health

1. HEALTH ASSESSMENT
An introduction
By Linda Grace

2. Learning Objectives
 Define health assessment
 Describe the purpose, types,
importance of health assessment
 Describe and practice the steps
involved in taking a nursing health
history
 Discuss the process of interviewing a
client.

3. Definitions
 Health:
 Health assessment;
◦ Refers to a systematic, deliberative and
interactive process by which a nurse uses critical
thinking skills to collect, validate, analyze and
synthesize data so as to make a judgment about
the health status and life processes of
individuals, families and communities.
◦ Data is both subjective (health history) and
objective (physical examination)
 Physical assessment (objective data);
◦ Involves collection of objective data on the
client’s physical health status.

4. The Nursing process
 Assessment is step one of the nursing
process.

5. Health assessment cont’d
 Focuses on both curative and preventive health care.
 Preventive health care; 3 categories,
◦ primary,
◦ secondary and
◦ tertiary prevention.
 Each level of prevention is based on a thorough
assessment of the client's health as status.
 Periodic health assessment needed to be performed by
a physician, or a nurse

6. Objectives of health assessment
 Surveillance of health status
 Identification of occult disease,
 For screening, and follow-up care
 Increasing client participation in health
care
 Accurately define the health and risk care
needs for individuals

7. Objectives of health assessment
cont’d
 Overall the major objective of health
assessment is to;
 To make a judgement (nursing
diagnosis, collaborative care and
referral) on the patients actual or
potential health problems

8. Important to note
 In order to achieve the objectives of
health assessment, it should be;
 The periodic assessment, at regular
intervals
 Health assessment is shared with the
client in a clear and understandable
manner
 The client must share in decision making
for his own care.

9. Frequency of routine comprehensive
assessment
 The persons under (35) years every (4 – 5) years
 The persons from (35 – 45) every (2 – 3) years.
 Persons from (45-55) years of age undergo a
thorough health assessment every year.
 Persons over (55) years may needs assessment
every 6 months or less
 Every time a client presents with a health care
need.

10. 1. Provides a systematic and continuous collection of
client data
2. It focuses on client responses to health problems
3. The nurse carefully examines the client’s body parts
to determine any abnormalities
4. The nurse relies on data from different sources
which can indicate significant clinical problems
5. Health assessment provides a base line used to plan
the clients care
Importance of nursing health
assessment

11. Importance of health assessment
6. Health assessment helps the nurse to
diagnose client’s problem & the
intervention
7. Complete health assessment involves a
more detailed review of client’s condition
8. Health assessment influence the choice of
therapies & client's responses

12. Purposes of health assessment
1. Gather data
2. Confirm or refuse data obtained in the
health history
3. To identify nursing diagnoses/medical dx
4. To make clinical judgments about client's
changing health status
5.To evaluate bio-psycho-social and spiritual
outcomes of care

13. Approaches to health assessment
Health Orientation Approach
 Performed in relation to the present health status of the
patient, the daily activities necessary to maintain health
and the internal and external environmental resources that
are available to promote and improve health.
 This approach is appropriate when patient comes for a
routine check up but is inadequate when patient is ill.
Disease or Problem Oriented Approach
 Information gathered relates to the present disease
condition and how it compares with the patient’s previous
health status, the patient’s experience (symptoms) of the
illness . What this means and what coping mechanisms are
being used.
 Here patient’s experiences and illness process are
demonstrated

14. Types of Assessment
 Comprehensive assessment: is
usually the initial assessment it very
thorough and includes detailed health
history and physical examination and
examine the client's overall health and
functional health status.

15. Types of Assessment
 Initial assessment: assessment
performed within a specified time on
admission. E.g. nursing admission
assessment
 Problem-focused assessment: used
to determine status of a specific problem
identified in an earlier assessment. e.g.
problem on urination-assessment on
fluid intake and urine output hourly.
Maybe an initial or ongoing assessment.

