Health, History, Assessment, Interview, Essay

Health History Assessment Interview Instructions

Please use the form produced in the attachment to collect all data on a “patient of 55 years or older” And also use the Health history grading rubric over and over to do the assignment as it is required, and not to miss anything out of it. Then summarize your findings in a narrative form.

“Please use the documentation form already provided in the attachment to collect all data on a “patient of 55 years or older” And also use the Health history grading rubric over and over to do the assignment as it is required, and not to miss anything out of it. Then summarize your findings in a narrative form.”

BOX 2.4 Review of Systems: Health History Assessment Interview Instructions

•General health state. Weight gain or loss, fatigue, weakness, malaise, pain, usual activity, fever, and chills.

•Nutrition and hydration. A history of conditions that increase the risk of malnutrition or obesity. Nausea and vomiting. Normal daily intake, weight and weight change, noting if changes were intentional or not, dehydration, dry skin, fluid excess with shortness of breath, or edema in the feet and legs. Diet practices to promote health.

•Skin, hair, and nails. A history of skin, hair, or nail disease. Rash, itching, pigmentation or texture change, lesions, sweating, dry skin, hair loss or change in texture, brittle or thin nails, and thick or yellow nails.

•Head and neck. A history of high or low thyroid hormone level. Headaches, syncope, dizziness, and sinus pain.

•Eyes. A history of poor vision or vision problems, glaucoma, cataracts. Use of contact lenses or glasses, change in vision, blurring, diplopia, light sensitivity, burning, redness, and discharge. Last eye examination and any changes at that time.

•Ears. A history of ear or hearing problems, hearing loss, and ear infections. Ear pain, change in hearing, tinnitus, and vertigo. Last hearing evaluation and results and ear protection.

•Nose, mouth, and throat. A history of mouth or throat cancer. Colds, sore throat, nasal obstruction, nosebleeds, cold sores, bleeding or swollen gums, tooth pain, tooth extractions, implants, dental caries, ulcers, enlarged tonsils, and dry mouth or lips. Difficulty chewing or swallowing and change in voice. Last dental cleaning and exam, and results.
•Thorax and lungs. A history of emphysema, asthma, or lung cancer. Wheezing, cough, sputum, dyspnea, last chest x-ray and results, and last tuberculin skin test and results.

•Heart and neck vessels. A history of congenital heart problems, myocardial infarction, heart surgery, heart failure, arrhythmia, and murmur. Chest pain or discomfort, palpitations, and exercise tolerance. Any screening tests such as electrocardiogram or stress test, screening for cholesterol, triglycerides, elevated lipids and results for any of these tests.

•Peripheral vascular. A history of high blood pressure, peripheral vascular disease, thrombophlebitis, blood clots, peripheral edema, ulcers, circulation, claudication, redness, pain, and tenderness. Any screening tests such as an ankle–brachial index and results.

•Breasts. A history of breast cancer or cystic breast condition. For adolescents, for males, gynecomastia. Pain, tenderness, discharge, lumps, last mammogram and results, and frequency and date of last self-examination.

•Abdominal-gastrointestinal. A history of colon cancer, gastrointestinal bleeding, cholelithiasis, liver failure, hepatitis, pancreatitis, colitis, ulcer, or gastric reflux. Appetite, nausea, vomiting, and diarrhea. Food intolerance or allergy, constipation, diarrhea, change in stool color, and blood in stool. Last sigmoidoscopy, colonoscopy, and stool for occult blood and results.

•Abdominal-urinary. Renal failure, polycystic kidney disease, urinary tract infection, and nephrolithiasis. Pain, change in urine, dysuria, urgency, frequency, nocturia, and incontinence. For children, toilet training and bed-wetting.

•Musculoskeletal. A history of injury and arthritis. Joint stiffness, pain, swelling, restricted movement, deformity, change in gait or coordination, and strength. Pain, cramps, and weakness. •Neurological. A history of head or brain injury, stroke, and seizures. Tremors, memory loss, numbness or tingling, and loss of sensation or coordination.

•Male genitalia. A history of undescended testicle, hernia, and testicular cancer. Pain, burning, lesions, discharge, and swelling. Change in penis or scrotum, and protection against pregnancy and sexually transmitted infections. Testicular self-examination and frequency.

