SlideShare a Scribd company logo
PLEASE SUBSCRIBE LIKE AND SHARE
 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 )

More Related Content

What's hot

Nursing Health Assessment
Nursing Health Assessment Nursing Health Assessment
Nursing Health Assessment
Shanta Peter
 
The techniques of physical examination
The techniques of physical examinationThe techniques of physical examination
The techniques of physical examination
Arsi University, Asella, Ethiopia
 
Nursing Health Assessment
Nursing Health AssessmentNursing Health Assessment
Nursing Health Assessment
Jeya Rajathurai
 
Health history
Health historyHealth history
Health history
Dr Magda Bayoumi
 
Healh assessment NURSING FOUNDATION
Healh assessment NURSING FOUNDATIONHealh assessment NURSING FOUNDATION
Healh assessment NURSING FOUNDATION
ANILKUMAR BR
 
Nursing process
Nursing processNursing process
Nursing process
Anant Wayzade
 
Roy's Adaptation Model
Roy's Adaptation ModelRoy's Adaptation Model
Roy's Adaptation Model
Sana Sultan
 
Nursing Health Assessment: Purpose, Types, Sources cld
Nursing Health Assessment: Purpose, Types, Sources cldNursing Health Assessment: Purpose, Types, Sources cld
Nursing Health Assessment: Purpose, Types, Sources cld
Carmela Domocmat
 
Health Assessment ...
Health Assessment ...Health Assessment ...
Health Assessment ...
DR .PALLAVI PATHANIA
 
Functional health assessment
Functional health assessmentFunctional health assessment
Functional health assessment
Nhelia Santos Perez
 
Urinary Elimination
Urinary EliminationUrinary Elimination
Urinary Elimination
Tosca Torres
 
Health Assessment
Health AssessmentHealth Assessment
Health Assessment
Sathish Rajamani
 
nursing - oxygenation
nursing - oxygenationnursing - oxygenation
nursing - oxygenation
twiggypiggy
 
Health asessment
Health asessmentHealth asessment
Health asessment
Abhilasha verma
 
Standardized nursing language powerpoint
Standardized nursing language powerpointStandardized nursing language powerpoint
Standardized nursing language powerpoint
Zulie Dorsan
 
Preparation of patient for health assessment
Preparation of patient for health assessmentPreparation of patient for health assessment
Preparation of patient for health assessment
Arifa T N
 
Interview and history taking
Interview and history takingInterview and history taking
Interview and history taking
LTCSolutions11
 
nsg diagnosis
nsg diagnosisnsg diagnosis
nsg diagnosis
Shaells Joshi
 
Nursing process,,,Assessment
Nursing process,,,AssessmentNursing process,,,Assessment
Nursing process,,,Assessment
Arifa T N
 
Nursing Process
Nursing ProcessNursing Process
Nursing Process
Chandan Banerjee
 

What's hot (20)

Nursing Health Assessment
Nursing Health Assessment Nursing Health Assessment
Nursing Health Assessment
 
The techniques of physical examination
The techniques of physical examinationThe techniques of physical examination
The techniques of physical examination
 
Nursing Health Assessment
Nursing Health AssessmentNursing Health Assessment
Nursing Health Assessment
 
Health history
Health historyHealth history
Health history
 
Healh assessment NURSING FOUNDATION
Healh assessment NURSING FOUNDATIONHealh assessment NURSING FOUNDATION
Healh assessment NURSING FOUNDATION
 
Nursing process
Nursing processNursing process
Nursing process
 
Roy's Adaptation Model
Roy's Adaptation ModelRoy's Adaptation Model
Roy's Adaptation Model
 
Nursing Health Assessment: Purpose, Types, Sources cld
Nursing Health Assessment: Purpose, Types, Sources cldNursing Health Assessment: Purpose, Types, Sources cld
Nursing Health Assessment: Purpose, Types, Sources cld
 
Health Assessment ...
Health Assessment ...Health Assessment ...
Health Assessment ...
 