16. Types of assessment
 Emergency assessment: rapid
assessment done during any physiologic
crisis of the client to identify life threatening
problems. .g. assessment of a client’s airway,
breathing status & circulation after a cardiac
arrest.
 Time-lapsed (periodic) assessment:
reassessment of client’s functional health
pattern done several months after initial
assessment to compare the clients current
status to baseline data previously obtained.

17. Types of data
 Mainly 2 types of data are obtained
during a health assessment of a client
 Subjective data
 Objective data

18. Subjective data
 Data given by a client or family, next of kin
 These are symptoms or sensations reported
 Such information can only be elicited and
verified only by the client
 Examples may include symptoms (pain,
hunger)
 Feeling e.g happiness, sadness
 Perceptions, desires, preferences, beliefs,
ideas, values.

19. Subjective data continued
 Biographical information (name, age,
religion, occupation
 History of present concern
 All health history
 Data from review of systems
 Health and lifestyle practices

20. Objective data
 Data directly observed by the nurse
 Includes
 Physical characteristics
 Body functions (heart or respiratory
rate)
 Appearance e.g dress and hygiene
 Behavior, mood and affect
 Measurement, blood pressure,
temperature, height
 Laboratory and imaging results

21. Components of a comprehensive
health Assessment
Health History
 Subjective data Symptoms
and health history
 Obtained through
interview/review of systems
 Identifies actual or
potential health problems,
support system, teaching
needs, discharge and
referral needs
 Use of effective
communications skills is
requisite
Physical Assessment
 Objective data
 Obtained by observation
and physical assessment
techniques (all physical
examination findings or
signs)
 Laboratory information
and test data
 Completes client’s health
picture/validates
subjective (health
history).
 Documentation of all

22. Steps for health Assessement
 Collection of subjective data
 Collection of objective data
 Validation of data
 Documentation of data
 These steps may overlap

23. Validation of data
 Crucial step
 Occurs along with the collection of subjective and
objective data
 Ensures that all relevant assessment data is collected
and is accurate
 Methods of validation include;
 Rechecking data
 Clarifying with the client by asking additional
questions
 Verify with another health care professional
 Compare your objective finding with the subjective
information

24. Documenting data
 “Not documented = Not done”
 A very important step
 Forms the database for the entire nursing
process and provides data to the entire
healthcare team
 Important in making valid conclusions and
promotes effective communication.
 Should be accurate and systematic
 Usually guided by institutional policy and
guidelines.

25. Modals for documentation
 Computer-based documentation
systems (Health/patient information
databases)..[Electronic
health/Medical records (HER, EMR)
 Paper based documentation
 All assessment data should be
accurately validated and documented
to minimize medical errors and
improve patient safety

26. 1. The Interview
 Definition: Communication process that
focuses on the client's development of
psychological, physiological, socio-cultural,
and spiritual responses, that can be treated
with nursing & collaborative interventions

27. Fig. 1 REMEMBER: The communication process.

28. Major purpose of a health interview:
 To obtain health history and to elicit symptoms and
the time course of their development. The interview
is conducted before physical examination is done.
Components of nursing interview
1. Introductory phase
2. Working phase
3. Termination phase

29. 1. Introductory phase:
 Introduction of yourself and explaining the
purpose of the interview to the client.
 Before asking questions, Let client to feel
Comfort, Privacy and Confidentiality

30. Working phase:
The nurse must listen and observe cues in addition to using
critical thinking skills to validate information received from
the client. The nurse identify client's problems and goals.
Termination phase:
1.The nurse summarizes information obtained during the
working phase
2. Validates problems and goals with the client.
3.Making plans to resolve the problems (nursing diagnosis
and collaborative problems are identified and discussed
with the client)

31. Communications techniques during
interview
 Interactional Skills
◦ Listening
◦ Attending
◦ Paraphrasing
◦ Leading
◦ Questioning
◦ Reflecting
◦ Summarizing

