HEALTH HISTORY

DEFINITION

The health history is a review of the client’s functional health patterns & the possible health related conditions that led the client to seek the health care agency at the time of Admission. While the medical history concentrates on symptoms and the progression of disease, the nursing health history focuses on the client’s functional health patterns, responses to changes in health status, and alterations in lifestyle.

NURSING HISTORY:

Nursing History Includes the following

• Important Health History/ Information
• Functional Health Pattern Assessment

Important Health History/ Information

This provides an overview of client’s background Information that Includes the following:

1. Demographic Information
2. Admission History
3. Past Medical/ Surgical History
4. Present History/ Medications
5. Developmental History
6. Family Health History
7. Immunization History
8. Personal History
9. Allergic History

• Demographic Information: Personal data including name, address, date of birth, gender, religion, race/ethnic origin, occupation, and type of health plan/insurance should be included. This information may be useful in helping to foster understanding of a client’s perspective.
• Admission History: The client’s reason for seeking health care should be described in the client’s own words. It is the client’ actual report of the event that precipitated the need for health care. The client’s perspective is important because it explains what is significant about the event from the client’s point of view. It is also important to determine the time of the onset of symptoms as well as a complete symptom analysis.
• Past Medical/Surgical History:
  • The past history provides Information about the client’s prior state of Health. The patient is specifically asked for the major Diseases in childhood or as an adult.
  • Any previous Illnesses, Injuries, Hospitalizations, Surgeries, Therapies, travel habits, or any use of supportive devices.
  • Specific Questioning in all these aspects is effective way of obtaining the past health history
• Present History & current Medications:
  • All present Illness, Injuries, hospitalizations, surgeries , blood Transfusions are recorded with the date & time of the event or Treatment.
  • The outcome of treatment whether completely resolved or if there is any residual effects those information should be obtained.
  • All medications currently taken, both prescription and over-the-counter, are to be recorded by name, frequency and dosage.
  • This information should include all medications such as birth control pills, laxatives, and non prescription pain relief medications. Ask which, if any, herbal preparations the client uses.
• Developmental History: Knowledge of developmental level is essential for considering appropriate norms of behavior and for appraising the achievement of relevant developmental tasks. Any recognized theory of growth and development can be applied in order to determine if clients are functioning within the parameters expected for their age group.
• Family History:
  • Ask any family history of acute and chronic illnesses that tend to be familial. The client should be instructed that family history refers to blood relatives. It is also helpful to indicate who the relative is in relation to the client (e.g., mother, father, sister).
  • Family History should include at least three (3) generations Family health history is used to assess the present risk of Illness and also to predict the possible risk of transferring the illness to the children and other family members who are risk of acquiring the Illness.
• Immunization History:
  • Any history of childhood or other communicable diseases should also be noted. In addition, a record of current immunizations of client should be obtained. This is particularly important with children; & also, records of immunizations for tetanus, influenza, and hepatitis B can also be important for adults.
  • If the client has travelled out of the country, the time frame should be indicated in order to determine incubation periods for communicable diseases. The client should also be asked about potential exposure to communicable diseases, such as tuberculosis, or to human immunodeficiency virus (HIV).
• Personal History:
  • In Personal history, it is important to inquire about the home environment, family situation, and client’s role in the family. For example, the client could be the parent of three children and the sole provider in a single-parent family.
  • The responsibilities of the client are important data through which the nurse can determine the impact of changes in health status and thus plan the care by determining Sources of support for clients in crisis, such as family, significant others, religion, or support groups, should be explored.
  • The habits like alcoholism, smoking, gambling, drug abuse should also be obtained to identify the potential risks on health. The hobbies like the leisure activities should also be explored to identify their impact on health status of the client.
• Allergic History: Any drug, food, or environmental allergies should be noted in the health history. In addition to the name of the allergen, the type of reaction to the substance like development of a rash or shortness of breath. This reaction should be recorded. Allergens should be recorded and documented carefully so that those drugs or foods should be avoided in the prescription.

