THE COMPLETE HEALTH

HISTORY
Objectives
 Define complete health history
Describe the purpose of complete health
history
Recognize the general guidelines and ethical
considerations during history taking
Discuss formats for health assessment
Health history can be defined as the
systematic collection of subjective and
objective data that is used for determining a
client’s functional health pattern status for the
purpose of midwifery diagnosis.
It is also a chronological and detailed health
record of a client.
 Purpose of history taking

 To establish a trusting relationships between

the Midwife and client
 Develops understanding about the patient
 Helps the patent to feel understood
 Guides on which body parts or systems to
focus during physical examination
 It can be therapeutic
 Phases of history taking
History taking has three basic phases:
1.Introductory phase:
In this phase, the Midwives introduces self and
explains the purposes of the interview to the
patient.
 Comfort, privacy and confidentiality are
provided.
2.Working phase:
• the Midwives facilitates the patient’s
comments about major biographical data,
reason for seeking health care, and functional
health pattern responses.
• This is the actual data collection phase.
3.Summary and closure phase:
The Midwives summarizes information obtained
from the patient during the working phase
and validates problems and goals with the
patient.
Possible plans to resolve the problems are
identified and discussed with the patient.
Guidelines for effective history taking
 Great the patient, call by Name and give
undivided attention.
 Keep comfort and privacy
 Never be in hurry even when you are in a
limited time.
 Design question appropriately, avoid leading
questions, begins with general questions.
 Facilitation
- You encourage the patent to say more
- Make eye contact
- Say Eh, Go on, I am listening.
 Reflection (repetition of patient’s words)
 Clarification
- If the patient words are ambiguous or
associations are not clear you must request for
clarification.
 Empathetic response
- You say ‘‘I understand your problem’’ it
may be behavioral providing a pieces of soft
for a patient tears.
 Confrontation
- If you observe clues of anger, anxiety or
depression you say, you don’t care about it.
 Ethical considerations in health
assessment
 The patient has a full right to know why you are
collecting the information.
 The client is fully informed about the process of
data collection and the decision of the client is
freely made.
 The midwife selectively records information
pertinent to the health status of the client.
 After the completion of data collection the
written document should be secured.
 Formats for health assessment
• There are three commonly used formats for
collecting assessment data.
1. Body systems approach
2. Functional patterns approach
3. Human response patterns approach
 1. Body systems approach
 It is the traditional approach in which the
midwife observes and records data about each
of the body systems.
Drawbacks:-
 It tends to be incomplete data base.
 It limits the midwife to perform holistic
midwifery assessment.
 It is difficult to develop Midwifery diagnosis.
 Most of the information contain the following
categories sequentially.
 Sequence of health history

 Biographical data
 Reason for seeking care
 History of present illness
 Past history
 Family history
 Review of systems
 1 – Biographical data

 Include name, address, phone number, age,

birth place, sex, marital status, occupation.
Source of history: - supply a record of:-
 Who furnishes the information?
 This is usually the client herself or himself,
although the source may be a relative friend.
 2.Reasons for seeking care

 This is a brief spontaneous statement in the

person’s own words that describes the reason
for the visit.
 It states one or two signs or symptoms and
their duration.
 It is enclosed in quotation marks to indicate
the person’s exact words.
 Reasons cont’d

 Eg. “Pushing down of pain” for two hours.

“Want to start jogging and need check-
up”.
 Most of the time reason for seeking care is
called the “chief complaint” (cc).
 Which labels the person a “complainer”, and
more importantly, does not include wellness
needs.
 Reasons cont’d
 Be careful, not to attempt to develop
midwifery diagnosis at this point.
 The client has given minimal information and
no physical assessment or diagnostic testing
has been performed.
 3. Present health or history of present
illness
 This phase is the clarification of the chief
complaint.
 In these step usually identifies major disease
mechanism and symptom.
 History of present illness should include the
following:-
 Present health cont’d
 A full, clear, chronological record of how each
of the symptoms developed.
 How the patient thinks and feels about the
illness, what concern lead to seeking attention
and how the illness affects the patient life and
function.
 The question includes

 The onset of the problem

 The setting in which it developed
 Its manifestation
 Any treatment or results
 The condition of the patient just before this
illness
 How the patient comes to the clinic
 Present health cont’d