32. Communications techniques during
interview
 Listening: - Paying Undivided
Attention to What the Client Says and
Does
 Attending: - Giving Full Attention to
Verbal and Nonverbal Messages

33. Communication techniques c’td
 Paraphrasing: - Restating the Client’s
Basic Message
 Leading: - Used to Encourage Open
Communication
◦ Techniques
 Direct leading
 Focusing
 Questioning

34. Communication techniques c’td
 Questioning: - Direct Way of Speaking with Clients to
Obtain Subjective Data for Decision Making and
Planning Care
◦ Closed and open-ended questions
 Reflecting: - Repeating the Client’s Verbal or
Nonverbal Message for the Client’s Benefit to Show that
the Nurse Has Empathy with the Client’s Thoughts,
Feelings, or Experiences
 Summarizing:- The Process of Gathering the Ideas,
Feelings, and Themes That Clients Have Discussed
Throughout the Interview and Restating Them in

35. Communications techniques: Questioning
1. Types of questions :
 Begin with open ended questions to assess client's
feelings e.g. what, how, which“
 Use closed ended question to obtain facts e.g." when,
did…etc
 Use list to obtain specific answers e.g. "is pain sever,
dull sharp
 Explore all data that deviate from normal e.g. “increase
or decrease the problem

36. 2. Types of statements to be use:
 Repeat your perception of client's response to clarify
information and encourage verbalization
3. Accept the client silence to recognize thoughts
4. Avoid some communication styles e.g.
 Excessive or not enough eye contact.
 Doing other things during getting history.
 Biased or leading questions e.g. "you don't feel bad“
why not ask, “how does that make you feel”
 Relying on memory to recall information

37. BEWARE: Communication barriers
 Barriers to Effective Client
Interactions
◦ False reassurance
◦ Interrupting or changing the subject
◦ Passing judgment
◦ Cross-examination
◦ Using technical terms
◦ Encountering sensitive issues
◦ Age, cultural, regional and emotional
variations

38. 5. Specific age variations :-
 Pediatric clients: validate information from parents.
 Geriatric clients: use simple words and assess hearing
acuity
6. Emotional variations:
 Be calm with angry clients and those who are anxious
and express interest with depressed client
 Sensitive issues "e.g. sexuality, dying, spirituality" you
must be aware of your own thought regarding these
things (self awareness very crucial).

39. 7. Cultural variations:
 Be aware of possible cultural variations in the
communication styles of self and clients:
Factors: ethnicity, body language, customs, nationality
etc
8. Use culture broker:
 Use culture broker as middleman if your client not speak
your language.
Use pictures for non reading clients.

40. Other barriers cont’d
 Diversity and Impact on the Nurse -
Client Interactions
 Education
 Health status
 Level of intelligence

41. Chapter (2)
Psychosocial assessment

42. Psychosocial assessment
 Psychological assessment involves person's
psychological growth and development throughout
his life.
 Discuss crises with the clients to assess relationship
between health & illness. “It depends on multiple
G&D theories e.g. Erickson, Piaget, and Freud …. etc.

43. Stages of Age
 Infancy period: birth to 12 months
Neonatal Stage: birth-28 days
Infancy Stage: 1-12 months
 Early childhood Stage: It’s refers to two integrated stages of
development
Toddler: 1 - 3years.
Preschool: 3 - 6 years.
 Middle childhood 6-12 years
 Late childhood:
Pre pubertal: 10 – 13 years.
Adolescence: 13 - 19 years
 Young adulthood 20-35 years
 Middle adulthood 40-60years
 Late adulthood 60 and more

44. Chapter (3)
Nutritional assessment

45. Nutritional assessment
 Nutrition plays a major role in the way an
individual looks, feels,& behaves.
 The body ability to fight disease greatly
depends on the individual's nutritional
status

46. Major goals of nutritional assessment
1. Identification of malnutrition.
2. Identification of over consumption
3. Identification of optimal nutritional status.
Components of Nutritional Assessment
1. Anthropometric measurement.
2. Biochemical measurement.
3. Clinical examination.
4. Dietary analysis

