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Chapter: Medical Surgical Nursing: Health Assessment

The Health History - Assessment

The Informant - Cultural Considerations - Content of the Health History - Past Life Events Related to Health - Education and Occupation - Environment - Lifestyle - Physical or Mental Disability - Self-Concept - Sexuality - Risk for Abuse - Stress and Coping Responses - Other Health History Formats -

The Health History


Throughout assessment, and particularly when obtaining the his-tory, attention is focused on the impact of psychosocial, ethnic, and cultural background on the person’s health, illness, and health-promotion behaviors. The interpersonal and physical en-vironments, as well as the person’s lifestyle and activities of daily living, are explored in depth. Many nurses are responsible for ob-taining a detailed history of the person’s current health problems, past medical history, family history, and a review of the person’s functional status. This results in a total health profile that focuses on health as well as illness and is more appropriately called a health history rather than a medical or a nursing history.


The format of the health history traditionally combines the medical history and the nursing assessment, although formats based on nursing frameworks, such as functional health patterns, have also become a standard. Both the review of systems and pa-tient profile are expanded to include individual and family rela-tionships, lifestyle patterns, health practices, and coping strategies. These components of the health history are the basis of nursing as-sessment and can be easily adapted to address the needs of any pa-tient population in any setting, institution, or agency.


Combining the information obtained by the physician and the nurse in one health history prevents duplication of informa-tion and minimizes efforts on the part of the person to providethis information. This also encourages collaboration among members of the health care team who share in the collection and interpretation of the data (Butler, 1999).




The informant, or the person providing the health history, may not always be the patient, as in the case of a developmentally de-layed, mentally impaired, disoriented, confused, unconscious, or comatose patient. The interviewer assesses the reliability of the informant and the usefulness of the information provided. For example, a disoriented patient is often unable to provide a reli-able database; people who abuse drugs and alcohol often deny using these substances. The interviewer must make a judgment about the reliability of the information (based on the context of the entire interview), and he or she includes this evaluation in the record.




When obtaining the health history, the interviewer takes into ac-count the person’s cultural background (Weber & Kelley, 2003). Cultural attitudes and beliefs about health, illness, health care, hospitalization, the use of medications, and the use of comple-mentary therapies are derived from each person’s experiences. They vary according to the person’s ethnic and cultural back-ground. A person from another culture may have a different view of personal health practices than the health care practitioner.


Similarly, people from some ethnic and cultural backgrounds will not complain of pain, even when it is severe, because outward expressions of pain are considered unacceptable. In some in-stances they may refuse to take analgesics. Other cultures have their own folklore and beliefs about the treatment of illnesses. All such differences in outlook must be taken into account and ac-cepted when caring for members of other cultures. Attitudes and beliefs about family relationships and the role of women and el-derly members of a family must be respected even if those atti-tudes and beliefs conflict with those of the interviewer.




When the patient is seen for the first time by a member of the health care team, the first requirement is a database (except in emergency situations). The sequence and format of obtaining data about the patient vary, but the content, regardless of format, usually addresses the same general topics. A traditional approach includes the following:


•     Biographical data


•     Chief complaint


•     Present health concern (or present illness)


•     Past history


•     Family history


•     Review of systems


•     Patient profile


Biographical Data


Biographical information puts the patient’s health history in con-text. This information includes the person’s name, address, age, gender, marital status, occupation, and ethnic origins. Some in-terviewers prefer to ask more personal questions at this part of the interview, while others wait until more trust and confidence have been established or until the patient’s immediate or urgent needs are first addressed. The patient in severe pain or with another ur-gent problem is unlikely to have a great deal of patience for an in-terviewer who is more concerned about marital or occupational status than with quickly addressing the problem at hand.

Chief Complaint

The chief complaint is the issue that brings the person to the at-tention of the health care provider. Questions such as, “Why have you come to the health center today?” or “Why were you admit-ted to the hospital?” usually elicit the chief complaint. In the home setting, the initial question might be, “What is bothering you most today?” When a problem is identified, the person’s exact words are usually recorded in quotation marks (Orient, 2000). However, a statement such as, “My doctor sent me” should be followed up with a question that identifies the probable reason why the person is seeking health care; this reason is then identified as the chief complaint.

