NALAPO, AIJEELENE D.

20181384
BSN 3- 1V
October 2, 2020

Describe the step by step ways on how the Nurse should obtain the Health History of the
Patient.

HEALTH HISTORY: allows to obtain relevant information about the health status of the
patient

CHIEF COMPLAINT OR PROBLEM: the reason that prompted the patient to seek
consultation.

It is important to concentrate on symptoms and

not on diagnosis to ensure that no information is
missed.
It is important to concentrate on symptoms and
not on diagnosis to ensure that no information is
missed.
t is important to concentrate on symptoms and
not on diagnosis to ensure that no information is
missed
 It’s important to concentrate on symptoms and not on diagnosis to ensure that no
information is missed.

It involves collecting 

 subjective data- information from the client's point of view (“symptoms”), including

feelings, perceptions, and concerns obtained through interviews
 Each symptom should be explored in more detail for clarification because this
helps to construct a more accurate description of the patient’s problems.
o Onset
o Duration
o Site and radiation
o Aggravating and relieving features
o Associated symptoms
o Fluctuating
o Frequency
 objective data- obtained through observation, physical examination, and laboratory
and diagnostic testing.

A variety of other important information is also collected during the interview;

 a person's health-related values

 beliefs and attitudes
 current health-related practices
 the socioeconomic
 cultural
 factors impacting on their health
  willingness and capacity to make health-related changes

HEALTH HISTORIES

 It is important for nurses to note that there are a number of different types of health
histories which may be collected from a patient:

 Comprehensive health history. This collects detailed information about a patient

 biographical data
 present health status
 past medical history- assess childhood and adult illnesses, hospitalizations, accidents, and
injuries.
It is important to capture the following information when taking a past medical
history:
 Diagnosis
 Dates
 Sequence
 Management
 family history
 medication history- it is crucially important and should consider not only what medication
the patient is currently taking but also he/she might have been taking until recently and also
the allergies
 personal situation
 review of all body systems

 Rapid or focused health history. This collects specific information about a clear
health-related issue or need with which a patient presents. The overview of the
patient’s symptoms as of the moment.