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SUBJECTIVE DATA IN HEALTHCARE ASSESSMENT
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- 2. Content 1. Definition 2. Typesof sources 3. Phases 4. Components of health history a. Biographical data b. Chief Complaints c. Present health–illness d. Past history e. Family history f. Psychosocial history
- 3. Definition Health History: Importantand relevant information given by the patient and/or patient family or significant other about the patient’s current and past history for the purpose of creating a health care plan pathway for the patient This makes up the subjective data
- 4. SUBJECTIVE DATA Health informationcollected from the patient, family, Nurse and Patient’s previous Medical health records.
- 5. Types of Sources 1.Primary source a. Patient 2. Secondary source a. Relative b. Spouse c. Good Samaritans d. Patient’s file e. Transfer Nurse f. Other medics
- 6. Phases 1. Pre-interaction Phase– occurs before the interview when the nurse gathers patient information from the patient’s chart or the transfer nurse or other meemebrs of the medical team. 2. Interview Phase – Nurse gathers information from the patient, clarifies any information and gathers missing information 3. Termination Phase - End the interview session and prepare patient for the Physical Assessment phase
- 7. Components of HealthHistory 1. Biographical data 2. Chief Complaints 3. Present health–illness 4. Past history 5. Family history 6. Psychosocial history
- 8. 1. Biographical Data Specificinformation that identifies the patient Example Name, Age, Date of birth, Address, Place of birth, Gender, Marital Status, Ethinic/Culture, Religion/Spirituality, Occupation, Source of Health Insurance Note the source and reliability of the information
- 9. Name: Kutus SaganaKirinyaga Age: 30 Date of birth: October 2nd 2018 Address: P.O. BOX 123 Mount Kenya Place of birth: Nyeri, Kenya Gender: female Marital Status: Married Ethinic/Culture: Gikuyu Religion/Spirituality: PCEA Occupation: Nurse Source of Health Insurance: NHIF Reliability of information: Very reliable
- 10. 2. Chief Complain Themain reason(s) that has made the patient seek medical attention Eg. ‘I am shaking like a leaf then I sweat like a pig, then my head hits me like a hammer and I hear a bell ringing in my ear’
- 11. 3. Present HealthHistory Describes how the chief complaint started. Should be complete, clear and chronological. Patient’s thought and feelings about the illness are explored. Symptoms presented – OLDCART Allergies: Specific reactions to the specific triggers Medication: Conventional, traditional, home remedies, borrowed, (non)prescribed, contraceptive. Note all they dynamic of medications Tobacco, alcohol and drugs being currently used
- 12. 4. Past History 1.Childhood illness: Chronic illness, immunizations 2. Adult illness: a. Medical-Screening tests done( pap smear, mammograms), Disease and conditions, Prevailing lifestyle illnesses, blood transfusion, Admissions, Sexual partenre b. Surgical – Dates, indications, diagnois after surgery, type of operations, (un)healed scars
- 13. c. Obstetrics andGynecological history – Menstrual history (Menarche, flow, frequency, days of flow, menopause), Contraceptives, Sexual function, Number of pregnancies, Number of children(alive or causes of death) d. Psychiatric – Dates, diagnosis, Admission and treatments e. Allergies – Include those that patient has out grown f. Substance use – Even if not presently using it.
- 14. 5. Family History Ageand health/causes of death of relatives like children, siblings, parents, grandparents, grandchildren and any other significant member. Ask for lifestyle diseases like DM, HPTN, lung diseases, kidney diseases, TB, Mental illness, suicide, substance use, allergies and alternative lifestyles
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- 16. 6. Personal andSocial History Patient’s personality and interests Sources of support Coping style Fears Strengths and weakness Sources of support Occupation Education
- 17. Activities of dailyliving Leisure activities Lifestyle habits that promote/risk health Safety measures Alternative healthcare practices Roles and relationships Self Concept – How does the patient feel about themselves and where they are in their lives NB: Some information can be gathered as you move on with the assessment
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- 19. Termination Phase • Terminatethe history taking session and prepare patient for either Head to Toe assessment or systematic assessment
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