Functional health assessment
Functional health assessmentFunctional health assessment
Functional health assessment
 
Urinary Elimination
Urinary EliminationUrinary Elimination
Urinary Elimination
 
Health Assessment
Health AssessmentHealth Assessment
Health Assessment
 
nursing - oxygenation
nursing - oxygenationnursing - oxygenation
nursing - oxygenation
 
Health asessment
Health asessmentHealth asessment
Health asessment
 
Standardized nursing language powerpoint
Standardized nursing language powerpointStandardized nursing language powerpoint
Standardized nursing language powerpoint
 
Preparation of patient for health assessment
Preparation of patient for health assessmentPreparation of patient for health assessment
Preparation of patient for health assessment
 
Interview and history taking
Interview and history takingInterview and history taking
Interview and history taking
 
nsg diagnosis
nsg diagnosisnsg diagnosis
nsg diagnosis
 
Nursing process,,,Assessment
Nursing process,,,AssessmentNursing process,,,Assessment
Nursing process,,,Assessment
 
Nursing Process
Nursing ProcessNursing Process
Nursing Process
 

Similar to Health assessment part 1 history takiong in english

HISTORY TAKING .pptx
HISTORY TAKING                       .pptxHISTORY TAKING                       .pptx
HISTORY TAKING .pptx
Juma675663
 
respiratory system PCD.pptx
respiratory system PCD.pptxrespiratory system PCD.pptx
respiratory system PCD.pptx
MonenusKedir
 
HEALTH HISTORY..docx
HEALTH HISTORY..docxHEALTH HISTORY..docx
HEALTH HISTORY..docx
NicoleJoyCelestino
 
General health assessment and history taking
General health assessment and history takingGeneral health assessment and history taking
General health assessment and history taking
Princy Francis M
 
HISTORY TAKING AND FAMILY ASSESSMENT IN PEDIATRIC NURSING
HISTORY TAKING AND FAMILY ASSESSMENT IN PEDIATRIC NURSINGHISTORY TAKING AND FAMILY ASSESSMENT IN PEDIATRIC NURSING
HISTORY TAKING AND FAMILY ASSESSMENT IN PEDIATRIC NURSING
Ritu Gahlawat
 
historytaking for medical careers doctors medical students.pdf
historytaking for medical careers doctors medical students.pdfhistorytaking for medical careers doctors medical students.pdf
historytaking for medical careers doctors medical students.pdf
MinhTrungTrnNguyn
 
History taking
History takingHistory taking
History taking
Shrif-gunda1
 
History taking
History takingHistory taking
History taking
Anwar Siddiqui
 
GBSN SEMESTER III YEAR II.docx
GBSN SEMESTER III YEAR II.docxGBSN SEMESTER III YEAR II.docx
GBSN SEMESTER III YEAR II.docx
CITY NURSING SCHOOL
 
History Taking.
History Taking.History Taking.
History Taking.
Shaikhani.
 
History taking-2rd lecture
History taking-2rd lectureHistory taking-2rd lecture
History taking-2rd lecture
Riaz Ahmed
 
Medical record 20110614
Medical record 20110614Medical record 20110614
Medical record 20110614
carolshaw7
 
1.Introduction & interview.pptx
1.Introduction & interview.pptx1.Introduction & interview.pptx
1.Introduction & interview.pptx
MustafaALShlash1
 
Nursingassessment 090719000406-phpapp02
Nursingassessment 090719000406-phpapp02Nursingassessment 090719000406-phpapp02
Nursingassessment 090719000406-phpapp02
Nursing Hi Nursing
 
History taking in psychiatry
History taking in psychiatryHistory taking in psychiatry
History taking in psychiatry
manishkumargoyal7
 
Physical assessment the of child
Physical assessment the of   childPhysical assessment the of   child
Physical assessment the of child
raveen mayi
 
History taking for nurses
History taking  for nursesHistory taking  for nurses
History taking for nurses
Nazia Alli
 
