Health Assessment - Lecture

Module #2 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Lesson title: STEPS OF HEALTH ASSESSMENT Materials:

Electronic gadget, pen, & notebook
Learning Targets:
At the end of the module, students will be able to: References:
1. Learn about the phases of the interview and the description
of each phase; Hogan-Quigley, B., Palm, M. L., & Bickley, L.
2. Explain the four types of histories and when they are used; (2012). Bates’ nursing guide to physical
3. Describe the components of a comprehensive health examination and history taking (2nd ed.)
history; and, Philadelphia, PA: Lippincott Williams &
4. Obtain a comprehensive health history from a patient. Wilkins.

A. LESSON PREVIEW/REVIEW

Let us have a quick review of what you have learned from the previous session. Kindly answer the posted question on the
space provided. You may use the back page of this sheet, if necessary. Here is the question:

As a nursing student, describe the significance of health assessment in provide care to patients.

B. MAIN 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

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 Health Assessment - Lecture
Module #2 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

● 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

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

This document is the property of PHINMA EDUCATION

 Health Assessment - Lecture
Module #2 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

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

Key Elements of the Past History:

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, 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, 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 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 meningitides meningitis, 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?

This document is the property of PHINMA EDUCATION

 Health Assessment - Lecture
Module #2 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Family history outlines or diagrams 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 provide a guide for gathering personal/social history from the patient and daily living routines that may
influence health and illness.

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?”

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

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

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

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

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

This document is the property of PHINMA EDUCATION

 Health Assessment - Lecture
Module #2 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

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 c. Working
b. Introduction d. Termination
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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

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

a. Dizziness c. Skin warm to touch
b. Headache d. Itchiness
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. Which of the following component of the adult health history lists childhood illnesses?
a. Family history c. History of present illness
b. Past history d. Review of systems
Answer: ________
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
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

 Health Assessment - Lecture
Module #2 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

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
Answer: ________
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
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

C. LESSON WRAP-UP

Thinking about Learning

CAT 3-2-1

This strategy provides a structure for you to record your own comprehension and summarize your learning. Let us see
your progress in this chapter!

Three things you learned:

1. _______________________________________________________________________________________

2. _______________________________________________________________________________________

3. _______________________________________________________________________________________

Two things that you’d like to learn more about:

1. __________________________________________________________________________________________

2. __________________________________________________________________________________________

One question you still have:

1. __________________________________________________________________________________________

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