Chapter 2. Patient Assessment
The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013).
Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012).
The hospital will have a form with assessment questions similar to the ones listed in Checklist 16.
Checklist 16: Health History Checklist| Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |
Steps | Additional Information |
| Determine the following: 1. Biographical data |
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| 2. Reason for seeking care and history of present health concern |
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| 3. Past health history |
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| 4. Family history |
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| 5. Functional assessment (including activities of daily living) |
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| 6. Developmental tasks |
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| 7. Cultural assessment |
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| Data source: Assessment Skill Checklists, 2014 |
- You are taking a health history. Why is it important for you to obtain a complete description of the patient’s present illness?
- You are taking a health history. What is one reason it is important for you to obtain a complete description of the patient’s lifestyle and exercise habits?
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- Which of the following questions would be most important for the nurse to ask firstwhen obtaining the health history?
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- A client arrives at the Emergency Department reporting shortness of breath. She iscyanotic with bilateral wheezing. The client begins to gasp for air and cannot speak. Thenurse begins to gather information so that interventions can resolve the immediatebreathing problem. Her assessment and interventions are concurrent. The nurse isperforming what type of health history?
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- A client scheduled for surgery tells the nurse that he is very anxious about the surgery.What is an appropriate action by the nurse when interacting with this client?
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