•Female genitalia. A history of ovarian or uterine cancer, ovarian cyst, endometriosis, number of pregnancies and children. Pain, burning, lesions, discharge, itching, and rash. Menstrual and physical changes, and protection against pregnancy and sexually transmitted infections. Last Pap smear and results.

•Anus, rectum, and prostate. A history of hemorrhoids; prostate cancer; benign prostatic hyperplasia; urinary incontinence, pain, burning, and itching; for men, hesitancy, dribbling, and loss in force of urine stream. Screening prostate-specific antigen test and result.

•Endocrine and hematological system. A history of diabetes mellitus, high or low thyroid levels, and anemia. Polydipsia, polyuria, unexplained weight gain or loss, changes in body hair and body fat distribution, excessive sweating or diaphoresis, intolerance to heat or cold, excessive bruising, and lymph node swelling. Result of last blood glucose test.

Health History Assessment Interview

Nursing 3200 – Health Assessment – Health History Form

Directions: You may use this form while you are interviewing your client to gather data to enter into DocuCare.

Interviewer/Examiner:

Date:

Source of Information: ___________________   Reliability of Source: ___________

Demographic Data	Name: Birth Date: Age Gender: Marital Status Occupation: Race & Ethnicity Primary language: Religion
Admission Assessment	Reason for seeking care (chief complaint)  and effect on current status (use quotes) History of Present Illness with symptom analysis       Family History: List all conditions over 3 generations. Client’s siblings, parents, and grandparents.           Past Health History: Previous Surgical Procedures Past Illnesses Transfusion History Injuries and trauma Obstetric history Screenings (Pap, Tb, etc.) Immunizations: Allergies: Review of Systems: Instructions: Type body system into DocuCare under the Past Medical History tab in the Notes section. Each system should have either the problem listed or “denies….” Health Promotion should be included. See box 2.4 pg 34 in text or key below Ex: Skin: c/o dry, itchy skin on arms. Denies psoriasis, hives, lesions, hx skin cancer, easy bruising, hair loss, changes in nails.  HP: Uses suntan lotion when in sun and reapplies frequently. Has consulted with dermatologist related to skin assessment. Does self skin assessment. Social History: Home situation Education Nicotine Use Alcohol Use Violence Screening Nutritional Screening Diet Assessment Exercise Screening Mental Health Screening Mood and behavior Sexual Activity Safety Measures Communication: Speech Assessment
Activities of Daily Living (ADL)	ADL Assessment See Box 2.3 p 33 of text
	Eating, bathing, dressing, Toileting, mobility
	Home maintenance
	Finances
Medication History	All medications, including OTC.. Must include reason for taking in Notes section
Nursing Dx	Use the CREATE YOUR OWN CARE DIAGNOSIS/CARE PLAN Include 2 Nursing dx. One should be a wellness dx.   One Expected Outcome for each diagnosis. Make them SMART (specific, measureable, achievable, relevant, time-bound)
Document if present or denies if not; include health promotion activities. Describe   General Overall Health State: Weight gain or loss; fatigue, malaise, pain, usual activity level, fever, chills.   Health Promotion:  Last physical exam (date/results)   Skin, hair, nails: History of skin, hair or nail disease (eczema, psoriasis, hives) pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion. Hair loss. Change in nail texture, color, or thickness.   Health Promotion: Amount of sun exposure, products used/method of care for skin and hair.     Head and neck: Any unusually frequent or severe headache, any head injury, dizziness (syncope) or vertigo. Hx of high or low thyroid. Neck pain.   Health Promotion: Helmet use, frequent blows to head, seatbelt use Eyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts.   Health Promotion: Wears glasses or contacts; last vision check or glaucoma test; how coping with loss of vision if any.   Ears Earaches: infections, discharge and its characteristics, tinnitus or vertigo.   Health Promotion: Hearing loss, hearing aid use, how loss affects the daily life, any exposure to environmental noise, method of cleaning ears.   Nose and Sinuses: Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smell.   Mouth and Throat: Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue. dysphagia. Hoarseness or voice change, tonsillectomy altered taste.   Health Promotion: Pattern of daily dental care, use of prostheses (dentures, bridge) and last dental checkup.   Breast and Axilla: Tenderness, lump or swelling, rash. Health Promotion: Performs breast & axilla self-examination, including its frequency and method used, last mammogram and results.   Respiratory: History of lung disease (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color. amount). hemoptysis. toxin or pollution exposure. Health Promotion: Last chest x-ray, smoking   Cardiovascular: Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion it takes to produce dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hyper­tension, coronary artery disease, anemia.  Health Promotion. Date of last ECG or other heart tests and results.   Peripheral Vascular: Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications, inter­mittent claudication, thrombophlebitis, ulcers.  Health Promotion. Does work involve long-term sitting or standing, avoid cross­ing legs at the knees, wear support hose.   Gastrointestinal: Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating). other abdominal pain, pyrosis (esophageal and stom­ach burning sensation with sour eructation), nausea and vomiting (character), vom­iting blood, history of abdominal disease (ulcer, liver or gallbladder, jaundice, ap­pendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions, hemorrhoids, fistula). Health Promotion. Use of antacids or laxatives.   Urinary System: Frequency, urgency, nocturia (the number of times the person awakens at night to urinate, recent change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color (cloudy or presence of hematuria), in­continence, history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate problems), pain in flank, groin, suprapubic region, or low back. Health Promotion. Measures to avoid or treat urinary tract infections, use of Kegel exercises after childbirth.   Male Genital System. Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia.  Health Promotion. Perform penile & testicular self-examination? frequency?   Female Genital System. Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding. Health Promotion:  Last gynecologic checkup, last Pap smear and results.   Sexual Health: Presently in a relationship involving intercourse? Aspects of sex satisfactory to you and partner, any dyspareunia (female), any changes in erection or ejaculation ( male), use of contraceptives method satisfactory?  Use of condoms/frequency. Aware of any contact with partner who has sexually transmitted disease (gonorrhea, chlamydia, HSV1 or 2, HPV, HIV/AIDS, syphilis).  Health Promotion:  genitalia self-examination, STI screening   Musculoskeletal System: History of arthritis or gout. In the joints: pain, stiffness, swelling (location, migratory nature), deformity, limitation or motion, noise with joint motion. In the muscles: any pain, cramps, weakness, gait problems or problems with coordinated activities. In the back: any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disc disease. Health Promotion:  How much walking /other exercise per day. Effect of limited range of motion on daily activities, such as on grooming, feeding, toileting. Dressing. Any mobility aids used.   Neurologic System: History of seizure disorder, stroke, fainting, black outs. In motor function: weakness, tic or tremor, paralysis, or coordination problems. In sensory function: numbness and tingling (paresthesia). cognitive function: memory disorder (recent or distant, disorientation). In mental status: any nervousness. Mood change. Depression, anxiety or any history of mental health dysfunction or hallucinations.   Hematological System: Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.   Endocrine System: History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia). History of thyroid disease, intolerance to beat or cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, and need for hormone therapy.

