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 A health assessment is a process to identify specific
health needs and level of health status of a person .
Basically health assessment involves two steps-
 History taking and
 Physical examination
 History taking is a part of health
assessment which involves asking specific
questions to the patient or the person who
know the patient and can give suitable
information. History taking is also known as
interviewing of patient.
• To establish rapport with the patient
• To establish or maintain nurse-patient relationship
for proper nursing care
• To obtain information useful for diagnosis
• To identify or clarify health problems
• To give information to the client or to
teach him or Her about health
• To counsel and/or assist the client in
finding solutions to problems
 Sit facing the client. Sitting suggests relaxation and
indicates that time will be allowed for the interview.
 Provide privacy, and attend to client’s comfort; for example,
supply pillows for support, a footstool, or a glass of water.
 Use simple language at first; increase complexity if
client is able to understand.
 Explain the purpose of the interview, how long it will
last, and how the information will be used.
 Use narrow questions to help the client focus, such as “Do
you have nausea with the vomiting?”
 Use open-ended questions such as “How do the headaches
begin?” to explore feelings and perceptions and to identify
areas requiring follow-up.
 look and listen carefully for clues,
both verbal and nonverbal.
Establish eye contact, avoid
answering for the client, and
explore clues in a nonthreatening
manner.
 Avoid interruptions and the appearance of being
distracted or bored, such as looking at the clock or
flipping pages in the record. Wait for answers. Silence
encourages thinking and often produces verbal
responses.
 Start history taking by collecting personal data such as
 Date of interview
 Name
 Gender
 Date of birth
 Place of birth
 Age
 Address
 Person to be contacted in an emergency (name,
relationship, address, phone number)
 Education
 Occupation (presently or before retirement)
 In this section we collect information about-
 Present problems
 Onset of problem
 Location of symptoms
 Chronology
 Precipitating factors
 Alleviating factors
 Aggravating factors
 Associated symptoms
 Treatments
 Client’s view of cause
 In this section we collect information about-
 Client’s perception of level of health in general
 Childhood illnesses (dates and types)
 Genogram (family history of diseases)
 Immunizations
 Allergies
 Serious accidents and/or injuries (dates)
 Major adult illnesses (types and dates)
 Behavioral problems
 Surgical procedures (types and dates)
 Other hospitalizations (types and dates)
 Environmental hazards
 Work: Type, length of time employed, stresses
 Rest and/or sleep: How much, when, aids
 Exercise and/or ambulation: How much, when
 Recreation, leisure, hobbies: Type, amount
 Nutrition: Time, foods, fluids, and amounts for all meals and
snacks; recent changes in appetite; special diet
 Alcohol and/or other drugs: Type, number of years used,
amount, perceived problems with level of use
 Tobacco: Type, number of years used, amount per day
 Urinary and bowel activity: Frequency, amount, problems
related to urinary and bowel activity
 Ambulating
 Dressing
 Grooming
 Bathing
 Toileting
 Eating
 Using the telephone
 Doing laundry
 Housekeeping
 Preparing food
 Driving
 Purchasing food
 The psychosocial history is important in any assessment that
considers a holistic view of the client, especially in a community
or long-term care setting. The psychosocial history involves the
client’s relationship to others such as family members, friends,
neighbors, colleagues at workplace and friends in social and
civic organizations in the community
 The psychosocial history includes-
 Significant stressors
 Coping ability
 Feelings about self: Self-concept, functional status,
adaptations, independence, body image, marital status etc.
 History of interpersonal trauma: Rape, incest, abuse as child
or spouse, other personal tragedies. Note ability to discuss,
current stage in resolution
 • Periods of grief and current status
 • Understanding of and feelings about current illness(es)
 The review of systems (sometimes called the review of
symptoms) helps the nurse to focus on each major system
major system of the body, noting from the health history
which systems may have special problems. This systematic
process prevents the omission of important assessment
information.
 It includes inquiry about
 General symptoms
 Integument (skin, hair, nails)
 Head
 Eyes
 Ears
 Nose and sinuses
 Mouth and throat
 Neck
 Lungs and thorax
 Breasts and axillae
 Cardiovascular system
 Abdomen
 • Musculoskeletal system
 • Male genitourinary system and rectum
 • Female genitourinary system and rectum
 • Neurologic
 • Adaptations in pregnancy
 This section includes history about-
 Interview all family members at the same time to observe
communication and decision-making patterns.
 Assess each family member’s health.
 Assess family’s health history

 family health history also includes family member’s ages at
death and causes of death.
 Note patterns of illness distribution across generations(for
example, cancer and heart disease).
 • Assess family structure: Single, nuclear, joint
 Ask whether there is anything else that the client
would like to tell or ask you. Assure the client that
information provided by him ill be kept confidential
and ill be used only for health care plan of him/her.
By – SURESH KUMAR ( Nursing Tutor )

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Health assessment part 1 history takiong in english

