful plan of care
What is essential for a successful plan of care?
identifies support systems
identifies learning needs
identifies discharge needs
identifies referral needs
What are the types of health history?
Complete and Focused
Complete Health History
a patient health history exam that is comprehensive and holistic
Focused Health History
a patient health history exam that is abbreviated
How do you determine which type of Health History exam to conduct?
It depends on the patient’s condition and amount of time you have
MD (physician) vs. Nursing Health History Exam
Physician:
Focuses on diagnosis and treatment of illness. Example: a physician might not ask
about a patient’s religion.
Nurse:
Focuses on diagnosis and treatment of human responses to health problems/injury.
Nursing health history is more comprehensive.
Components of a Health History
-Biographical data
-reason for seeking health care
- Patient expectations
- Current health status
Biographical Data
Factual demographic data about the patient (gender, age, religion, etc)
Reasons for seeking health care
Let’s you know the chief concern or problem
Patient expectations
May not be the same as the reason seeking medical care. It provides for patient
satisfaction.
What does the patient want to get out of the visit, what is the patients thought, what
does the patient want to go?
Current Health Status
It is the collection of essential information about the symptoms
REMEMBER the acronym PQRST
PQRSTU for current health status
Provocative/Palliative- what provokes it/makes it better/makes it worse?
Quality/quantity- what does it feel like? What makes it better or worse? Might need to
give examples: dull, burning, sharp…
Radiation- is it in one area?
Severity- scale of 0-10. Always on a scale.
Timing- when did it stat? How long has it lasted?
Understanding
Concomitant symptoms
Two symptoms occurring at the same time
Past History Components of a Health History
Hospitalizations
Serious or chronic illness
Allergies
Accidents or injuries
Military service
Surgeries
Immunizations