Present Health Concern or Illness

The history of the present health concern or illness is the single most important factor in helping the health care team to arrive at a diagnosis or determine the person’s needs. The physical exami-nation is helpful but often only validates the information obtained from the history. A careful history assists in correct selection of ap-propriate diagnostic tests. While diagnostic test results can be helpful, they often support rather than establish the diagnosis.


If the present illness is only one episode in a series of episodes, the entire sequence of events is recorded. For example, a history from a patient whose chief complaint is an episode of insulin shock describes the entire course of the diabetes to put the cur-rent episode in context. The details of the health concern or pres-ent illness are described from onset until the time of contact with the health care team. These facts are recorded in chronological order, beginning with, for example, “The patient was in good health until . . .” or “The patient first experienced abdominal pain 2 months prior to seeking help.”


The history of the present illness or problem includes such in-formation as the date and manner (sudden or gradual) in which the problem occurred, the setting in which the problem occurred (at home, at work, after an argument, after exercise), manifesta-tions of the problem, and the course of the illness or problem. This includes self-treatment (including complementary therapies), medical interventions, progress and effects of treatment, and the patient’s perceptions of the cause or meaning of the problem.


Specific symptoms (pain, headache, fever, change in bowel habits) are described in detail, along with the location and radia-tion (if pain), quality, severity, and duration. The interviewer also asks if the problem is persistent or intermittent, what factors ag-gravate or alleviate it, and if any associated manifestations exist.


Associated manifestations are symptoms that occur simultane-ously with the chief complaint. The presence or absence of such symptoms may shed light on the origin or extent of the problem, as well as on the diagnosis. These symptoms are referred to as sig-nificant positive or negative findings and are obtained from a re-view of systems directly related to the chief complaint. For example, if the person reports a vague symptom such as fatigue or weight loss, all body systems are reviewed and included in this sec-tion of the history. If, on the other hand, the person’s chief com-plaint is chest pain, only the cardiopulmonary and gastrointestinal systems may be included in the history of the present illness. In either situation, both positive and negative findings are recorded to define the problem further.

Past Health History


A detailed summary of the person’s past health is an important part of the database. After determining the general health status, the interviewer may inquire about immunization status and any known allergies to medications or other substances. The dates of immunization are recorded, along with the type of allergy and ad-verse reactions. The person is asked to provide information, if known, about his or her last physical examination, chest x-ray, electrocardiogram, eye examination, hearing tests, dental checkup, as well as Papanicolaou (Pap) smear and mammogram (if female), digital rectal examination of the prostate gland (if male), and any other pertinent tests. Previous illnesses are then discussed. Nega-tive as well as positive responses to a list of specific diseases are recorded. Dates, or the age of the patient at the time of illness, as well as the names of the primary health care provider and hospi-tal, the diagnosis, and the treatment are also recorded. A history of the following areas is elicited:


·        Childhood illness—rubeola, rubella, polio, whooping cough, mumps, chickenpox, scarlet fever, rheumatic fever, strep throat


·        Adult illnesses


·         Psychiatric illnesses


·         Injuries—burns, fractures, head injuries


·         Hospitalizations


·         Surgical and diagnostic procedures


·        Current medications—prescription, over-the-counter, home remedies, complementary therapies


·        Use of alcohol and other drugs


If a particular hospitalization or major medical intervention is related to the present illness, the account of it is not repeated; rather, the report refers to the appropriate part of the report, such as “see history of present illness” or “see HPI” on the data sheet.


Family History


The age and health status, or the age and cause of death, of first-order relatives (parents, siblings, spouse, children) and second-order relatives (grandparents, cousins) are elicited to identify diseases that may be genetic in origin, communicable, or possi-bly environmental in cause. The following diseases are generally included: cancer, hypertension, heart disease, diabetes, epilepsy, mental illness, tuberculosis, kidney disease, arthritis, allergies, asthma, alcoholism, and obesity. One of the easiest methods of recording such data is by using the family tree or genogram (Fig. 5-2). The results of genetic testing or screening, if known, are recorded.


