Health History II Flashcards
What are the components of a Nursing Health History?
- Biographical data
- Source of history
- Reason for seeking care
- Current state of health
- Past health history
- Family health history
(health status and medical history of family) - Functional health and activities of daily living (ADL’s)
- Developmental Variables
- Psychological variables
- Spiritual health
- Socio-cultural variables
What are the 3 steps in obtaining a health history?
- Gather supplies
- health history form, client chart - Perform safety steps
- perform hang hygiene - Greet the patient and provide privacy
- introduce yourself, your role, and purpose of your visit
- explain the process
- ensure the clients privacy and dignity
What are the 3 components of biological data?
1) Culture, ethnicity, and subculture
- date of birth, nationality, relationship status, religious practices
- to examine special beliefs/needs that can impact care plan
2) Educational level, occupation, and working status
- helps to identify client strengths and limitations impacting health
- helps you to tailor q’s to clients’ level of understanding
3) Client supports - indicates availability of potential caregivers and suppoort
2 Sources of History
1) Primary Source
- Communicate with the CLIENT to collect subjective data
2) Secondary Source
- May also collect data from the client’s chart, family, care partners, other healthcare providers
How to ask the reason for seeking care?
- explain why you are interviewing the client (say: “tell me what brought you in today)
- use OLDCARTSS framework
OLDCARTSS Framework
Onset – When did it start?
Location – Where is it located? Does it radiate to any other location?
Duration – How long have you had it?
Character – Can you describe it?
Aggravating factors – What makes itbetter?
Relieving factors – What makes it worse?
Timing – When does it happen? Is it constant?Come and go? Morning versus night?
Severity – How bad would your rate it on a scale of0-10?
Self-perception- What do you think could becausing it?
- Not always appropriate to ask
(Ie. If they fell and broke their arm)
Pain Assessment using OLDCARTSS.
Onset – When did the pain start? What were you doing when the pain started?
Location – Where do you feel the pain? Does it radiate somewhere else?
Duration – Is the pain constant or does it come and go?
Character – What does the pain feel like? Can you describe it? (ie. aching, stabbing, burning, sharp)
- important not to ask leading q’s, bc the client will automatically choose from 1 of the options rather then describe their pain
Aggravating factors – What makes your pain worse?
Relieving factors – What makes your pain better?
Timing – What time of day does the pain occur? Is it constant?Come and go? Morning versus night?
Severity – How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you’ve ever experienced?
Self-perception- What do you think is causing the pain? How is the pain affecting you and/or your family?
If a client reports nausea, which elements of OLDCARTSS can you leave out?
1) Location and 2) Character
- nausea can not really be described
What is involved in a clients current state of health?
- General state of physical, mental, social and spiritual health
- Signs, symptoms and related problems
- Client’s perception/feelings about what caused health concern to occur
- Impact on activities of daily living
- Medications or treatments used & effectiveness
- Use OLDCARTSS to assess
What is involved in past medical history?
- Medications: prescribed, over-the-counter, alternative, recreational
- Allergies: medication, food, materials, environment
- Smoking/ETOH
- Childhood illnesses
- Chronic illnesses
- Acute illnesses
- Surgeries
- Accidents
- Injuries
- Obstetrical health
(If babies make it full-term, fertility issues, current or past pregnancies, miscarriages) - History of vaccination
Functional Health & ADL’s
1) Nutrition
- Financial ability to purchase food, appetite, food and fluid intake, diet
2) Elimination
- excretion including bladder and bowel
3) Mobility
- difficulty getting in/out of bed, climbing stairs)
4) Cognitive/Perceptual
- Assistive devices
- Cognitive functional abilities (ie. Memory, orientation, reasoning, judgement)
5) Role-Relationship
- Isolation, negative, or abusive relationships
- Loss of family member/job
6) Sexuality reproductive
- Gender identity, sexual orientation, reproductive issues
7) Value belief
- Values, beliefs, and goals that guide decisions about healthcare and provide strength and comfort
8) Coping stress and tolerance
- Loss of employment, deterioration of relationships, precarious living circumstances
9) Self-perception and self-concept
- Subjective thoughts, feelings, or attitudes of a patient about themselves
10) Health perception and management
- A clients perception of their health and how it is managed
11) Environmental health
- Safety of clients physical environment
What are developmental variables?
- Developmental stage
- Relationship status & living arrangement (ie. tell me about your relationships with your family)
- Number of children
- Occupation (past or present)
- Significant life experiences
- Housing
- Safety measures (e.g., use of seat belts)
What is Psychological Health
- Mental processes
- Self-perception
- Relationships and support systems
- Statements regarding client’s feelings about self
Psychological Health Interview Questions
- Tell me what makes you who you are.
- Are you satisfied with where you are in your life?
- Have you experienced a loss in your life or a death that is meaningful to you?
- Have you had a recent breakup or divorce?
What is encompassed by Spiritual Health & Sociocultural?
- Cultural or health-related beliefs and practices
- Nutritional considerations related to culture
- Social and community considerations
- Religious affiliation, spiritual beliefs and/or practices
- Primary language, other languages spoken
- Family composition and relationships