Comprehensive nursing assessment
Comprehensive nursing assessmentComprehensive nursing assessment
Comprehensive nursing assessment
Kristine Mae Fernandez
 
Patient Assessment And Clinical Interviewing
Patient  Assessment And  Clinical  InterviewingPatient  Assessment And  Clinical  Interviewing
Patient Assessment And Clinical Interviewing
dunerafael
 
History Taking in Neurology.pptx
History Taking in Neurology.pptxHistory Taking in Neurology.pptx
History Taking in Neurology.pptx
ROSHINIBG
 

Similar to Health assessment part 1 history takiong in english (20)

HISTORY TAKING .pptx
HISTORY TAKING                       .pptxHISTORY TAKING                       .pptx
HISTORY TAKING .pptx
 
respiratory system PCD.pptx
respiratory system PCD.pptxrespiratory system PCD.pptx
respiratory system PCD.pptx
 
HEALTH HISTORY..docx
HEALTH HISTORY..docxHEALTH HISTORY..docx
HEALTH HISTORY..docx
 
General health assessment and history taking
General health assessment and history takingGeneral health assessment and history taking
General health assessment and history taking
 
HISTORY TAKING AND FAMILY ASSESSMENT IN PEDIATRIC NURSING
HISTORY TAKING AND FAMILY ASSESSMENT IN PEDIATRIC NURSINGHISTORY TAKING AND FAMILY ASSESSMENT IN PEDIATRIC NURSING
HISTORY TAKING AND FAMILY ASSESSMENT IN PEDIATRIC NURSING
 
historytaking for medical careers doctors medical students.pdf
historytaking for medical careers doctors medical students.pdfhistorytaking for medical careers doctors medical students.pdf
historytaking for medical careers doctors medical students.pdf
 
History taking
History takingHistory taking
History taking
 
History taking
History takingHistory taking
History taking
 
GBSN SEMESTER III YEAR II.docx
GBSN SEMESTER III YEAR II.docxGBSN SEMESTER III YEAR II.docx
GBSN SEMESTER III YEAR II.docx
 
History Taking.
History Taking.History Taking.
History Taking.
 
History taking-2rd lecture
History taking-2rd lectureHistory taking-2rd lecture
History taking-2rd lecture
 
Medical record 20110614
Medical record 20110614Medical record 20110614
Medical record 20110614
 
1.Introduction & interview.pptx
1.Introduction & interview.pptx1.Introduction & interview.pptx
1.Introduction & interview.pptx
 
Nursingassessment 090719000406-phpapp02
Nursingassessment 090719000406-phpapp02Nursingassessment 090719000406-phpapp02
Nursingassessment 090719000406-phpapp02
 
History taking in psychiatry
History taking in psychiatryHistory taking in psychiatry
History taking in psychiatry
 
Physical assessment the of child
Physical assessment the of   childPhysical assessment the of   child
Physical assessment the of child
 
History taking for nurses
History taking  for nursesHistory taking  for nurses
History taking for nurses
 
Comprehensive nursing assessment
Comprehensive nursing assessmentComprehensive nursing assessment
Comprehensive nursing assessment
 
Patient Assessment And Clinical Interviewing
Patient  Assessment And  Clinical  InterviewingPatient  Assessment And  Clinical  Interviewing
Patient Assessment And Clinical Interviewing
 
History Taking in Neurology.pptx
History Taking in Neurology.pptxHistory Taking in Neurology.pptx
History Taking in Neurology.pptx
 

More from MY STUDENT SUPPORT SYSTEM .

Medication administration oral medication in hindi
Medication administration  oral medication in hindiMedication administration  oral medication in hindi
Medication administration oral medication in hindi
MY STUDENT SUPPORT SYSTEM .
 
Malaria in hindi
Malaria  in hindiMalaria  in hindi
Malaria in hindi
MY STUDENT SUPPORT SYSTEM .
 
Malaria in english
Malaria  in englishMalaria  in english
Malaria in english
MY STUDENT SUPPORT SYSTEM .
 