Review of Systems


The systems review includes an overview of general health as well as symptoms related to each body system. Questions are asked about each of the major body systems in terms of past or present symptoms. Reviewing each body system helps reveal any relevant data. Negative as well as positive answers are recorded. If the pa-tient responds positively to questions about a particular system, the information is analyzed carefully. If any illnesses were previ-ously mentioned or recorded, it is not necessary to repeat them in this part of the history. Instead, reference is made to the appro-priate place in the history where the information can be found.


A review of systems can be organized in a formal checklist, which becomes a part of the health history. One advantage of a checklist is that it can be easily audited and is less subject to error than a system that relies heavily on the interviewer’s memory.

Patient Profile


In the patient profile, more biographical information is gathered. A complete composite, or profile, of the patient is critical to an analysis of the chief complaint and of the person’s ability to deal with the problem. A complete patient profile is summarized in Chart 5-1.

The information elicited at this point in the interview is highly personal and subjective. During this stage, the person is encour-aged to express feelings honestly and to discuss personal experi-ences. It is best to begin with general, open-ended questions and to move to direct questioning when specific facts are needed. The patient is often less anxious when the interview progresses from information that is less personal (birthplace, occupation, educa-tion) to information that is more personal (sexuality, body image, coping abilities).


A general patient profile consists of the following content areas:


•     Past life events related to health


•     Education and occupation


•     Environment (physical, spiritual, cultural, interpersonal)


•     Lifestyle (patterns and habits)


•     Presence of a physical or mental disability


•     Self-concept


•     Sexuality


•     Risk for abuse


•     Stress and coping response




The patient profile begins with a brief life history. Questions about place of birth and past places of residence help focus at-tention on the earlier years of life. Personal experiences during childhood or adolescence that have special significance may be elicited by asking, “Was there anything that you experienced as a child or adolescent that would be helpful for me to know about?”

The interviewer’s intent is to encourage the person to make a quick review of his or her earlier life, highlighting information of particular significance. Although many patients may not recall anything significant, others may share information such as a per-sonal achievement, a failure, a developmental crisis, or an in-stance of physical or emotional abuse.



Inquiring about current occupation can reveal much about a per-son’s economic status and educational preparation. A statement such as, “Tell me about your job” often elicits information about role, job tasks, and satisfaction with the position. Direct questions about past employment and career goals may be asked if the per-son does not provide this information.

Asking the person what kind of educational requirements were necessary to attain his or her present job is a more sensitive approach to educational background than asking whether he or she graduated from high school. Information about the patient’s general financial status may be obtained by questions such as, “Do you have any financial concerns at this time?” or “Sometimes there just doesn’t seem to be enough money to make ends meet. Are you finding this true?” Inquiry about the person’s insurance coverage and plans for health care payment is also appropriate.


The person’s physical environment and its potential hazards, spir-itual awareness, cultural background, interpersonal relationships, and support system are included in the concept of environment.

Physical Environment


Information is elicited about the type of housing (apartment, du-plex, single-family) in which the person lives, its location, the level of safety and comfort within the home and neighborhood, and the presence of environmental hazards (eg, isolation, poten-tial fire risks, inadequate sanitation). The patient’s environment takes on special importance if the patient is homeless or living in a homeless shelter or has a disability.

Spiritual Environment

The term “spiritual environment” refers to the degree to which a person thinks about or contemplates his or her existence, accepts challenges in life, and seeks and finds answers to personal ques-tions. Spirituality may be expressed through identification with a particular religion. Spiritual values and beliefs often direct a per-son’s behavior and approach to health problems and can influ-ence responses to sickness. Illness may create a spiritual crisis and can place considerable stress on a person’s internal resources and beliefs. Inquiring about spirituality can identify possible support systems as well as beliefs and customs that need to be considered in planning care. Thus, information is gathered in the following three areas:


·         The extent to which religion is a part of the person’s life


·        Religious beliefs related to the person’s perception of health and illness


·        Religious practices


The following questions can be used in a spiritual assessment:


·      Is religion or God important to you?


