Health history

INTRODUCTION:

The health history is a chronologic and detailed record of the client. Its purpose is to elicit information regarding the variables that may affect the client’s health status. These data are then used to develop nursing diagnosis and subsequent plans for individual care. For the ill client health history serves as a back ground material related to the development of present symptoms and associated difficulties. A nurse utilizes health history to provide individualized care to determine the impact of illness on the client and the family, to determine health teaching needs and to begin discharge planning. The nursing health history is different from medical history. A physician takes a medical history to assist in diagnosis and treatment of an illness.

PURPOSES

1.To elicit information about all the variables that may affect the client’s health status.
2.To obtain data that helps the nurse to understand and appreciate client’s life experience.
3.To initiate a non judgemental, trusting interpersonal relationship with the client.

GUIDELINES FOR THE HEALTH HISTORY INTERVIEW

The health history interview process is affected by external and internal factors that affect the health history. Data quality and quantity are enhanced by sensitivity of the client and by one’s skill level with the interview process.

1.Preparation of the environment

a) When possible conduct the interview in a comfortable setting, using a quiet room with a closed door which decreases interruption.
b) Reduce or eliminate distractions and inform colleagues to avoid interruptions.
c) Use comfortable chairs to establish rapport. Adjust the distance between chairs to the client’s preference and sense of personal space.
d) Ensure a moderate room temperature to promote comfort.
e) Provide indirect lighting to prevent glare and strong shadows that may distort observations of non verbal clues.

2.Preparation of the client

a) After introduction explain the nature and purpose of the health history interview.
b) Speak in a moderate tone of voice, calmly and patiently.
c) Ask no probing, client centred questions, which help to put the client at ease. as the interview progress focused questions and therapeutic communication technique help to identify problem areas.
d) Alternate between open ended and closed questions depending on the data being collected.
e) Through out the interview observe non verbal communication for signs pf discomfort with the topic under discussion.
f) Respect the clients wish to decline discussing a topic.
g) Be aware of interview style and skills. Non verbal behaviour can either facilitate or inhibit client responses and affect the quality of the historical data.
3. Preparation of the Interviewer

a) Reduce repetition questioning and proceed in a structured and flexible manner. Until the nurse is comfortable with the interview format, use a pocket sized outline o0f the history format as an aid.
b) Take brief notes and inform the client in advance that you will be taking notes so as not to disrupt the flow of the interview. Avoid extensive notes taking, because it suggests that you are not listening attentively.
c) Compile the written history after interview.
d) Terminate the interview by summarizing highlights and allowing the client to add or clarify information.
e) Inform the client about how the physical examination will proceed.


COMPONENTS OF THE HEALTH HISTORY

The health history includes subjective data regarding the following
1.Biographical and demographic information
2.Physical Health history including review of system
3.Past health history
4.Family health history
5.Personal history
6.Psychosocial history
7.Environmental history
8.Review of system
9.Appraisal of the clients health maintenance and health promotion behaviour to asses health risks

1. BIOGRAPHICAL AND DEMOGRAPHIC INFORMATION

The extent and type of biographical and demographic information may vary depending on agency protocol. Include the date of interview because the information gathered constitutes baseline assessment. If the clients health status changes, the health history and physical examination reflect the extent of the change over the time. These provide clues about personal health risk. some risks may be ascribed to age, sex, family history, location of residence. Various health screening procedures are recommended based on age, gender, and background data. For e.g. periodical pelvic examinations for women’s and screening of visual acuity and testing for glaucoma for aged persons.


Biographical and demographic data;

Full name
Age
Sex
Address
Date and time of admission
Nationality
Religion
Primary language
Date and place of birth
Educational status
Marital status
Occupation
Income (per month)
Significant others
Phone number
Emergency contact
Legal guardian
Source of information
Diagnosis

2. PHYSICAL HEALTH HISTORY

Chief complaints
It begins with the client’s subjective statement of reason for seeking health care. It reveals the clients perception of the present health problem. The client may talk about what the problem means and how he is coping. When the client reports a health problem, either past or current, the nurse proceeds with a symptom analysis.