Leptospirosis in hindi
Leptospirosis in hindiLeptospirosis in hindi
Leptospirosis in hindi
MY STUDENT SUPPORT SYSTEM .
 
Leptospirosis in english
Leptospirosis in englishLeptospirosis in english
Leptospirosis in english
MY STUDENT SUPPORT SYSTEM .
 
Japanese encephalitis in hindi
Japanese encephalitis in hindiJapanese encephalitis in hindi
Japanese encephalitis in hindi
MY STUDENT SUPPORT SYSTEM .
 
Japanese encephalitis in english
Japanese encephalitis in englishJapanese encephalitis in english
Japanese encephalitis in english
MY STUDENT SUPPORT SYSTEM .
 
Hepatitis in hindi
Hepatitis in hindiHepatitis in hindi
Hepatitis in hindi
MY STUDENT SUPPORT SYSTEM .
 
Hepatitis in english
Hepatitis in englishHepatitis in english
Hepatitis in english
MY STUDENT SUPPORT SYSTEM .
 
Giving injections in hindi
Giving injections in hindiGiving injections in hindi
Giving injections in hindi
MY STUDENT SUPPORT SYSTEM .
 
Giving injections in english
Giving injections in englishGiving injections in english
Giving injections in english
MY STUDENT SUPPORT SYSTEM .
 
Food hygiene and food borne diseases in hindi
Food hygiene and food borne diseases in hindiFood hygiene and food borne diseases in hindi
Food hygiene and food borne diseases in hindi
MY STUDENT SUPPORT SYSTEM .
 
Food hygiene and food borne diseases in english
Food hygiene and food borne diseases in englishFood hygiene and food borne diseases in english
Food hygiene and food borne diseases in english
MY STUDENT SUPPORT SYSTEM .
 
An introduction to medication administration in hindi
An introduction to medication administration in hindiAn introduction to medication administration in hindi
An introduction to medication administration in hindi
MY STUDENT SUPPORT SYSTEM .
 
An introduction to medication administration in english
An introduction to medication administration in englishAn introduction to medication administration in english
An introduction to medication administration in english
MY STUDENT SUPPORT SYSTEM .
 
Rubella in hindi
Rubella in hindiRubella in hindi
Rubella in hindi
MY STUDENT SUPPORT SYSTEM .
 
Rubella in english
Rubella in englishRubella in english
Rubella in english
MY STUDENT SUPPORT SYSTEM .
 
Pertusis in hindi
Pertusis in hindiPertusis in hindi
Pertusis in hindi
MY STUDENT SUPPORT SYSTEM .
 
Pertusis in english
Pertusis in englishPertusis in english
Pertusis in english
MY STUDENT SUPPORT SYSTEM .
 
Mumps in hindi
Mumps in hindiMumps in hindi

More from MY STUDENT SUPPORT SYSTEM . (20)

Medication administration oral medication in hindi
Medication administration  oral medication in hindiMedication administration  oral medication in hindi
Medication administration oral medication in hindi
 
Malaria in hindi
Malaria  in hindiMalaria  in hindi
Malaria in hindi
 
Malaria in english
Malaria  in englishMalaria  in english
Malaria in english
 
Leptospirosis in hindi
Leptospirosis in hindiLeptospirosis in hindi
Leptospirosis in hindi
 
Leptospirosis in english
Leptospirosis in englishLeptospirosis in english
Leptospirosis in english
 
Japanese encephalitis in hindi
Japanese encephalitis in hindiJapanese encephalitis in hindi
Japanese encephalitis in hindi
 
Japanese encephalitis in english
Japanese encephalitis in englishJapanese encephalitis in english
Japanese encephalitis in english
 
Hepatitis in hindi
Hepatitis in hindiHepatitis in hindi
Hepatitis in hindi
 
Hepatitis in english
Hepatitis in englishHepatitis in english
Hepatitis in english
 
Giving injections in hindi
Giving injections in hindiGiving injections in hindi
Giving injections in hindi
 