FUNCTIONAL HEALTH ASSESSMENT PATTERN

Assess the patient’s Functional health problems to identify positive functions and to determine the dysfunctional health patterns. These dysfunctional health patterns results in formulation of nursing diagnosis and plan of care. In contrast the clients with effective functional health pattern can lead to higher level of wellness.

Components of Health Assessment Pattern:

1. Health perception -Health Management Pattern
2. Nutrition - Metabolic Pattern
3. Elimination Pattern
4. Activity - Exercise pattern
5. Sleep- Rest Pattern
6. Cognitive – Perceptual Pattern
7. Self Perception – Self Concept Pattern
8. Role- Relationship Pattern
9. Sexuality – Reproductive Pattern
10. Coping- Stress Tolerance Pattern
11. Values- Beliefs pattern

• Health Perception- Heath Management Pattern: This functional health pattern focuses on patients perceived level of health & well being and personal practices to improve/ maintain health like regular screening practices & following health lifestyle. This patterns identifies the risk factors by obtaining family history & health habits (smoking, Alcohol, Sexual & Drug abuse) and exposure to environmental hazards. Ask the client to describe the client’s health problem the onset, course, the importance of treatment, the knowledge of health problem and ability to use appropriate resources to manage the problem.
  • Questions to Identify client's Perceived level of Health & Well being:
    • Reason to visit health care Agency?
    • General State of Health? Practices followed to be healthy?
    • Problems related to health compliance?
    • Cause of Illness? Management done? & its results?
    • Family Health History?
    • Risk factors of Illness like smoking, Alcoholism or drugs?
    • Allergies if any?
    • Immunizations done?
• Nutrition- Metabolic Pattern: The process of Ingestion, digestion, absorption &metabolism are identified in this pattern. A 24-hour food diary should be obtained from the client to evaluate the dietary intake & its impact on health. The impact of psychological factors on health is also identified. Factors like meal preparation, food budget, food preferences are also assessed. Metabolism is assessed by evaluating the weight gain, weight loss, energy level & skin lesions and dryness. Determine the symptoms like nausea, vomiting, Intestinal gas or pain that can interfere with appetite.
  • Questions to Identify Nutrition-Metabolic Pattern:
    • Daily amount of food & fluid Intake and any nutritional supplements used?
    • Weight loss or weight gain in the previous period?
    • Appetite changes?
    • Food preferences ?
    • Food Allergies?
    • Any Skin Problems like Dryness, lesions, healing factors etc.?
    • Dental Problems?
• Elimination Pattern: Assess the bowel, bladder & skin elimination pattern. Elicit the consistency, amount, color and unusual odor of urine & stools. Identify the bladder & bowel control functions. Determine the use of drugs or enema to aid in elimination pattern. Assess the use of any collecting devices like catheters & colostomy equipment. Skin is assessed for excretory functions like presence of Edema, dryness, pruritus & Perspiration.
  • Questions to Identify elimination Pattern:
    • Describe the frequency, character, color, odor of the urine & stools?
    • Describe the use of drugs like laxatives & Enema for bowel Elimination & use of Diuretics for bladder Elimination, their dose frequency & route also should be determined?
    • Ask for perspiration, itching & odor problems?
• Activity- Exercise Pattern: Assess the client’s regular exercise pattern, leisure & Recreational Activities. Assess the activities of daily living such as toileting, bathing, Eating & moving Independently and specific problems that limit the activities are noted.
  • Questions to Identify Activity- Exercise Pattern:
    • Is there sufficient energy to perform daily Activities or assistance Needed?
    • Exercise Pattern: Type & Regularity?
    • Does the client spare time for leisure Activities?
    • Is there any specific problems like dyspnea, chest pain, palpitations, Muscle Stiffness, aching &Weakness that hinders the activity?
    • Ability to do daily activities like cooking, feeding, Grooming, mobility, Bathing, Dressing, Toileting, Shopping etc. should be identified?
• Sleep- Rest Pattern: This describes the client’s pattern of sleep, rest & relaxation and the client’s perception to the importance of sleep & relaxation. The client’s usual activities related to bed time and usual sleeping pattern should be determined.
  • Questions to ask related to Sleep-Rest Pattern:
    • How many hours of sleep per day?
    • Habit of taking naps in the noon time?
    • Sleep onset Problems?