Symptom analysis
It is the client’s description of the health problem characteristics. In addition to assessing these characteristics, ask the client to provide an opinion about the cause of the manifestations or problem. Clients often have insight as to the nature and the cause of their problems. Explore fears and concerns to identify and treat their responses to health problems.
Areas included are
a)Timing;
It includes onset, duration, and frequency.
-Onset-refers to when a manifestation was first noticed. (Hours, days, months ago)
- Duration-is how long the manifestation lasts. (Minutes, hours, days, weeks)
-Frequency is how often a manifestation occurs (daily, weekly, and monthly)
.
b) Quality;
Ask the client to discriminate manifestation quality with adjectives such as sharp, stabbing, dull aching, cramping, cold, searing, burning, numb,
Tingling, loose, solid, soft, hard, and tight or crushing.

c) Quantity;
Severity of the pain is qualified by asking the client to rate the symptom on a scale such as 1-5 or 1-10. Assist the client in describing the size, amount and number or extent of manifestation as well as the severity or intensity. Assess the manifestations effect by asking how usual daily activities have been affected.
.
d) Location;
Ask the client to show where a symptom is located on the body, and whether it moves or is stationary.
.
e) Precipitating factor;
Ask the client does he know what may have led to the manifestation s occurrence? Ask what the client was doing at the time the manifestation noticed.

f) Aggravating and relieving factors;
Ask the client to recall whether any factor alleviate the symptom or make it worse.
.
g) Associated manifestations;
Inquire whether the client has noticed anything in conjunction with the manifestation.


Past health history

It may be important for determining both current and future health risk status.
It includes information about

Growth and development;
Any known problems with growth and development including prenatal or birth history or delay in language speech motor skills.

Immunization
Record childhood immunization and whether kept up to date, note last of T.T booster and influenza vaccination.

Past illness;
Ask spout measles, mumps, rubella, chicken pox, whooping cough, rhematic fever, poliomyelitis, asthma, T.B.


Serious or chronic illness;
Note the presence of DM, heart disease,
Hypertension, kidney problem, ulcers, thyroid problem, migraine head aches, seizure, stroke, arthritis, cancer, anamia, HIV etc.


Hospitalisation
Date and reason for each admission
Summary of treatment, length of hospitalisation
Name of primary care physician
Reaction to these events and their out comes

Surgeries
Date and time of procedure performed
Name of the surgeon
Note whether performed on inpatient or outpatient basis
Client’s reaction to the procedure and out come

Serious injuries or accidents
Date and type of injuries or accidents
Ask specifically about head injuries, fractures, burns, or other trauma
Note client’s reaction to each and their outcome.


Obstetric history
For completed pregnancies; number, course of each pregnancy,
Labour, delivery, post partum period, delivery date, birth weight, sex,
Infant’s health.
For uncompleted pregnancies; number, duration of pregnancy, date
And circumstances
Complications

Last visit to health care providers
Record most recent dates for dental, physical, vision, hearing
Examination
Date and results of screening or diagnostic tests performed.

Allergies
Description of allergies and reactions
Include medications, food, contact agents, environmental agent


Medications
Ask about common medications such as aspirin, vitamins, antacids,
Birth control pills, topical creams and lotions
Ask about dose, route, frequency, time of the day, reason for taking,
Are there problems with taking, who prescribed each drug and when


4. FAMILY HEALTH HISTORY

The family health history helps to identify family linked diseases that affect health status and risk for potential health problems

1.Inquire about relationship of family members, their ages (if living), the age at which they died the cause of death, the presence of other health problem.
2.Include a statement summarising health problems in the family.
3.Ask specifically about heart disease, hypertension, stroke , epilepsy, mental illness,T.B,DMthyroidproblems,arthritis,cancer, obesity,alcoholism,alzeimer’s disease, HIV, anaemia, haemophilia, migrains,allergies, asthma.
4.Diagram the data as a visual display to track health risk status.



4 .PERSONAL HISTORY
The next component is aimed at determining the kind of environment the client is accustomed to. Information is obtained related to occupational history, financial status, personal habits, daily activities, diet, sleeping pattern, recreation
.
Occupational history;
Inquire whether client is presently employed or unemployed. It helps to asses stress level and mental status of the client. Ask about the occupational hazards of the client’s job. Knowing that a client who is complaining of chest pain and cough has worked with industry for some years may help to pinpoint the contributing factor to the illness. Inquire about the geographical location of the work place. If the employment area is in pollutant region they may aggravates the existing condition.

Personal habits;
Information must be obtained regarding the use of cigarettes, alcohol

Diet;
A clients eating pattern s may be the clue to a problem of obesity or malnutrition. the clients eating habits may also direct to areas for further assessment; for example the adolescent who exist on fad food may develop skin problems, obesity or anaemia while the elderly person subsisting on te and toast may be in fluid and electrolyte imbalance and malnourished.
Inquire about the typical diet on a normal day, how much he eats how many meals he consumes per day? Who prepares the food? Does he eat and then vomit? Does he think he is too fat? Does the client is on special diet? Has he had any disturbances in digestion, chewing or swallowing?