Giving injections in english
Giving injections in englishGiving injections in english
Giving injections in english
 
Food hygiene and food borne diseases in hindi
Food hygiene and food borne diseases in hindiFood hygiene and food borne diseases in hindi
Food hygiene and food borne diseases in hindi
 
Food hygiene and food borne diseases in english
Food hygiene and food borne diseases in englishFood hygiene and food borne diseases in english
Food hygiene and food borne diseases in english
 
An introduction to medication administration in hindi
An introduction to medication administration in hindiAn introduction to medication administration in hindi
An introduction to medication administration in hindi
 
An introduction to medication administration in english
An introduction to medication administration in englishAn introduction to medication administration in english
An introduction to medication administration in english
 
Rubella in hindi
Rubella in hindiRubella in hindi
Rubella in hindi
 
Rubella in english
Rubella in englishRubella in english
Rubella in english
 
Pertusis in hindi
Pertusis in hindiPertusis in hindi
Pertusis in hindi
 
Pertusis in english
Pertusis in englishPertusis in english
Pertusis in english
 
Mumps in hindi
Mumps in hindiMumps in hindi
Mumps in hindi
 

Recently uploaded

Top five deadliest dog breeds in America
Top five deadliest dog breeds in AmericaTop five deadliest dog breeds in America
Top five deadliest dog breeds in America
Bisnar Chase Personal Injury Attorneys
 
Azure Interview Questions and Answers PDF By ScholarHat
Azure Interview Questions and Answers PDF By ScholarHatAzure Interview Questions and Answers PDF By ScholarHat
Azure Interview Questions and Answers PDF By ScholarHat
Scholarhat
 
DRUGS AND ITS classification slide share
DRUGS AND ITS classification slide shareDRUGS AND ITS classification slide share
DRUGS AND ITS classification slide share
taiba qazi
 
How to Manage Your Lost Opportunities in Odoo 17 CRM
How to Manage Your Lost Opportunities in Odoo 17 CRMHow to Manage Your Lost Opportunities in Odoo 17 CRM
How to Manage Your Lost Opportunities in Odoo 17 CRM
Celine George
 
The History of Stoke Newington Street Names
The History of Stoke Newington Street NamesThe History of Stoke Newington Street Names
The History of Stoke Newington Street Names
History of Stoke Newington
 
Liberal Approach to the Study of Indian Politics.pdf
Liberal Approach to the Study of Indian Politics.pdfLiberal Approach to the Study of Indian Politics.pdf
Liberal Approach to the Study of Indian Politics.pdf
WaniBasim
 
writing about opinions about Australia the movie
writing about opinions about Australia the moviewriting about opinions about Australia the movie
writing about opinions about Australia the movie
Nicholas Montgomery
 
Executive Directors Chat Leveraging AI for Diversity, Equity, and Inclusion
Executive Directors Chat  Leveraging AI for Diversity, Equity, and InclusionExecutive Directors Chat  Leveraging AI for Diversity, Equity, and Inclusion
Executive Directors Chat Leveraging AI for Diversity, Equity, and Inclusion
TechSoup
 
The basics of sentences session 5pptx.pptx
The basics of sentences session 5pptx.pptxThe basics of sentences session 5pptx.pptx
The basics of sentences session 5pptx.pptx
heathfieldcps1
 
A Strategic Approach: GenAI in Education
A Strategic Approach: GenAI in EducationA Strategic Approach: GenAI in Education
A Strategic Approach: GenAI in Education
Peter Windle
 
clinical examination of hip joint (1).pdf
clinical examination of hip joint (1).pdfclinical examination of hip joint (1).pdf
clinical examination of hip joint (1).pdf
Priyankaranawat4
 
Advanced Java[Extra Concepts, Not Difficult].docx
Advanced Java[Extra Concepts, Not Difficult].docxAdvanced Java[Extra Concepts, Not Difficult].docx
Advanced Java[Extra Concepts, Not Difficult].docx
adhitya5119
 