47. 1. Anthropometric measurement
 Measurement of size, weight, and proportions of human body.
 Measurement includes: height, weight, skin fold thickness, and
circumference of various body parts, including the head, chest, and
arm.
 Assess body mass index (BMI) to shows a direct and
continuous relationship to morbidity and mortality in studies of
large populations. High ratios of waist to hip circumference
are associated with higher risk for illness & decreased life
span.
BMI = (Wt. in kilograms) = 60 = 60 =
23.4
(High in meters) 2 (1.6)2 2.56

48. BMI RANGE
Condition Rang kg/m2
Very thin less than 16.0
Thin 16.0 - 18.4
Average/normal 18.5- 24.9
Overweight 25–29.9
Obese 30-34.9
Highly obese ≥ 35

49. 2. Biochemical Measurement
 Useful in indicating malnutrition or the development of
diseases as a result of over consumption of nutrients.
Serum and urine are commonly used for biochemical
assessment.
 In assessment of malnutrition, commonly tests include:
total lymphocyte count, albumin, serum transferrin,
hemoglobin, and hematocrit …etc. These values taken
with anthropometric measurements, give a good overall
picture of an individual's skeletal and visceral protein
status as well as fat reserves and immunologic response.

50. 3. Clinical examination
 Involves, close physical evaluation and may
reveal signs suggesting malnutrition or over
consumption of nutrients.
 Although examination alone doesn't permit
definitive diagnosis of nutritional problem, it
should not be overlooked in nutritional
assessment

51. Nutritional assessment technique for clinical examination
A. Types of information needed
 Diet: Describe the type: regular or not, special,
"e.g. teeth problem, sensitive mouth.
 Usual mealtimes: How many meals a day: when?
Which are heavy meals?
 Appetite: "Good, fair, poor, too good “polyphagia".
 Weight: stable? How has it changed?

52.  Food preferences: e.g." prefers beef to other meats"
 Food dislike: What & Why? Culture related?
 Usual eating places: Home, snack shops, restaurants.
 Ability to eat: describe inabilities, dental problems:
"ill fitting dentures, difficulties with chewing or
swallowing
 Elimination" urine & stool: nature, frequency
problems
 Exercise & physical activity: how extensive or
deficient

53.  Psycho social - cultural factors: Review any thing which
can affect on proper nutrition
 Taking Medications which affect the eating habits
 Laboratory determinations e.g.: “Hemoglobin, protein,
albumin, cholesterol, urinalyses"
 Height, weight, body type "small, medium, large"
After obtaining information, summarize your findings and
determine the nutritional diagnosis and nutritional plan of
care.
Imbalanced nutrition: Less than body requirements, related to
lack of knowledge and inadequate food intake
Risk for infection, related to protein-calorie malnutrition

54. B. Signs & symptoms of malnutrition
 Dry and thin hair
 Yellowish lump around eye, white rings around both
eyes, and pale conjunctiva
 Redness and swelling of lips especially corners of
mouth
 Teeth caries & abnormal missing of it
 Dryness of skin (xerosis): sandpaper feels of skin
 Spoon shaped Nails " Koilonychia “ anemia
 Tachycardia, elevated blood pressure due to
excessive sodium intake and excessive cholesterol,
fat, or caloric intake
 Muscle weakness and growth retardation

56. 4. Dietary analysis
 Food represent cultural and ethnic background and
socio- economic status and have many emotional
and psychological meaning
 Assessment includes usual foods consumed &
habits of food
 The nurse ask the client to recall every thing
consumed within the past 24 hour including all
foods, fluid, vitamins, minerals or other
supplements to identify the optimal meals
 Should not bias the client's response to question
based on the interviewer's personal habits or
knowledge of recommended food consumption

57. Diseases affected by nutritional problems
1- Obesity: excess of body fat.
2- Diabetes mellitus.
3- Hypertension.
4- Coronary heart disease.
5- Cancer.

