23.1 Health History Introduction
Open Resources for Nursing (Open RN)
Learning Objectives
- Establish a therapeutic nurse-patient relationship
- Use effective verbal and nonverbal communication techniques
- Collect health history data
- Modify assessment techniques to reflect variations across the life span and cultural variations
- Document actions and observations
- Recognize and report significant deviations from norms
“‘Sickness’ is what is happening to the patient. Listen to them.”[1]
The profession of nursing is defined by the American Nurses Association as “the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.[2] Simply put, nurses treat human responses to health problems and/or life processes. Nurses look at each person holistically, including emotional, spiritual, psychosocial, and physical health needs. They also consider problems and issues that the person experiences as a part of a family and a community. To collect detailed information about a patient’s human response to illness and life processes, nurses perform a health history. A health history is part of the Assessment phase of the nursing process. It consists of using directed, focused interview questions and open-ended questions to obtain symptoms and perceptions from the patient about their illnesses, functioning, and life processes. While obtaining a health history, the nurse is also simultaneously performing a general survey. Visit the “General Survey Assessment” chapter for more information.
Answer Key to Chapter 2 Learning Activities
1. Select the assessment findings requiring immediate follow-up by the nurse.
| Vital Signs | |
|---|---|
| Temperature | 98.9 °F (37.2°C) |
| Heart Rate | *182 beats/min* |
| Respirations | *36 breaths/min* |
| Blood Pressure | 152/90 mm Hg |
| Oxygen Saturation | *88% on room air* |
| Capillary Refill Time | *>3* |
| Pain | 9/10 chest discomfort |
| Physical Assessment Findings | |
| Glasgow Coma Scale Score | 14 |
|---|---|
| Level of Consciousness | Alert |
| Heart Sounds | *Irregularly regular* |
| Lungs Sounds | Clear bilaterally anterior/posterior |
| Pulses-Radial | *Rapid/bounding* |
| Pulses-Pedal | *Weak* |
| Bowel Sounds | Present and active x 4 |
| Edema | Trace bilateral lower extremities |
| Skin | Cool, clammy |
2. Indicate whether the actions are “Indicated” (i.e., appropriate or necessary), “Contraindicated” (i.e., could be harmful), or “Nonessential” (i.e., makes no difference or are not necessary).
| Nursing Action | Indicated | Contraindicated | Nonessential |
|---|---|---|---|
| Apply oxygen at 2 liters per nasal cannula. | X | ||
| Call imagining for a STAT lung CT. | X | ||
| Perform the National Institutes of Health (NIH) Stroke Scale Neurologic Exam. | X | ||
| Obtain a comprehensive metabolic panel (CMP). | X | ||
| Obtain a STAT EKG. | X | ||
| Raise head-of-bed to less than 10 degrees. | X | ||
| Establish patent IV access. | X | ||
| Administer potassium 20 mEq IV push STAT. | X |
Answers to interactive elements are given within the interactive element.
Infection confined to a small area of the body, typically near the portal of entry, and usually presents with signs of redness, warmth, swelling, warmth, and pain.
