Health Assessment (Lecture)

STUDENT ACTIVITY SHEET

BS NURSING / FIRST YEAR
Session # 2

Materials:
LESSON TITLE: Steps of Health Assessment Book, pen and notebook, index card/class list
LEARNING OUTCOMES:
Upon completion of this lesson, the nursing student can:

1. Learn about the phases of the interview and the

description of each phase; References: Bates’ Nursing Guide to Physical
2. Explain the four types of histories and when they are used; Examination and History Taking (Second Edition)
3. Describe the components of a comprehensive health by Beth Hogan-Quigley, Mary Louise Palm, and
history; Lynn Bickley.
4. Obtain a comprehensive health history from a patient.

MAIN LESSON (60 minutes)

The students will study and read Chapter 3 of their book about this lesson:

Interviewing and Communication

Health History Interview
- a conversation with a purpose within three folds using health history format:
• 1. establish a trusting and supportive relationship
• 2. gather information
• 3. Offer information
Health History Format
• - is a structured framework for organizing patient information in written, electronic, and verbal form to
communicate effectively with other health care providers.
• - patient’s information is concisely organized into three categories:
 past
 present
 family history
Phases of Interview
1. Pre-interview: set the stage for a smooth interview
● Self-Reflection
Self-reflection is a continual part of professional development in clinical work. It brings a deepening
personal awareness to our work with patients, which is one of the most rewarding aspects of patient care.
● Review patient record
● Set interview goals
● Review own clinical behavior and appearance

2. Introduction: put the patient at ease and establish trust

● Greet the patient and establish rapport
● Establish the agenda for the interview

3. Working: obtain patient information

● Invite the patient’s story
● Identify and respond to emotional clues
● Expand and clarify the patient’s story
● Generate and test diagnostic hypotheses
● Negotiate a plan, including further evaluation, treatment, education and self-management support and
prevention

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 THE SEVEN ATTRIBUTES OF A SYMPTOM
1. Onset. When did (does) it start? Setting in which it occurs, including environmental factors, personal activities,
emotional reactions, or other circumstances that may have contributed to the illness.
2. Location. Where is it? Does it radiate?
3. Duration. How long does it last?
4. Characteristic Symptoms. What is it like? How severe is it? (For pain, ask a rating on a scale of 1 to 10.)
5. Associated Manifestations. Have you noticed anything else that accompanies it?
6. Relieving/Exacerbating Factors. Is there anything that makes it better or worse? 7. Treatment. What have you
done to treat this? Was it effective?
• EXPLORE THE PATIENT ’S PERSPECTIVE (FIFE)
● The patient’s Feelings, including fears or concerns, about the problem
● The patient’s Ideas about the nature and the cause of the problem
● The effect of the problem on the patient’s life and Function
● The patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal or
family experiences

4. Termination:
● Summarize important points
● Discuss plan of care
“So, you will take the medicine as we discussed, check your blood glucose daily, and make a follow-up
appointment for 4 weeks. Do you have any questions about this?” Address any related concerns or questions that
the patient raises.

Types of data:

 Subjective data are information from the client's point of view (“symptoms”), including feelings, perceptions, and
concerns obtained through interviews.

 Objective data are observable and measurable data (“signs”) obtained through observation, physical
examination, and laboratory and diagnostic testing.

History of Present Illness (HPI). This section of the history is a complete, clear, and chronologic account of the
problems prompting the patient to seek care. The narrative should include the onset of the problem, the setting in which it
has developed, its manifestations, and any treatments. The HPI should reveal the patient’s responses to the symptoms
and the effect the illness has had on daily living.

Key Elements of the History of Present Illness:

 Seven attributes of each principal symptom
 Self-treatment for the symptom by the patient or family
 Past occurrences of the symptom(s)
 Pertinent positives and/or negatives from the review of systems
 Risk factors or other pertinent information related to the symptom

Seven Attributes of a Symptom

OLD CART, or Onset, Location, Duration, Characteristic Symptoms, Associated Manifestations,

Relieving/Exacerbating Factors, and Treatment

1. Onset. When did (does) it start? Setting in which it occurs, including environmental factors, personal activities,
emotional reactions, or other circumstances that may have contributed to the illness.
2. Location. Where is it? Does it radiate?
3. Duration. How long does it last?
4. Characteristic Symptoms. What is it like? How severe is it? (For pain, ask a rating on a scale of 1 to 10.)
5. Associated Manifestations. Have you noticed anything else that accompanies it?
6. Relieving/Exacerbating Factors. Is there anything that makes it better or worse?

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 7. Treatment. What have you done to treat this? Was it effective?

Key Elements of the Past History:

Allergies. Allergies, including specific reactions to each medication, such as rash or nausea, must be recorded. Allergies
to foods, insects, or environmental factors along with the patient’s reaction should also be noted.

Medications. Medications, including name, dose/route, and frequency of use, are included. Also list home remedies,
nonprescription drugs, vitamins, mineral or herbal supplements, oral contraceptives, and medicines borrowed from family
members or friends. If the patient is unsure, ask him or her to bring in all medications to see exactly what is taken.

