Health History

Full Answer Section

     

• Exercise: Exercises regularly
• Diet: Eats a healthy diet
• Sleep: Gets 7-8 hours of sleep per night
• Stress level: Manages stress well

Past Medical History

• Childhood illnesses: Chickenpox, measles, mumps, rubella
• Adult illnesses: None
• Hospitalizations: None
• Surgeries: None
• Accidents or injuries: None
• Medications: None
• Allergies: No known allergies
• Immunizations: Up to date

Family History

• Father: Died of heart attack at age 65
• Mother: Alive and well
• Siblings: One brother, alive and well
• Children: None

Review of Systems

• General: No complaints
• Skin, hair, and nails: No complaints
• Head, eyes, ears, nose, and throat: No complaints
• Cardiovascular: No complaints
• Respiratory: No complaints
• Gastrointestinal: No complaints
• Genitourinary: No complaints
• Musculoskeletal: No complaints
• Neurological: No complaints
• Hematologic: No complaints
• Endocrine: No complaints
• Psychiatric: No complaints

Interviewing Techniques

• Open-ended questions: Used to encourage the interviewee to share information.
• Closed-ended questions: Used to gather specific information.
• Active listening: Paying attention to what the interviewee is saying and asking clarifying questions.
• Reflection: Repeating back what the interviewee has said to ensure understanding.
• Summarization: Summarizing the key points of the interview.

Challenges

• The interviewee was initially hesitant to share information about their family history. I encouraged them to share by explaining the importance of family history in understanding their own health risks.
• The interviewee became emotional when discussing a past illness. I gave them time to collect themselves and offered support.

Comfort Level I was initially nervous about taking a health history. However, I found that the interviewing techniques I learned in Module 2 were helpful in putting the interviewee at ease and gathering the information I needed. How This Information Can Assist the Nurse in Determining the Health Status of a Client The information gathered in a health history can help the nurse to:

• Identify potential health risks
• Develop a plan of care
• Provide education and counseling
• Evaluate the effectiveness of interventions

For example, the information gathered in this health history suggests that the interviewee is at increased risk for heart disease due to their family history. The nurse can use this information to educate the interviewee about lifestyle changes that can reduce their risk of heart disease. The nurse can also refer the interviewee to a healthcare provider for further evaluation. In conclusion, taking a health history is an important part of the nursing process. The information gathered in a health history can help the nurse to provide comprehensive and individualized care.  

Sample Solution

   

Summary of Health History

Present Health

• Chief complaint: None
• Current medications: None
• Allergies: No known allergies
• Immunizations: Up to date
• Surgeries: None
• Accidents or injuries: None
• Tobacco use: Never smoked
• Alcohol use: Drinks socially on occasion
• Drug use: None