58. Chapter (4)
Sleep-wakefulness patterns

59. Assessment of sleep-wakefulness patterns
 Normal human has “homeostasis” (ability to
maintain a relative internal constancy)
 Any person may complain of sleep-pattern
disturbance as a primary problem or
secondary due to another condition
 1/4 of clients who seek health care
complain of a difficulty related to sleep

60. Factors affecting length and quality of sleep
1. Anxiety related to the need for meeting a tasks, such
as waking at an early hour for work.
2. The promise of pleasurable activity such as starting
a vacation.
3. The conditioned patterns of sleeping.
4. Physiologic wake up.
5. Age differences.
6. Physiologic alteration, such as diseases

61. NOTE: Good sleep depends on the number of awakenings and the
total number of sleeping hours
The nurse can assess sleep pattern by doing interview with the
client or using special charts or by EEG
Disorders related to sleep
1.Sleep disturbances affects family life, employment, and
general social adjustment
2. Feelings of fatigue, irritability and difficulty in
concentrating
3. Difficulty in maintaining orientation

62. 4. Illusions, hallucination (visual & tactile )
5. Decreased psychomotor ability with decreased
incentive to work
7. Tremor of hands
Increase in gluco-corticoid and adrenergic
hormone secretion
9. Increase anxiety with sense of tiredness
10. Insomnia "short end sleeping periods“
11. Sleep apnea "periodic cessation of breathing that
occurs during sleep

63. 12. Hypersomnia: "sleeping for excessive periods” the
sleep period may be extended to 16-18 hours a day
13. Peri-hypersomnia. "Condition that is described as
an increased use for sleep "18-20 hours a day" lasts
for only few days
14. Narcolepsy "excessive day time drowsiness or
uncontrolled onset of sleep.
15. Cataplexy: abrupt weakness or paralysis of
voluntary muscles e.g. arms, legs & face last from
half second to 10 minutes, once or twice a year
16. Hypnagogic hallucinations: " Disturbing or
frightening dream that occur as client is falling a
sleep

64. Assessment of sleep habits
 Let the client record the times of going to sleep and
awakening periods, including naps.
 Allow client to described their sleep habits in their
own words
You can ask the following questions:
How have you been sleeping?‖
Can you tell me about your sleeping habits?"
Are you getting enough rest?"
Tell me about your sleep problem"
A Good comprehensive History includes: a general sleep
history AND psychological history

65. Frameworks for collecting client data
 2 frameworks that are peculiar to
Nursing
 Generic Nursing History format
 Gordon’s functional health pattern
assessment model

66. Generic Nursing History Framework
 Provides a foundation for identifying client problems
 Provides a focus for physical examination.
 Mainly focus on collecting subjective data.
Major components
 Biographical data
 Reasons for seeking health care
 History of presenting health concern
 Past health histories
 Family histories
 Review of systems for current health problems
 Lifestyle and health practices (Activities of daily living)
 Developmental levels
 Photocopy page 19 in Weber & Kelley, 2014

67. Gordon’s functional heath pattern
assessment model
 Useful in collecting patient data to
formulate nursing diagnosis.
 Consists of 11 functional health
patterns
 A pattern is a sequence of related
behavior that assists a nurse in
collecting and categorizing data
 Can be applied to clients of all ages,
families and communities

68. The functional health pattern
framework summary
1. Client profile
2. Developmental history
3. Health-perception- health management pattern
4. Nutritional metabolic pattern
5. Elimination pattern
6. Activity-exercise pattern
7. Sexuality-reproduction pattern
8. Sleep-rest pattern
9. Sensory-perceptual pattern
10. Cognitive pattern
11. Role-relationship pattern
12. Self-perception-self-concept pattern
13. Coping-stress tolerance pattern
14. Value-belief pattern

