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    Health History: Charles Z. Ariola JR., MSN, LPT

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    Charlz Zipagan
    The document discusses the process of health assessment, which includes collecting a health history and conducting a physical examination. The health history involves gathering biographic data, chief complaints, and details about the client's present health, past health, family history, personal history, and socioeconomic situation. Collecting a thorough health history allows the healthcare provider to understand the client's full health status and determine an appropriate treatment plan.

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    Health History: Charles Z. Ariola JR., MSN, LPT

    Uploaded by

    Charlz Zipagan
    45 views19 pages
    The document discusses the process of health assessment, which includes collecting a health history and conducting a physical examination. The health history involves gathering biographic data, chief complaints, and details about the client's present health, past health, family history, personal history, and socioeconomic situation. Collecting a thorough health history allows the healthcare provider to understand the client's full health status and determine an appropriate treatment plan.

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    HEALTH HISTORY

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    The document discusses the process of health assessment, which includes collecting a health history and conducting a physical examination. The health history involves gathering biographic data, chief complaints, and details about the client's present health, past health, family history, personal history, and socioeconomic situation. Collecting a thorough health history allows the healthcare provider to understand the client's full health status and determine an appropriate treatment plan.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    45 views19 pages

    Health History: Charles Z. Ariola JR., MSN, LPT

    Uploaded by

    Charlz Zipagan
    The document discusses the process of health assessment, which includes collecting a health history and conducting a physical examination. The health history involves gathering biographic data, chief complaints, and details about the client's present health, past health, family history, personal history, and socioeconomic situation. Collecting a thorough health history allows the healthcare provider to understand the client's full health status and determine an appropriate treatment plan.

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    HEALTH HISTORY

    CHARLES Z. ARIOLA JR., MSN, LPT.


    HEALTH ASSESSMENT

    Health assessment is the collection of data


    about client’s health status.
    PURPOSES
     To collect data about physical, mental and social
    well being of client.
     To get clear picture of the client’s health
    status and health related problems.
     To determine the cause and extent of disease.
     To determine the nature of treatment required
    for client.
     To collect data systematically.
     To get a holistic (complete) view of the client.
     To formulate appropriate nursing care plan.
    PROCESS OF HEALTH
    ASSESSMENT

    Health history

    Physical examination
    HEALTH
    HISTORY
    Health history is the collection of data
    regarding client’s health in an chronological
    order.
    COMPONENTS OF HEALTH
    HISTORY
    1. Biographic data
    2. Chief complaints
    3. Present health history
    4. Past health history
    5. Family history
    6. Personal history
    7. Socio economic history
    1. Biographic data
    This includes information regarding client’s
    name, age, gender, marital status, occupation,
    education, I.P no, treating doctor & diagnosis.
    2. Chief complaints
    It is the brief statement of client’s problem
    for which client needs care.
    Eg: Client is complaining of cough
    since 2 weeks, fever since yesterday and
    headache since today.
    3. Present health history
    Present health history is the expansion
    of chief complaints. It should include
    location, quality, quantity, exaggerating
    and relieving factors.
    Eg: Client is admitted to the hospital with the
    complains of cough with mucus secretion since 2
    weeks, cough increases during night and decreases
    with rest, fever with temperature 100⁰F since
    yesterday and headache at forehead since today
    which decreases with rest and rates 7 in pain scale.
    Present medical history

    Present surgical history


    4. Past health history
    It is the information about client’s previous
    experience with any disease or surgery. This
    health history includes the detail of
     Childhood illness
     Adult illness
     Psychiatric illness
     Injuries, burns, fractures etc.
     Hospitalization
     Surgical & diagnostic procedures
     Current medications
    Past medical history

    Past surgical history


    5. Family history
    This is the information about the client’s family
    members and their health status.
    Family tree
    This is the diagrammatic representation of
    family members. Three generations has to be
    denoted in family tree. Family tree is also
    known as genogram.
    - Male

    - Female

    - Male patient

    - Female patient

    - Male dead

    -Female dead
    Name, age Name, age Ind
    ex
    - Male
    Name, age Name, age Name, age Name, age

    - female

    Name, age Name, age Name, age Name, age


    Index

    Name Name, age


    - Male

    - Female
    Name, age Name, age Name, age Name, age

    - Patient

    - Dead
    Name, age Name, age Name, age Name, age
    6. Personal history
    It includes client’s personal details such as
    dietary pattern, sleep pattern, activity level,
    elimination pattern, alcoholism, smoking habits
    etc
    7. Socio economic history
    Collecting data regarding client’s life style,
    working environment, personal relationship
    with other human beings, monthly or annual
    income, housing facilities.
    Biographic
    data

    Chief
    complaints
    Health Medical
    history Present
    health
    history Surgical

    Past health Medical


    Health history

    assessment
    Family Surgical

    history

    Personal
    history
    Physical
    examination
    Socio
    economic
    history

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