Sleeping pattern;
The most common disorder is insomnia. Clients with psychosis and neurosis suffer from insomnia. Sleep and rests clearly affect the total well being. The more prevalent physical conditions disposes to insomnia are chronic pain, DM, gastric ulcer, angina pectoris, and respiratory disorders. Some physical characteristics that may indicate troubled sleeping pattern are dark circles, under eyes, puffy eyelids, irritability, headache, fatigue, and decreased attention span.
Inquire about total hours of sleep, when do they sleep and wake up?, have they experienced any difficulty in sleeping?, if they have experienced difficulty what remedies they tried? Has anything happened recently that might attribute to their sleeping difficulty? Do they have trouble fall asleep? Do they wake up during the night? Do they wake up morning feeling fatigued? Do they experience nightmares, sleepwalking bedwetting?


Activities of daily living;
When assessing daily activities, we will gather information about difficulties he might have experienced in the basic activities. We should also determine whether the client is independent in performing daily activities or whether he needs supervision or assistance?
Inquire whether he has any difficulty with feeding, grooming, brushing, bathing, dressing? Can he get out of bed? Can he get into a chair? Is he unable to carry out certain activities? How much assistance does he need? Does he require adaptive devices to perform activities?

Recreation / hobbies;
Discussion might include such things like exercise, hobbies and other interests and even time spent with family and friends.

Sexuality;
If the client is sick energy, enthusiasm and interest for sexual activity are generally decreased. Keeping in mind the nursing goal of promoting and maintaining health status and having background knowledge of sexuality will enable the nurse to pursue this area of health assessment with clients.


5. PSYCHOSOCIAL HISTORY

Psychosocial assessment assists the nurse in understanding a client’s response to circumstances and events which intern influences the client’s ability to function. It encomposses gathering information about psychological pattern and social experiences. It requires sensitivity and interpersonal skills by the nurse.
The term psychosocial denotes the melding of the 2 dimensions because it is impossible to separate the effects of psychological factors from those of social factors.

Psychosocial risk factors
During the health history interview, nurse will assess for risk factors which indicates that the client is at risk for psychosocial problem.
Those factors are
Social history
Personal history
Level of stress
Usual coping pattern

If these risk factors are present, proceed with a detailed assessment.


Psychological history

It encompasses gathering information about thoughts, feelings, motivation, mood, personal strengths, weakness, stressors, values and beliefs and spirituality, motor activity, behaviour, mental status, level of consciousness, attention span, orientation, speech and communication, memory, general knowledge, calculations, abstract thinking, insight, judgement. Record subjective data in health history and objective data in the physical assessment form.


Sociologic history
It includes information about psychosocial development, social network, socioeconomic status, and culture.

Psychosocial development;
It refers to a person’s level of growth and development. It occurs across the life span and includes physical, emotional, psychological, social and cognitive components. An understanding of human growth and development provides a foundation from which to asses the client.

Social network;
It is the group of people that surrounds, interacts, with, and sustains a person with intimacy, special integration, nurturing, reassurance, and assistance. The nurse becomes the part of a client’s social network when the client enters the health delivery system.
Collect social network data by observing the client during interactions with family members, visitors. Do not assume that only family members are the most important people. When planning care include significant others.

Socioeconomic status;
An individual’s economic position in the society is referred as socioeconomic status. For persons in the lower income areas may not get adequate clothing which may decrease the protection and opens 5the individual to illness. And they give importance to shelter than food so they are often weak, anaemic and malnourished.


5. ENVIORNMENTAL HISTORY
Ask about
Location of house (urban or rural)
Type of house
Whether client owns or rents the home
Environmental sanitation
Type of water supply
Method of sewage disposal
Drainage
Lavatory facilities
Lighting
Ventilation





6. REVIEW OF SYSTEM

General condition
Inquire about fever, chills, sweats, night sweats, weakness, weight loss, fatigue, malaise, nausea, vomiting, and he

Skin
Inquire about past skin problems like scars, birth marks, burns, purities, rashes, a change in skin colour, temperature, bruising, psoriasis, eczema, sun exposure, skin care habits, and a sore that does not heal presence of any tattoos.
.
Hair
Is there any problem with alopecia, dryness, brittleness, dandruff?