Childhood illnesses. Childhood illnesses, such as measles, rubella, mumps, whooping cough, chickenpox, rheumatic
fever, scarlet fever, and polio, are included in the Past History. Also included are any chronic childhood illnesses, such as
asthma.

Adult Illnesses. Adult Illnesses in each of the following areas:

● Medical: Illnesses such as diabetes, hypertension, hepatitis, asthma, or HIV; hospitalizations
● Surgical: Dates, reasons for surgery, and types of operations or treatments
● Accidents: type, dates, treatment and residual disability of major accidents
● Psychiatric: Illness and time frame, hospitalizations, and treatments

Health Maintenance
● Immunizations: Ask whether the patient has received vaccines for tetanus, pertussis, diphtheria, polio, measles,
mumps influenza, varicella,hepatitis B, Haemophilus influenzae type B, Neisseria meningitidesmeningitis, and
pneumococci. Include the dates of original and booster immunizations.
● Screening Tests: Such as tuberculin tests, cholesterol tests, stool for occult blood, Pap smears, and mammograms.
Include the results and the dates the tests were performed. Alternatively, screening tests maybe asked about during and
documented in the Review of Systems.
● Safety Measures: Seat belts in cars, smoke/carbon monoxide detectors, sports helmets or padding, etc.
● Risk Factors:
Tobacco: Do you use or have you ever used tobacco? At what age did you start? How many packs per
day (ppd) do you smoke? How many ppd in the past?
Environmental Hazards: In home or work environment?
Substance Abuse: Do you use or have you ever used marijuana, cocaine, heroin, or other recreational
drugs?
Alcohol: How much alcohol do you drink per sitting and per week?

Family History. Under Family History, outline or diagram on a genogram the age and health, or age and cause of death,
of each immediate relative, including parents, grandparents, siblings, children, and grandchildren.

Review of Systems. Understanding and using Review of Systems questions are often challenging for beginning
students. Think about asking a series of questions going from “head to toe.” It is helpful to prepare the patient for the
questions to come by saying, “The next part of the history may feel like a hundred questions, but they are important and I
want to be thorough.” Most Review of Systems questions pertain to symptoms, but on occasion some nurses also include
diseases like pneumonia or tuberculosis.

Health Patterns. The Health Patterns section provides a guide for gathering personal/social history from the patient and
daily living routines that may influence health and illness.

The Mental Health History. Cultural constructs of mental and physical illness vary widely, causing marked differences in
acceptance and attitudes. Think how easy it is for patients to talk about diabetes and taking insulin compared with
discussing schizophrenia and using psychotropic medications. Ask open-ended questions initially. “Have you ever had
any problem with emotional or mental illnesses?” Then move to more specific questions such as “Have you ever visited a
counselor or psychotherapist?” “Have you ever been prescribed medication for emotional issues?” “Have you or has
anyone in your family ever been hospitalized for an emotional or mental health problem?”

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 CHECK FOR UNDERSTANDING (10 minutes)
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 25 minutes for this activity:

Multiple Choice

1. The primary goal in the introduction phase of the interview is for the nurse to
a. Obtain subjective data
b. Make the patient comfortable
c. Greet the patient
d. Establish rapport

RATIONALE:

2. Which of the following is an example of a subjective data?

a. Cyanosis
b. A blood pressure of 140/90 mmHg
c. Blurred vision
d. Heart rate of 89 beats per minute

RATIONALE:

3. This outlines or diagrams age and health, or age and cause of death, of siblings, parents, grandparents
a. History of present illness
b. Past history
c. Family history
d. Health patterns

RATIONALE:

4. This phase of the interview is where the nurse invites the patient’s story, identify and respond to emotional cues,
and expand and clarify the patient’s story
a. Pre-interview
b. Introduction
c. Working
d. Termination

RATIONALE:

5. The primary source of health history would be from which of the following?
a. Parents
b. Patient
c. Spouse
d. Siblings

RATIONALE:

6. Which of the following is an example of an objective information?

a. Dizziness
b. Headache
c. Skin warm to touch
d. Itchiness

RATIONALE:

7. Which of the following component of the adult health history lists childhood illnesses?
a. Family history
b. Past history
c. History of present illness

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 d. Review of systems

RATIONALE:

8. This is a component of the adult health history that documents personal/social history
a. Health patterns
b. Chief complaint(s)
c. Identifying data
d. History of present illness

RATIONALE:

9. Which of the following is NOT an identifying data in the adult health history?
a. Age
b. Date of birth
c. Gender
d. Immunization status

RATIONALE:

10. This helps amplify the patient’s chief complaint and describes how each symptom developed
a. Identifying data
b. History of present illness
c. Health patterns
d. Past history

RATIONALE:

LESSON WRAP-UP (10 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: Turn and talk

(Students turn to talk partner/s to – find out, summarize, clarify, share ideas, point of view or opinions)

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