Developed G. Avery 1994, Revised 5/14/2003, S.Croft; 8/09 cim; 8/10 gn;  revised 8/17 ek

 

School of Nursing

NURS320- Health Assessment

Health History Grading Rubric

Criteria	Points  Possible	Points Earned	Comments
Demographics: ·         Clinical descriptor (initials) ·         Age ·         Gender ·         Race ·         Height/weight ·         Marital status ·         Religion ·         Advance directive ·         Isolation precaution ·         Primary admitting dx ·         Allergies with reaction	5
History of chief present concern (how does their current health status affect their outlook on life and quality of life)	10
Family history (3 generations)	10
Past Medical Hx ·         Previous surgical procedures ·         General medical history ·         Transfusion hx ·         Pain hx ·         Screenings ·         Immunizations	15
Review of Systems ·         Documentation of positive signs/symptoms ·         Description of positive symptoms ·         Health promotion behaviors addressed	15
Social history ·         Home situation ·         Education ·         Nicotine use ·         Alcohol use ·         Drug use ·         Violence screening ·         Nutritional screening ·         Exercise screening ·         Mental health screening ·         Sexual activity ·         Safety measure	10
Activities of daily living ·         ADL assessment ·         Mood behavior ·         Diet assessment ·         Diet consumption ·         Speech assessment ·         Communication	10
MAR: Home medication history (include dosage, generic name, and reason for taking)	10
Nursing dx (2) One must be wellness diagnosis   Two goals (one for each nursing diagnosis). No interventions needed.	10
Summary: Summarize your findings in a narrative form. Document under Notes tab	5
Total points:	100

Gn 8/20/11, rev 8/11, rev1/15jgr; rev8/15jgr; rv 1/20dn