Nails
Are there any problems with brittleness, cracking, or splitting? Is there any change in nail texture? Does the client bite his nails?

Haematopoietic
Inquire about fatigue, unusual bleeding, easy bruising, ecchymosed, anaemia, leukaemia, exposure to radiation, any blood transfusion.

Endocrine
Inquire about the presence of DM, thyroid problem or goitre, impotence, hirsutism, hormone treatment.

Head
Inquire about trauma, or blow, injury to the head, headaches, dizziness, syncope, vertigo, seizures.

Eyes
Inquire about the eye infections, chalazion, glaucoma, cataract, detached retina, strabiscus, vision problem, blindness, redness, itching, and lacrimation, discharge, swelling around eyes, photophobia, and last eye examination, wearing of lens or eye glasses.


Nose and sinuses
Ask if there is any history of frequent colds, sinus infection, nasal stuffiness, allergies, nasal trauma or fracture, sneezing, runny nose, pain over sinuses, epistaxis, breathing difficulty, use of nasal sprays or other cold, sinus medications.

Ears
Inquire about past problems with ear infections, loss of hearing, tinnitus, buzzing, ear pain, discharge, vertigo.

Mouth and pharynx
Inquire about a history of sore throats, or oral infections, such as cold sores, thrush, bleeding gums, and dry mouth, difficulty in chewing or swallowing, oral surgery, voice change, last dental examination, dental hygiene practices, presence of any denture.



Neck
Ask about neck injury, goitre, pain, limited neck movement, presence of lumps, or tenderness or swelling in the neck.

Breast and axillae
Ask the client about a history of fibrocystic breast disease, cancer, gynacomastia breast pain, swelling, pruritis, nipple discharge, lumps, breast surgery, taking of estrogens and corticosteroid.

Lungs
Inquire about a past history of breathing problem like asthma, emphysema, wheezing, pleurisy, bronchitis, T.B, smoking habit, chronic cough, haemoptysis, night sweats, dyspnoea, orthopnea, pain with breathing, cyanosis, taking chest x-ray.

Heart
Ask the client about a history of rheumatic fever, congenital heart disease, heart murmur, MI, cardiac surgery, hypertension, thyroid problem. Are there current problem with; chest pain, syncope, vertigo, palpitation, paroxysmal noctural dyspnoea, orthpnea, sudden weight gain, edema of hands, or feet, hyper lipidemia. Has the client ever had any cardiac tests, such as ECG, coronary angiogram, echocardiogram?

Gastro intestinal
Inquire about history of ulcer, indigestion, heart burn, hernia, liver disease, hepatitis, pancreatic disease, appendicitis, use if alcohol, cancer ,unusual bowel pattern,diarrhea, constipation, bowel incontinence, flatulence, rectal pain or itching, pain abdomen, use if laxatives or enemas, or suppositories.

Urinary
Does the client have a history of bladder infection, kidney problems,
urinary tract stones, STD, UTI if there are any problems with urinary
frequency, dysuria, pyuria, urgency, incontinence, nocturia, polyuria,
oligouria, flank or low back pain, change of the urine, foam in the urine,
And discharge from the urethra?
Has the client had tests of the urinary system such as urinalysis,
Cystoscopy, IVP?

Genitoreproductive
Is there any history of genital lesions, sores, ulcers, urethral discharge, odour, pain, pruritis, STD, infertility, pelvic diseases, endometritis.? History of age at menarche, menopause. In case of males inquire about inguinal hernia, prostate problem, impotence, reproductive cancer, testicular pain.

Musculoskeletal
Ask about problems with sprains, stains, fractures, dislocations, arthritis, gout, back ache, bursitis, osteomyelitis, scoliosis, spinal deformity, limited movement, muscle twitches, cramps, spasms, pain, weakness, muscle atrophy, stiffness, redness, and swelling.


Neurologic
Is there any history of loss of consciousness, fainting, seizures, paralysis, parasthesia, trauma to the nervous system, cerebral vascular accident? Are there current problem with vertigo, syncope, tremors, spasms, speech problem, headache, loss of balance.

Psychiatric
Ask about history of depression, bipolar disease, OCD, sleeping problems, eating disorder, memory problem, anxiety attacks, using of psychotropic substances. Does the client currently have problem with mood swings, sleeping problem, anxiety, change in appetite, memory lapses, inability to concentrate, phobias, delusions, hallucination


7. HEALTH PROMOTION AND HEALTH RISK APPRAISAL

Health risk appraisal examines factors that affect potential for developing a particular health problem.
Risk factors are
-Genetic or biologic
-Behavioural
-Environmental
Determining health risk status identifies high risk clients who may benefit from timely interventions. In health risk appraisal assess the client’s willingness and motivation to modify or reduce risk factors.
Health risk factors are categorised for assessment purpose.