  • 2.  A health assessment is a process to identify specific health needs and level of health status of a person . Basically health assessment involves two steps-  History taking and  Physical examination
  • 3.  History taking is a part of health assessment which involves asking specific questions to the patient or the person who know the patient and can give suitable information. History taking is also known as interviewing of patient.
  • 4. • To establish rapport with the patient • To establish or maintain nurse-patient relationship for proper nursing care • To obtain information useful for diagnosis • To identify or clarify health problems
  • 5. • To give information to the client or to teach him or Her about health • To counsel and/or assist the client in finding solutions to problems
  • 6.  Sit facing the client. Sitting suggests relaxation and indicates that time will be allowed for the interview.  Provide privacy, and attend to client’s comfort; for example, supply pillows for support, a footstool, or a glass of water.
  • 7.  Use simple language at first; increase complexity if client is able to understand.  Explain the purpose of the interview, how long it will last, and how the information will be used.
  • 8.  Use narrow questions to help the client focus, such as “Do you have nausea with the vomiting?”  Use open-ended questions such as “How do the headaches begin?” to explore feelings and perceptions and to identify areas requiring follow-up.
  • 9.  look and listen carefully for clues, both verbal and nonverbal. Establish eye contact, avoid answering for the client, and explore clues in a nonthreatening manner.
  • 10.  Avoid interruptions and the appearance of being distracted or bored, such as looking at the clock or flipping pages in the record. Wait for answers. Silence encourages thinking and often produces verbal responses.
  • 11.  Start history taking by collecting personal data such as  Date of interview  Name  Gender  Date of birth  Place of birth  Age
  • 12.  Address  Person to be contacted in an emergency (name, relationship, address, phone number)  Education  Occupation (presently or before retirement)
  • 13.  In this section we collect information about-  Present problems  Onset of problem  Location of symptoms  Chronology  Precipitating factors
  • 14.  Alleviating factors  Aggravating factors  Associated symptoms  Treatments  Client’s view of cause
  • 15.  In this section we collect information about-  Client’s perception of level of health in general  Childhood illnesses (dates and types)  Genogram (family history of diseases)  Immunizations  Allergies
  • 16.  Serious accidents and/or injuries (dates)  Major adult illnesses (types and dates)  Behavioral problems  Surgical procedures (types and dates)  Other hospitalizations (types and dates)  Environmental hazards
  • 17.  Work: Type, length of time employed, stresses  Rest and/or sleep: How much, when, aids  Exercise and/or ambulation: How much, when  Recreation, leisure, hobbies: Type, amount  Nutrition: Time, foods, fluids, and amounts for all meals and snacks; recent changes in appetite; special diet
  • 18.  Alcohol and/or other drugs: Type, number of years used, amount, perceived problems with level of use  Tobacco: Type, number of years used, amount per day  Urinary and bowel activity: Frequency, amount, problems related to urinary and bowel activity
  • 19.  Ambulating  Dressing  Grooming  Bathing  Toileting  Eating  Using the telephone  Doing laundry  Housekeeping  Preparing food  Driving  Purchasing food
  • 20.  The psychosocial history is important in any assessment that considers a holistic view of the client, especially in a community or long-term care setting. The psychosocial history involves the client’s relationship to others such as family members, friends, neighbors, colleagues at workplace and friends in social and civic organizations in the community
  • 21.  The psychosocial history includes-  Significant stressors  Coping ability  Feelings about self: Self-concept, functional status, adaptations, independence, body image, marital status etc.
  • 22.  History of interpersonal trauma: Rape, incest, abuse as child or spouse, other personal tragedies. Note ability to discuss, current stage in resolution  • Periods of grief and current status  • Understanding of and feelings about current illness(es)
  • 23.  The review of systems (sometimes called the review of symptoms) helps the nurse to focus on each major system major system of the body, noting from the health history which systems may have special problems. This systematic process prevents the omission of important assessment information.
  • 24.  It includes inquiry about  General symptoms  Integument (skin, hair, nails)  Head  Eyes  Ears  Nose and sinuses  Mouth and throat  Neck  Lungs and thorax  Breasts and axillae  Cardiovascular system  Abdomen
  • 25.  • Musculoskeletal system  • Male genitourinary system and rectum  • Female genitourinary system and rectum  • Neurologic  • Adaptations in pregnancy
  • 26.  This section includes history about-  Interview all family members at the same time to observe communication and decision-making patterns.  Assess each family member’s health.  Assess family’s health history 
  • 27.  family health history also includes family member’s ages at death and causes of death.  Note patterns of illness distribution across generations(for example, cancer and heart disease).  • Assess family structure: Single, nuclear, joint
  • 28.  Ask whether there is anything else that the client would like to tell or ask you. Assure the client that information provided by him ill be kept confidential and ill be used only for health care plan of him/her.
  • 29. By – SURESH KUMAR ( Nursing Tutor )