How to Fix the Import Error in the Odoo 17
How to Fix the Import Error in the Odoo 17How to Fix the Import Error in the Odoo 17
How to Fix the Import Error in the Odoo 17
Celine George
 
Pride Month Slides 2024 David Douglas School District
Pride Month Slides 2024 David Douglas School DistrictPride Month Slides 2024 David Douglas School District
Pride Month Slides 2024 David Douglas School District
David Douglas School District
 
RPMS TEMPLATE FOR SCHOOL YEAR 2023-2024 FOR TEACHER 1 TO TEACHER 3
RPMS TEMPLATE FOR SCHOOL YEAR 2023-2024 FOR TEACHER 1 TO TEACHER 3RPMS TEMPLATE FOR SCHOOL YEAR 2023-2024 FOR TEACHER 1 TO TEACHER 3
RPMS TEMPLATE FOR SCHOOL YEAR 2023-2024 FOR TEACHER 1 TO TEACHER 3
IreneSebastianRueco1
 
The basics of sentences session 6pptx.pptx
The basics of sentences session 6pptx.pptxThe basics of sentences session 6pptx.pptx
The basics of sentences session 6pptx.pptx
heathfieldcps1
 
BÀI TẬP BỔ TRỢ TIẾNG ANH 8 CẢ NĂM - GLOBAL SUCCESS - NĂM HỌC 2023-2024 (CÓ FI...
BÀI TẬP BỔ TRỢ TIẾNG ANH 8 CẢ NĂM - GLOBAL SUCCESS - NĂM HỌC 2023-2024 (CÓ FI...BÀI TẬP BỔ TRỢ TIẾNG ANH 8 CẢ NĂM - GLOBAL SUCCESS - NĂM HỌC 2023-2024 (CÓ FI...
BÀI TẬP BỔ TRỢ TIẾNG ANH 8 CẢ NĂM - GLOBAL SUCCESS - NĂM HỌC 2023-2024 (CÓ FI...
Nguyen Thanh Tu Collection
 
Your Skill Boost Masterclass: Strategies for Effective Upskilling
Your Skill Boost Masterclass: Strategies for Effective UpskillingYour Skill Boost Masterclass: Strategies for Effective Upskilling
Your Skill Boost Masterclass: Strategies for Effective Upskilling
Excellence Foundation for South Sudan
 
MARY JANE WILSON, A “BOA MÃE” .
MARY JANE WILSON, A “BOA MÃE”           .MARY JANE WILSON, A “BOA MÃE”           .
MARY JANE WILSON, A “BOA MÃE” .
Colégio Santa Teresinha
 
Life upper-Intermediate B2 Workbook for student
Life upper-Intermediate B2 Workbook for studentLife upper-Intermediate B2 Workbook for student
Life upper-Intermediate B2 Workbook for student
NgcHiNguyn25
 

Recently uploaded (20)

Top five deadliest dog breeds in America
Top five deadliest dog breeds in AmericaTop five deadliest dog breeds in America
Top five deadliest dog breeds in America
 
Azure Interview Questions and Answers PDF By ScholarHat
Azure Interview Questions and Answers PDF By ScholarHatAzure Interview Questions and Answers PDF By ScholarHat
Azure Interview Questions and Answers PDF By ScholarHat
 
DRUGS AND ITS classification slide share
DRUGS AND ITS classification slide shareDRUGS AND ITS classification slide share
DRUGS AND ITS classification slide share
 
How to Manage Your Lost Opportunities in Odoo 17 CRM
How to Manage Your Lost Opportunities in Odoo 17 CRMHow to Manage Your Lost Opportunities in Odoo 17 CRM
How to Manage Your Lost Opportunities in Odoo 17 CRM
 
The History of Stoke Newington Street Names
The History of Stoke Newington Street NamesThe History of Stoke Newington Street Names
The History of Stoke Newington Street Names
 