Risk factors include the following
Race and genetic or family related factors
Age related factors
Biologic factors
Personal factors
Life style factors
environmental and occupational factors
socioeconomic factors
Awareness of health risk factors may motivate a client to seek a screening procedures and to practice health promotion behaviours , particularly for health promotion that are treatable or manageable through timely interventions. A client with multiple risk factors linked to health problems is at greater risk for development of those problems than the client with fewer or no risk factors.
After assessing the risk profile, evaluate the client’s health risk status. Examine each identified risk factors with the client to determine whether its effects can be modified. If the client is interested in reducing health risks, intervene either directly or indirectly.
Health promotion needs change with age and gender. Specific screening procedures are performed during health assessment to determine potential and actual health problems. For health maintenance and prevention, specific health management behaviours are recommended based on age.
Screening procedures help to assess for a health problem or for risk of future health problem. They can be used to asses’ health status and to recommend further follow up or screening procedures.



RECORDING THE HEALTH HISTORY INTERVIEW

Record interview data in the health record according to agency protocol. The format is organised and all positive and negative findings must be recorded. Data are clear, concise, comprehensive, and consistent with no gaps. Use approved agency abbreviations and terminology, when possible to promote communication among health care team members.
In health assessment seeks to gather as much data about the client as possible, both subjective and objective.


HEALTH ASSESSMENT FORMAT

1. Biographical and demographic data;

Full name
Age
Sex
Address
Phone number
Date and time of admission
Nationality
Religion
Primary language
Date and place of birth
Educational status
Marital status
Occupation
Income (per month)
Significant others
Emergency contact
Legal guardian
Source of information
Diagnosis

2. Physical health history

Chief complaints( current symptoms or reason for seeking health care)


Symptom analysis
a) Timing;
Onset-
Duration-
Frequency-
.
b) Quality;

c) Quantity;
.
d) Location;
.
e) Precipitating factor;

f) Aggravating and relieving factors;
.
g) Associated manifestations;

3. Past health history

a) Developmental history

b) Immunization

c) Past illnesses

d) Serious or chronic illness

e) Hospitalisation

f) Surgeries

g) Serious injuries or accidents

h) Obstetric history

i) Last visit to health care provider
j) Allergies

k) Medications

4. Family health history


5. Personal history

- Occupational history

- Sexuality

-Personal habits

-Diet

-Sleeping pattern

-Activities of daily living

6. Psychosocial history

- General appearance
- Motor activity
-Behaviour
-Mental status
-Level of consciousness
-Orientation to person, time and place
-Mood and Affect
-Speech and Communication
-Thought process and content
-Attention span
-Memory
-General knowledge
-Calculations
- Abstract reasoning
-Perceptual distortion
- Judgement
- Insight
- Motivation
- Personal strengths
- Values and beliefs
-Spirituality
- Psychosocial development
-Social network
- Socioeconomic status

7. Environmental history

8. Review of system

General

Integument

Haematopoietic

Endocrine

Head

Eyes

Ears

Nose and sinuses

Mouth and pharynx

Neck

Breasts and axillae

Lungs

Heart

Gastrointestinal

Urinary

Genitoreproductive

Musculoskeletal

Neurologic

Psychiatric


COLLECTING HISTORY FROM PATIENTS OF DIFFERENT AGES

1. Talking with parents;
To obtain histories on infants and children under 5years of age, gather information from parents, third party, or from guardian.


2. Talking with children;
Children of 5 years or older are able to add significantly to the history and can describe more accurately the severity of the symptoms and their own level of concern regarding them. It’s better to begin such interviews by discussing an interesting, no threatening subjects.

3. Talking with adolescents;
Adolescents tend to open up when the focus of the interview is on themselves and their problems. Then a good way to begin the interview with adolescents is to chat informally about their friends, school, hobbies, family etc.




5.Talking with aged client;
Give an elderly person extra time to respond to the questions and speak slowly and in a low voice. Do not try to accomplish everything in one visit. Multiple visits may be less fatiguing and more productive.



CONCLUSION

The health history interview is the first part of the assessment of the client’s health status and is usually carried out before the physical examination. A nurse utilizes health history to provide individualized care, to determine health teaching needs and to begin discharge planning.