·       If yes, in what way?


·       If no, what is the most important thing in your life?


·       Are there any religious practices that are important to you?


·      Do you have any spiritual concerns because of your present health problem?


Interpersonal and Cultural Environment


Cultural influences, relationships with family and friends, and the presence or absence of a support system are all a part of one’s in-terpersonal environment. The beliefs and practices that have been shared from generation to generation are known as cultural or ethnic patterns. They are expressed through language, dress, di-etary choices, and role behaviors, in perceptions of health and ill-ness, and in health-related behaviors. The influence of these beliefs and customs on how a person reacts to health problems and interacts with health care providers cannot be underestimated (Fuller & Schaller-Ayers, 2000). For this reason, the health history includes information about ethnic identity (cultural and social) and racial identity (biologic). The following questions may assist in obtaining relevant information:


·       Where did your parents or ancestors come from? When?


·       What language do you speak at home?


·       Are there certain customs or values that are important to you?


·       Is there anything special you do to keep in good health?


·       Do you have any specific practices for treating illness?


Family Relationships and Support System

An assessment of family structure (members, ages, roles), patterns of communication, and the presence or absence of a support sys-tem is an integral part of the patient profile. Although the tradi-tional family is recognized as a mother, a father, and children, many different types of living arrangements exist within our so-ciety. “Family” may mean two or more people bound by emo-tional ties or commitments. Live-in companions, roommates, and close friends can all play a significant role in an individual’s support system.



The lifestyle section of the patient profile provides information about health-related behaviors. These behaviors include patterns of sleep, exercise, nutrition, and recreation, as well as personal habits such as smoking and the use of drugs, alcohol, and caffeine. Although most people readily describe their exercise patterns or recreational activities, many are unwilling to report their smok-ing, alcohol use, and drug use; many deny or understate the de-gree to which they use such substances. Questions such as, “What kind of alcohol do you enjoy drinking at a party?” may elicit more accurate information than, “Do you drink?” The specific type of alcohol (eg, wine, liquor, beer) and the amount ingested per day or per week (eg, 1 pint of whiskey daily for 2 years) are described.


When alcohol abuse is suspected, additional information may be obtained by using common alcohol screening questionnaires such as the CAGE (Cutting down, Annoyance by criticism, Guilty feelings, and Eye-openers), AUDIT (Alcohol Use Disorders Identification Test), TWEAK (Tolerance, Worry, Eye-opener, Amnesia, Kut down), or SMAST (Short Michigan Alcoholism Screening Test). Chart 5-2 shows the CAGE Questions Adapted to Include Drugs (CAGEAID).


Similar questions can be used to elicit information about smoking and caffeine consumption. Questions about drug use follow naturally after questions about smoking, caffeine con-sumption, and alcohol use. A nonjudgmental approach will make it easier for the person to respond truthfully and factually. If street names or unfamiliar terms are used to describe drugs, the person is asked to define the terms used.


Investigation of lifestyle should also include questions about complementary and alternative therapies. It is estimated that as many as 40% of Americans use some type of complementary or al-ternative therapies, including special diets, the use of prayer, visu-alization, or guided imagery, massage, meditation, herbal products, and many others (Evans, 2000; King, Pettigrew & Reed, 1999; Kuhn, 1999). Marijuana is used for symptom management, espe-cially pain, in a number of chronic conditions (Mathre, 2001).



The general patient profile also needs to contain questions about any hearing, vision, cognitive, or physical disability. The presence of an obvious physical deformity—for instance, if the patient walks with crutches or needs a wheelchair to get around—needs further investigation. The etiology of the disability should be elicited; the length of time the patient has had the disability and the impact on function and health access are important to assess.




Self-concept refers to one’s view of oneself, an image that has de-veloped over many years. To assess self-concept, the interviewer might ask the person how he or she views life: “How do you feel about your life in general?” A person’s self-concept can be threat-ened very easily by changes in physical function or appearance or other threats to health. The impact of certain medical conditions or surgical interventions, such as a colostomy or a mastectomy, can threaten body image. Asking, “Do you have any particular concerns about your body?” may elicit useful information about self-image.




