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

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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Charlz Zipagan
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60 views

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

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.

Uploaded by

Charlz Zipagan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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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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