69. Chapter (5)
THE Health History taking

70. Definition of Health History
Systematic collection of subjective data stated by
the client, on there health condition
Data is used to determine a client’s functional
health pattern/status.
A Health History Interview is a Planned, Formal
Interaction Between the Nurse and the Client

71. Phases of taking health history
Two phases:-
The interview
phase which elicits
the information
(primary sources)
The recording
phase (secondary
Phases : B
◦ Preinteraction
phase
◦ Initial interview
◦ Focused
interview

72. Guidelines for Taking Nursing History
Private, comfortable, and quiet
environment.
Allow the client to state problems and
expectations for the interview.
Orient the client the structure, purposes,
and expectations of the history.

73. Guidelines for Taking Nursing History cont..
Communicate and negotiate priorities
with the client
Listen more than talk.
Observe non verbal communications e.g.
"body language, voice tone, and
appearance".

74. Guidelines for Taking Nursing History cont..
Review information about past health history
before starting interview.
Balance between allowing a client to talk in an
unstructured manner and the need to structure
requested information.
Clarify the client's definitions (terms &
descriptors)

75. Guidelines for Taking Nursing History cont..
Avoid yes or no question (when detailed
information is desired).
Write adequate notes for recording?
Record nursing health history soon after
interview.

76. Types of Nursing Health History
Complete health history: taken on initial visits
to health care facilities.
Interval health history: collect information in
visits following the initial data base is collected.
Problem- focused health history: collect data
about a specific problem

77. Health History: components
Bio-dermographic data
 D-Date
 N-Name
 A-Age
 S-Sex
 R-Region
 T-Tribe
 A-Address
 N-Next of kinLevel of
education
 Occupation
 Others: Distance to the
nearest health centre
 Source of referral
Past health history
 Presenting complaint
 History of present
complaint
 Past medical history
 Past surgical history
 Past obstetric history
 Past gynaecology
history
 Family history
 Social history

78. Purpose of obtaining Biographic data
 Date: Record keeping
 Name: For identification
 Age: For Dose calculation, ward allocation:
children from adults, disease distribution
 Sex: Disease distribution, ward allocation
 Religion: To observe religious beliefs

79. Purpose of obtaining biographic data..
 Tribe: To observe cultural beliefs
 Address: For easy patient follow up
 Next of Kin: someone from whom
consent can be obtained from in case
patient is a minor or unconscience.

80. Purpose of obtaining biographic data....
 Level of education: Helps to know how
much information to give someone during
health education and in the simplest terms.
 Occupation: To rule out occupation
hazards
 Distance to the nearest health
centre: to know the health seeking
behaviour of some one.

81. Health/medical history: order
 Presenting complaint
 History of present complaint
 Past medical history
 Past surgical history
 Past obstetric history
 Past gynaecology history
 Family history
 Social history
 Activities of daily living.
 Review of systems.

82. Presenting complaint
 Signs and symptoms
 Duration of the presenting signs and
symptoms
 This in usually the main reason for
seeking healthcare.
 .......................many times it will be pain

83. 2- Chief Complaint: “Reason For Hospitalization
Examples of chief complaints:
Chest pain for 3 days.
Swollen ankles for 2 weeks.
Fever and headache for 24 hours.
Pap smear needed.
Physical examination needed for camp.

84. 3-History of present illness
Gathering information relevant to the
chief complaint, and the client's
problem, including essential and
relevant data, and self medical
treatment.

85. Component of Present Illness
Introduction: "client's summary and usual
health".
Investigation of symptoms: "onset, date, gradual
or sudden, duration, frequency, location, quality,
and alleviating or aggravating factors".
Negative information.
Relevant family information.
Disability "affected the client's total life".

86. SYMPTOM ANALYSIS
P Q R S T
a. Provocative or Palliative
 First occurrence :
 What were you doing when you first experienced
or noticed the symptom?
 What to trigger it ? stress? Position?, activity?
 What seems to cause it or make it worse? For a
psychological symptom .
 What relieves the symptom : change diet? Change
position ? Take medication ? Being active?
 Aggravation: what makes the symptom worse?