 For the well person, this is a short statement

about the general state of health.
 For the ill person, this section is a
chronological record of the reason for health
includes eight critical characteristics.
 Present health cont’d

1. Location
 Be specific, ask the person to point to it.
 Be specific like “pain behind the eyes”, “jaw
pain”.
 Is the pain localized to this site or radiating?
Is the pain superficial or deep?
2. Character
 This calls for specific description.
 The terms as burning, sharp, dull, aching, red,
swollen, bruised, loud, soft, foul, sweet.
 Present health cont’d
3. Quality or severity:
 Attempt to quantify the sign or symptoms
according to the level of intensity, how it
affects activities of daily living, frequency,
volume, number, size … etc.
 Ex. profuse menstrual flow soaking five pads
per hour.
 Present health cont’d

4. Timing: - (onset, duration, frequency)

 when did the symptom first appear?
 Give the specific time, or state specifically
how long ago the symptom started prior to
arrival.
 The symptom begins suddenly or gradually,
when it starts, during activity, rest time?
5. Setting:-where the person was or what was
the person doing when the symptom started?
 Did the pain start by itself?”
 Present health cont’d

6. Aggravating or relieving factors:

 what makes the pain worse?
 Is it aggravated by weather, activity, food,
medication and time of the day?
 What relieves it, ex. Rest, medication
7. Associated factors- is this primary symptom
associated with others.
Ex. Urinary frequency and burning associated
with fever and chills?
8. Client’s perception
 Finds out the meaning of the symptom by
asking how it affects daily activities.
 Also ask directly “what do you think it
means?”
 4. Past Health
 This explores prior illnesses or events may
have residual effects on the current health
state.
– Childhood illnesses – record the occurrence
of measles, mumps, pertusis and rheumatic
fever.
– Accidents or injuries record auto accidents,
fractures; penetrating wounds head injuries
and burns.
 Past Health cont’d

– Serious or chronic illnesses - indicate the

presence of diabetes, hypertension, heart
disease and seizure disorder.
– Hospitalization -record the cause, name of
the hospital, how the condition was treated,
and length.
– Operations-record the type of surgery, date,
name of the hospital and how the person
recovered.
 Past Health cont’d

- Obstetric history - records

- the number of pregnancies (gravid),
- number of viable births (parity) and
- the number of abortions.
 5. Family History

 Ask about the age and health or the age and

cause of death of blood relative such as
parents, grandparents and siblings.
 These data may have genetic significance for
the client.
 Specifically ask for any family history of:
heart disease, high blood pressure, tuberculosis
and diabetes.
 6. Review of System

 The purposes of this section are:

- To evaluate the past and present health state
of case body system.
- To double-check in case any significant data
were omitted in the present illness section and
- To evaluate health information practices.
 Review of System

 The order of the examination of body systems

is roughly head to toe.
 When recording information, avoid writing
“negative” after the system heading.
 You need to record the presence or absence of
all symptoms; otherwise the reader does not
know which factors you asked.
 Review of System cont’d

 Never record some physical finding or

objective data here, ex: “Skin warm ad dry”.
The history should be limited to client
responses or subjective data (factors that the
person says were or were not present.
 Review of System cont’d

 General overall health state- asks about the

person’s present weight, fatigue, weakness,
fever, chills, sweats.
 Skin- records any history of skin disease, color
change, excessive dryness, rash or lesions.
 Head- head ache, head injury
 Eyes- ask about difficulty with vision, eye pain,
diplopia, redness or swelling or discharge. …
 Ears- ask about earaches, infections,
discharge,…
 Nose and sinuses inquire about discharge and
its characteristics, any severe colds, sinus pain,
nose bleeding, allergies…
 Mouth and Throat-ask about mouth pain,
frequent sore throat, bleeding gums,
toothaches, lesion in the mouth….
 Neck -ask about pain, limitation of motion,
lumps or swelling, goiter …
 Breast-ask about pain, lump, nipple,
discharge, self examination….
 Axilla-ask about tenderness lump or swelling
and rash.
 Respiratory system- ask about history of lung
disease (asthma, bronchitis, pneumonia,
tuberculosis), chest pain with breathing,
wheezing.
 Cardiovascular system – ask about dyspnea,
chest pain, hypertension, varicose vein.
 GIT: - ask about appetite, nausea, vomiting,
heart burn, abdominal pain, and hemorrhoid.
 Genito urinary tract: - ask about flank pain,
dysurea, urgency, hematurea, pyurea,
incontinence, menstrual history, STI, and
treatment.
 Musculo skeletal: - ask about muscle or joint
pain, stiffness, arthritis, back ache.
 Neurologic: - ask about fainting, seizure,
weakness, paralysis, numbness or loss of
sensation, involuntary movements (tremors),
poor memory,…..
 Endocrine: - ask about heat or cold
intolerance, excessive sweating, diabetes,
excessive thrust or hunger, polyurea,….
 The Functional Pattern Approach