Liberal Approach to the Study of Indian Politics.pdf
Liberal Approach to the Study of Indian Politics.pdfLiberal Approach to the Study of Indian Politics.pdf
Liberal Approach to the Study of Indian Politics.pdf
 
writing about opinions about Australia the movie
writing about opinions about Australia the moviewriting about opinions about Australia the movie
writing about opinions about Australia the movie
 
Executive Directors Chat Leveraging AI for Diversity, Equity, and Inclusion
Executive Directors Chat  Leveraging AI for Diversity, Equity, and InclusionExecutive Directors Chat  Leveraging AI for Diversity, Equity, and Inclusion
Executive Directors Chat Leveraging AI for Diversity, Equity, and Inclusion
 
The basics of sentences session 5pptx.pptx
The basics of sentences session 5pptx.pptxThe basics of sentences session 5pptx.pptx
The basics of sentences session 5pptx.pptx
 
A Strategic Approach: GenAI in Education
A Strategic Approach: GenAI in EducationA Strategic Approach: GenAI in Education
A Strategic Approach: GenAI in Education
 
clinical examination of hip joint (1).pdf
clinical examination of hip joint (1).pdfclinical examination of hip joint (1).pdf
clinical examination of hip joint (1).pdf
 
Advanced Java[Extra Concepts, Not Difficult].docx
Advanced Java[Extra Concepts, Not Difficult].docxAdvanced Java[Extra Concepts, Not Difficult].docx
Advanced Java[Extra Concepts, Not Difficult].docx
 
How to Fix the Import Error in the Odoo 17
How to Fix the Import Error in the Odoo 17How to Fix the Import Error in the Odoo 17
How to Fix the Import Error in the Odoo 17
 
Pride Month Slides 2024 David Douglas School District
Pride Month Slides 2024 David Douglas School DistrictPride Month Slides 2024 David Douglas School District
Pride Month Slides 2024 David Douglas School District
 
RPMS TEMPLATE FOR SCHOOL YEAR 2023-2024 FOR TEACHER 1 TO TEACHER 3
RPMS TEMPLATE FOR SCHOOL YEAR 2023-2024 FOR TEACHER 1 TO TEACHER 3RPMS TEMPLATE FOR SCHOOL YEAR 2023-2024 FOR TEACHER 1 TO TEACHER 3
RPMS TEMPLATE FOR SCHOOL YEAR 2023-2024 FOR TEACHER 1 TO TEACHER 3
 
The basics of sentences session 6pptx.pptx
The basics of sentences session 6pptx.pptxThe basics of sentences session 6pptx.pptx
The basics of sentences session 6pptx.pptx
 
BÀI TẬP BỔ TRỢ TIẾNG ANH 8 CẢ NĂM - GLOBAL SUCCESS - NĂM HỌC 2023-2024 (CÓ FI...
BÀI TẬP BỔ TRỢ TIẾNG ANH 8 CẢ NĂM - GLOBAL SUCCESS - NĂM HỌC 2023-2024 (CÓ FI...BÀI TẬP BỔ TRỢ TIẾNG ANH 8 CẢ NĂM - GLOBAL SUCCESS - NĂM HỌC 2023-2024 (CÓ FI...
BÀI TẬP BỔ TRỢ TIẾNG ANH 8 CẢ NĂM - GLOBAL SUCCESS - NĂM HỌC 2023-2024 (CÓ FI...
 
Your Skill Boost Masterclass: Strategies for Effective Upskilling
Your Skill Boost Masterclass: Strategies for Effective UpskillingYour Skill Boost Masterclass: Strategies for Effective Upskilling
Your Skill Boost Masterclass: Strategies for Effective Upskilling
 
MARY JANE WILSON, A “BOA MÃE” .
MARY JANE WILSON, A “BOA MÃE”           .MARY JANE WILSON, A “BOA MÃE”           .
MARY JANE WILSON, A “BOA MÃE” .
 
Life upper-Intermediate B2 Workbook for student
Life upper-Intermediate B2 Workbook for studentLife upper-Intermediate B2 Workbook for student
Life upper-Intermediate B2 Workbook for student
 

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 )