87. SYMPTOM ANALYSIS
P Q R S T
b. Quality Or Quantity
 QUALITY:
 How would you describe the symptom- how it feels,
looks, or sounds?
 QUANTITY:
 How much are you experiencing now?
 Is it so much that it prevents you from performing any
activity?

88. SYMPTOM ANALYSIS
P Q R S T
C. Region Or Radiation
 Region :
Where does the symptom occur?
 Radiation :
Does it travel down your back or arm, up your
neck or down your legs?

89. SYMPTOM ANALYSIS
P Q R S T
d. Severity scale
 Severity
 How bad is symptom at its worst?
 Course
 Does the symptom seem to be getting better,
getting worse?

90. SYMPTOM ANALYSIS
P Q R S T
e. Timing
 Onset :
 On what date did the symptom first occur
Type of onset :
 How did the symptom start sudden? Gradually?
 Frequency :
 How often do you experience the symptom ; hourly ?
Daily ? Weekly? monthly
 Duration :
 How long does an episode of the symptom last

91. Past medical history (PMH)
Ask about:
 patient’s general condition currently, in the
near past and in general
 Previous admission (index or not)
 Any current medical conditions.
 Previous or current infectious conditions e.g
,malaria, RTI, rheumatic fever, Hep B etc
 Past medical illness esp chronic conditions:
rheumatic fever, DM, heart diseases,
hypertension, renal disease, CVA (stroke),
COPD, epilepsy, asthma, SCD etc

92. PMHx cont’d
Past drug history
◦ Are you on or have been on any
drug/drugs?
◦ Type and reason
◦ name,
◦ dose/day,
◦ route,
◦ how long
◦ Side effects
 Any drug allergies and symptoms

93. Past surgical history (PSHx)
Ask about:
 Any previous surgical operations, time
done and recovery.
 History of blood transfusion and
tolerance to BT.
 H/o accidents, trauma/injury and
fractures.
 Any surgical conditions

94. P Obstetrics & Gynecological history
_women only
Ask about:
◦ Menarche/menopause
◦ Previous pregnancies and deliveries, LNMP,
EDD
◦ Menses, duration, flow
◦ Any gynecological conditions and
complications
◦ Any family planning method ever used and
when.
◦ ETC

95. Family history
Ask about:
 Family in general, family members
 Familial conditions e.g sickle cell
disease,DM, hypertension, cancers,
and genetic conditions
 A family tree can help summarize
these assessments

96. Family history, sample family tree
with DM as a condition
Pt
X
DM DM
DM

97. Social history
Ask about:
 Social habits:
◦ Smoking: When started, how long been
smoking, when stopped or contemplating
smoking,
◦ If currently smoking. How many cigarettes.
Smoking is assessed in packs/year:- number
of year smoking*packs/day.
◦ Some qns: Do you smoke? Have you ever
smoked for a significant period of time?
When did you stop?
◦ How much do you/did you smoke on
average every day?

98. Social history continued
Social habits:
 Alcohol. Do you drink alcohol
◦ How much alcohol do you drink in an average week?
(express in units)
 Occupation: What do you do for a living?
 Travel: Have you travelled anywhere recently?
 Housing: What sort of housing do you live in?
◦ Do you live with anyone else at home?
◦ Determine if they live alone in a house, flat, sheltered
housing, residential or nursing home:
◦ Source of water and neighborhood.
 Recreation: Any activities for recreation. Do you
have any pets?

99. Activities of daily living
 How has the illness affected your ability
to perform your ADL.
 How are you coping at home?
 Are you able to cook/clean/wash/go
shopping on your own or do you need
help?
 Do you need help to move around?
 Do you need a walking stick/wheelchair?
 Do you have stairs to climb?
 Do you have any carers? How often do
they come?