When you assess your patient / client using

the functional health pattern approach, either
you may take subjective data first and then do
physical examination, or you may take both
subjective and objective data at the same time
for every pattern
 Cont….
1.Date
2.Time- in rapidly changing conditions.
3.Identifications- name, age, sex, address,
religion, ethnicity.
4.Source of referral
5.Source of information
6.Date of admission( if admitted)
 Cont…
7.Medical diagnosis( if established)
8.Condition on admission ( if applicable)
9.Vital signs( optional )
10.Assessment of the eleven functional health
patterns
 The Eleven Functional Health Pattern

1. Health Perception and Management

2. Exercise and Activity
3. Nutrition and Metabolism
4. Elimination
5. Sleep and Rest
6. Self Perception and Concept
7. Roles and Relationships
 Cont…
8. Coping and Stress Tolerance
9. Sexuality and Reproductive Pattern
10. Values and Belief Pattern
11. COGNITION AND PERCEPTION
1. Health Perception – Health Management
Pattern
 It describes client’s perceived pattern of health
and well being and how health is managed.
 Relevance of health for daily activities
 Preventive measures; general health care
behaviors.
 Potential self care problems.
 2. Nutritional – Metabolic Pattern

 It describes pattern of food and fluid

consumption relative to metabolic need and
pattern indicators of restricted nutrient supply.
 Daily eating times
 Recent weight change and reason
 Swallowing, chewing, eating problems, food
allergies,..
 Condition of skin, hair, nails, teeth, etc
 3. Elimination Pattern

 It describes pattern of excretory function

(bowel, bladder).
 Constipation, diarrhoa
 Skin condition- color, temprature, tugor ,
lesions, edema, pruritus.
 4. Activity – Exercise Pattern

 It describes pattern of exercise, activity,

leisure, and recreation.
 Exercise, activity, leisure, and recreation
patterns.
 Limitation in activities of daily living.
 5.Sleep- Rest pattern

 It describes patterns of sleep, rest, and

relaxation.
 Usual sleep habit,
 Perception of quality and quantity of sleep
 6. Cognitive – Perceptual Pattern

 It describes sensory, perceptual, and cognitive

pattern.
 Sensory adequacy- hearing, sight, smell,
touch, taste
 Use of prosthetic devices( glasses, hearing
aids)
 Memory abilities…
 7. Self-perception – Self-concept Pattern

 It describes self-concept and perceptions of

self (body comfory, image, feeling state).
 Self description
 Effects of health on self
 Posture, eye contact, voice and speech
patterns.
 8. Role – Relationship Pattern

 It describes pattern of role engagements and

relationships.
 Life role and responsibilities
 Satisfaction or dissatisfaction in family, work,
and societal relationships.
 9. Sexuality – Reproductive Pattern

 It describes client’s pattern of satisfaction and

dissatisfaction with sexuality pattern, describes
reproductive patterns.
 Adequate of sexual knowledge
 Reproductive state – eg. Pre-menopausal or
post menopausal.
 10. Coping – Stress Tolerance Pattern

 It describes general coping patterns and

effectiveness of the pattern in terms of stress
tolerance.
 General coping strategies
 Support systems
 Ability to manage situations.
 11. Value – Belief Pattern

 It describes pattern of values and beliefs,

including spiritual and /or goals that guide
choices or decisions.
 Spiritual practices
 Value or belief conflict.
 3.The human response patterns

 This approach divides a person’s health status

into nine human response patterns:
 Exchanging, communicating, relating, valuing,
choosing, moving, perceiving, knowing and
feeling .
Drawbacks:-
 Confusing
 Midwifery diagnosis are expressed in terms of
human responses.
THANK YOU !!!