    • Other problems like bedwetting, somnambulism, night mares, early awakening etc.?
    • Ask for usual sleep time rituals & patterns and sleeping position?
    • Ask for any use of medications to Induce Sleep?
• Cognitive- Perceptual Pattern: Assessment of this pattern involves description of the senses (smell, vision, hearing, taste & touch) & cognitive functions such as communication, memory & decision making Assess for the clients ability to do activity with altered senses and any examination or care taken Assess the client’s ability to communicate about their understanding of Illness and its treatment
  • Questions to ask related to Cognitive-Perceptual Pattern
    • Assess hearing Acuity & use of Hearing Aids?
    • Visual acuity & use of Visual Aids like glasses & lens?
    • Any change is taste, touch & smell sensation?
    • Any recent change in memory?
    • Ability to learn things?
    • Ability to perceive pain and how it is managed?
    • Ability to communicate?
    • Understanding about Illness & Treatment?
• Self Perception- Self concept Pattern: This describes the patient’s self perception which is determining the attitude about the client’s personal abilities, body Image & general sense of worth Self concept is determined by the way client Interacts with each other, the description about the client’s self attitude as expressions of hopelessness or loss of control & inability to care for oneself.
  • Questions to ask related to self-Perception- Self Concept Pattern: 
    • Self description and perception?
    • Effect of illness on self image?
    • Contributing and relieving factors?
• Role- Relationship Pattern: This pattern describes the roles and major responsibilities like patient’s self evaluation of their performance and behaviors that are related to their roles. Determine the relationship of the client with the family, social and work environment and the effect of the present condition on their roles and relationships.
  • Questions to ask in Role- Relationship Pattern:
    • Living independently?
    • Or with family and significant others?
    • Difficult family problems and problem solving measures?
    • Family and others feeling about illness and hospitalization?
    • Need for any change in roles?
    • Problems with handling children?
    • Any social groups or agencies to support the income needs?
    • Any feeling of isolation in the area of living?
• Sexuality- Reproductive Pattern: This pattern describes the satisfaction or dissatisfaction with personal sexual life and reproductive pattern. Assess for illnesses, surgical procedures or medications and treatment that affects the sexual function. Assess the knowledge of the client in relation to sexuality and reproduction. Patients sexual and reproductive concern must be managed by effective teaching methods and identifying the treatment options.
  • Questions to ask in Sexuality- Reproductive Pattern:
    • Any effect of Illness that has caused changes in Sexual Relations?
    • Use of Contraceptives & its problems?
    • Menstrual History like year of Menarche/ Menopause? Last Menstrual Periods?Menstrual Irregularities etc.
    • In Reproductive history Ask for Abortions, Gravida, Para, Gender of the Children Any Effect of Present Illness & treatment on Sexuality?
    • Any Presence of Sexually Transmitted Diseases ?
• Coping- Stress Tolerance Pattern: This describes the clients general coping pattern to stress and stressors. The major losses are changes experienced in recent years may be documented. Identify the client’s current stressors or problems and ability to deal with the stressor and relieve tension should be noted. Identify and record the individual or groups that provide support for the clients during stressful situation.
  • Questions to ask for Coping- Stress Tolerance Pattern:
  • What is the cause of tension?
  • Use of medications, drugs or alcohol to relieve stress?
  • Is the client alone or someone to support now?
  • Any recent life changes, loss or grief?
  • Any use of effective problem solving techniques and coping strategies?
• Values- Belief Pattern: This pattern describes the values, goals and spiritual belief that guide the health related behaviors. Document the client’s culture and ethnic background and their effect on health and illness. Honor the client’s religious practices and use of religious materials and identify the plan of care that cause conflict to the client’s value or belief system.
  • Questions to ask for Values- Belief Pattern:
    • Is the client satisfied with life?
    • Do the client have belief on religion and its importance in their life?
    • Any conflict between treatment & Beliefs?

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