100. Review of systems (ROS)
Collection of data about the past and the present
of each of the client physical and physiological
systems.
(Review of the client’s physical, sociologic, and
psychological health status may identify hidden
problems and provides an opportunity to
indicate client strength and disabilities

101. ROS components: systematic
approach.
General review of skin, hair, head, face, eyes,
ears, nose, sinuses, mouth, throat, neck nodes and
breasts.
Assessment of respiratory and cardiovascular
system.
Assessment of gastrointestinal system.
Assessment of urinary system.
Assessment of genital system.
Assessment of extremities and musculoskeletal
system.
Assessment of endocrine system.
Assessment of heamatologic system

102. Ros, general health & HEENT
 General health: Ask about: height, weight (recent
weight gain or loss) and general wellbeing
 Neuropsychological: h/o convulsions, fatigue,
weakness, depression.
Chlidren; ask abt h/o convulsions
 Head: h/o head trauma, headache,
dizziness(vertigo), or memory loss. Children: shape
of the head, fontanelles, trauma
 Hair: h/o; changes in texture, color, distribution or
loss. Children: also ask abt; scalp lesions or itchness

103.  Skin; rashes, changes in moles or
other lesions and skin color e.g in
vitiligo
◦ Children also birthmarks, ecchymotic
marks

104.  Eyes: h/o vision disturbances, use of
glasses or contact lenses, eye disease
(glaucoma, cataracts, short/long
sightedness, infection), date of last
vision examination.
Children: also h/o ability to follow a
moving object, difficulty in vision, eye
infections
 Ears: ask about h/o: hearing difficulties,
use of hearing aids, ear disease(infection,
discharge, dizziness), hearing test exam.

105.  Nose: h/o epistasis, infections, discharge
(rhinorrhea), loss of smell, sinus problems
h/o of nose surgery e.g in polyps..
 Mouth: dental carries or cavities, use of
dentures, braces or retainers, inflammations
and lesions in the oral cavity, loss of taste,
date of last dental visit. Children; number of
teeth present, cavities, false teeth and
extraction.
 Throat: h/o difficult swallowing, infections
e.g tonsilitis or hoarseness
◦ Children; history of streptococcal infection.

106.  Neck: h/o of neck stiffness, swollen LN,
neck trauma.
 Chest: discharge or masses in the
breasts (male/female), BSE in females,
◦ Chest trauma.
◦ Children; symmetry of the chest

107.  Respiratory system: H/O; cough
(productive or non-productive), dyspnea, chest
pain, stridor, wheezing, shortness of breath,
asthma, previous RS conditions.
◦ Children: frequent colds or cough, previous severe
respiratory illness
 Cardiovascular system, CVS: Ask abt chest
pain (e.g left sides radiating to the shoullder,
angina pectoris pain), h/o of hypertension,
edema of extremities, past heart disease,
fatigue and activity tolerance, palpitations. h/o
of anemias, children also: cyanosis, shortness
of breath, tolerance to play.

108.  Gastrointestinal system: ask about
 Appetite, nausea, vomiting, diarrhoea,
jaundice constipation, hemorrhoids, bowel
habits, color of stools, previous GI surgery.
 Genito-urinary system, ask about;
 Urinary frequency, urgency, incontinence
or hestitancy. Pain on urination, blood in
urine, color of urine. Amount of urine.
◦ Female: vaginal discharge, pruritis, infections,
STIs,
◦ Males: prostate problems, STIs, sexual
difficulties e.g erectile dysfuntion or premature
ejaculation.

109.  Musculoskeletal and extremities:
h/o trauma, joint pain, swelling and
stiffness. Bone pain, fractures, varicose
veins.
 Back; pain, stiffness, h/o spinal injury

110.  Hematological system: anemia,
transfusions ( reason for, any reactions to
transfusion and severity); bleeding
tendencies, easy bruising, patechiae
(bleeding under the skin).
 Endocrine system: thyroid disease,
DM, any hormone replacement therapy.