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    Health Assessment Biographical

    Uploaded by

    Amal A Hassan
    The document discusses the components and purpose of a nursing health history. It explains that a health history gathers subjective data from the patient to help create a care plan that promotes health and addresses issues. It lists the typical components included in a health history such as biographic data, chief complaint, history of present illness, past health history, family history, functional assessment, developmental tasks, and cultural assessment. The health history allows nurses to understand the patient's situation and collaborate on the best approach to their care.

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    Health Assessment Biographical

    Uploaded by

    Amal A Hassan
    133 views11 pages
    The document discusses the components and purpose of a nursing health history. It explains that a health history gathers subjective data from the patient to help create a care plan that promotes health and addresses issues. It lists the typical components included in a health history such as biographic data, chief complaint, history of present illness, past health history, family history, functional assessment, developmental tasks, and cultural assessment. The health history allows nurses to understand the patient's situation and collaborate on the best approach to their care.

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    health assessment biographical

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    The document discusses the components and purpose of a nursing health history. It explains that a health history gathers subjective data from the patient to help create a care plan that promotes health and addresses issues. It lists the typical components included in a health history such as biographic data, chief complaint, history of present illness, past health history, family history, functional assessment, developmental tasks, and cultural assessment. The health history allows nurses to understand the patient's situation and collaborate on the best approach to their care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    133 views11 pages

    Health Assessment Biographical

    Uploaded by

    Amal A Hassan
    The document discusses the components and purpose of a nursing health history. It explains that a health history gathers subjective data from the patient to help create a care plan that promotes health and addresses issues. It lists the typical components included in a health history such as biographic data, chief complaint, history of present illness, past health history, family history, functional assessment, developmental tasks, and cultural assessment. The health history allows nurses to understand the patient's situation and collaborate on the best approach to their care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 11

    BIOGRAPHIC DATA

    z
    z
    Health History

    § 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
    z

    § 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.
    Components of a nursing health history
    z

    Biographic data
    § Client’s name

    § Address

    § Age

    § Sex

    § Marital status

    § Occupation

    § Religious preference

    § Health care financing

    § Usual source of medical care


    z
    Chief complaint or season for visit

    § The answer given to the question e.g “can you tell me the
    reason you came to the hospital or clinic today ?”

    § The chief complaint should be recorded in the client’s own words


    z
    History of present illness
    § Chief complaint

    § Onset of present health concern

    § Duration

    § Course of the health concern Signs, symptoms, and related problems

    § Medications or treatments used (ask how effective they were)

    § What aggravates this health concern

    § What alleviates the symptoms

    § What caused the health concern to occur

    § Related health concerns

    § How the concern has affected life and daily activities

    § Previous history and episodes of this condition


    z
    Past health history

    § Allergies (reaction)

    § Serious or chronic illness

    § Recent hospitalizations

    § Recent surgical procedures

    § Emotional or psychiatric problems (if pertinent)

    § Current medications: prescriptions, over-the counter, herbal remedies

    § Drug/alcohol consumption
    z
    Family history

    § Pertinent health status of family members

    § Pertinent family history of heart disease, lung


    disease, cancer, hypertension, diabetes,
    tuberculosis, arthritis, neurological disease,
    obesity, mental illness, genetic disorders
    Functional assessment (including activities of daily
    z
    living)
    § Activity/exercise, leisure and recreational

    § activities (assess for falls risk)

    § Sleep/rest

    § Nutrition/elimination

    § Interpersonal relationships/resources

    § Coping and stress management

    § Occupational/environmental hazards
    z
    Developmental tasks

    § Current significant physical and


    psychosocial changes/issues
    z
    Cultural assessment

    § Cultural/health-related beliefs and practices

    § Nutritional considerations related to culture

    § Social and community considerations

    § Religious affiliation/spiritual beliefs and/or


    practices

    § Language/communication

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