Welcome to part two of the series on how to do a super-duper-awesome-sauce head to toe nursing assessment. If you missed part one about how to rock the general survey, you can find it here.
Don’t forget to download your FREE general survey checklist that goes along with that post. You know how your mind goes blank right when you walk into a patient’s room? Don’t worry, I’ve got your back. Just follow this printable checklist so you can assess with confidence.
The second part of the nursing assessment is the health history. The health history is a series of questions that the nurse asks in order to make the assessment and plan of care as specific to the patient as possible.
The health history includes 4 main parts:
1. Demographic and biographic information
2. Presenting problem/chief complaint
3. Medical, psychiatric, family history
4. Activities of daily living (ADLs)
Keep in mind that some of these questions may be uncomfortable for patients to answer. Do your best to create a comfortable and safe environment for every patient and use your fabulous therapeutic communication skills to help them through this process.
And remember that it is not a reflection on you if they decline to answer specific questions. Just move on to the next question.
You always begin the health history with demographic and biographical information. This includes:
2. Birth date
3. Relationship status
4. Contact information
5. Legal forms (advanced directive and a living will)
Always be sure to get a contact phone number of a spouse, relative or trusted friend in case there is an emergency.
Next, you need to ask about their chief complaint. Keep the these questions in mind:
1. What brought them into your facility?
2. When did their condition start?
3. Has it happened before?
4. What was the situation around the onset of their condition?
5. Is there anything they have found that helps to improve it?
6. Is there anything that makes it worse?
7. Have they taken any medications for this condition?
8. What medications are they currently taking? Make sure to include the name of the drug, the dose, when they usually take it, what route they take it, and when the last dose was taken.
The medical, psychiatric, and family history is usually the longest section of your health history assessment. Make sure to address the following:
2. Past surgeries and hospitalizations
3. Immunization status
4. Health complaints that may or may not be connected to their chief complaint
5. Treatments and medications used in the past
6. Past or present drug use (cigarette, alcohol, illicit drugs)
7. Reproductive and ovulation history (females)
8. Psychosocial or psychiatric concerns
9. Safety concerns
10. Coping mechanisms.
11. Close relative health and psychiatric status
12. Close relative ages of death and cause of death
It is also important to ask about their ADL’s. Ask questions about their:
1. Eating habits
2. Sleeping habits
4. Work status
5. Use of assistive devices
6. The layout of their house (especially addressing stairs or steps if they have decreased mobility and distance to the bathroom and kitchen if they need to be on oxygen or other devices)
7. Spiritual practices
Obviously, there are a lot of questions that need to be asked through this process. To make it more efficient and complete, most facilities provide a health history form with all of the questions they require you to ask. So you don’t need to worry about memorizing every single question.
Always refer to your facility policies and checklist to make sure that you have asked all of the required questions.
The more health histories you take and assessments you do, the less you will need to refer to a checklist. Even though right now you feel like you may never reach that point, you absolutely will. Trust me, we’ve all been there. You’re going to be a pro in no time!
Comment below and let me know how these steps helped you at clinical. And be sure to check out next weeks blog post where we begin the physical assessment process.
Comerford, K. C., & Hodgson, B. E. (2013). Assessment made incredibly easy. Ambler, PA: Lippincott Williams & Wilkins.