No area of assessment is more personal than the sexual history. Interviewers are frequently uncomfortable with such questions and ignore this area of the patient profile or conduct a very cur-sory interview at this point. Lack of knowledge about sexuality and anxiety about one’s own sexuality may hamper the inter-viewer’s effectiveness in dealing with this subject (Ross, Channon-Little & Rosser, 2000).


Sexual assessment can be approached at the end of the inter-view, at the time interpersonal or lifestyle factors are assessed, or it can be a part of the genitourinary history within the review of systems. For instance, it may be easier to approach a discussion of sexuality after a discussion of menstruation. A similar discus-sion with the male patient would follow questions related to the urinary system.


Obtaining the sexual history provides an opportunity to dis-cuss sexual matters openly and gives the person permission to express sexual concerns to an informed professional. The inter-viewer must be nonjudgmental and must use language appropri-ate to the patient’s age and background. It is advisable to begin the assessment with a general question concerning the person’s developmental stage and the presence or absence of intimate re-lationships. Such questions may lead to a discussion of concerns related to sexual expression or the quality of a relationship, or to questions about contraception, risky sexual behaviors, and safer sex practices.


Finding out whether a person is sexually active should precede any attempts to explore issues related to sexuality and sexual func-tion. Care should be taken to initiate conversations about sexuality with elderly patients and not to treat them as asexual beings (Miller, Zylstra & Stranridge, 2000). Questions are worded in such a way that the person feels free to discuss his or her sexual-ity regardless of marital status or sexual preference. Direct ques-tions are usually less threatening when prefaced with such statements as, “Most people feel that . . .” or “Many people worry about. . . .” This suggests the normalcy of such feelings or be-havior and encourages the person to share information that might otherwise be omitted from fear of seeming “different.”


If the person answers abruptly or does not wish to carry the dis-cussion any further, then the interviewer should move to the next topic. However, introducing the subject of sexuality indicates to the person that a discussion of sexual concerns is acceptable and can be approached again in the future if so desired.



A topic of growing importance in today’s society is physical, sex-ual, and psychological abuse. Such abuse occurs at all ages, to men and women from all socioeconomic, ethnic, and cultural groups (Little, 2000; Marshall, Benton & Brazier, 2000). Few patients, however, will discuss this topic unless they are asked specifically about it. Therefore, it is important to ask direct questions, such as:


·      Is anyone physically hurting you?


·       Has anyone ever hurt you physically or threatened to do so?


·      Are you ever afraid of anyone close to you (your partner, caretaker, or other family members)?


If the person’s response indicates that abuse is a risk, further assessment is called for and efforts are made to ensure the per-son’s safety and provide access to appropriate community and professional resources and support systems. 

Further discussion of domestic violence and abuse. When questioned directly, elderly patients rarely admit to abuse (Marshall, Benton & Brazier, 2000). Health care professionals should assess for risk factors, such as high levels of stress or al-coholism in caregivers, evidence of violence, high emotions as well as financial, emotional, or physical dependency. Patients who are elderly or disabled are at increased risk for abuse and should be asked about it as a routine part of assessment.




Each person handles stress differently. How well we adapt de-pends on our ability to cope. During a health history, past cop-ing patterns and perceptions of current stresses and anticipated outcomes are explored to identify the person’s overall ability to handle stress. It is especially important to identify expectations that the person may have of family, friends, and caregivers in pro-viding financial, emotional, or physical support.




The health history format discussed is only one pos-sible format that is useful in obtaining and organizing information about a person’s health status. Some consider this traditional for-mat to be inappropriate for nurses because it does not focus exclu-sively on the assessment of human responses to actual or potential health problems. Several attempts have been made to develop an assessment format and database with this focus in mind. One ex-ample is the nursing database prototype based on the North Amer-ican Nursing Diagnosis Association’s (NANDA) Unitary Person Framework and its nine human response patterns: exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. Although there is support in nursing for using this approach, no consensus for its use has been reached.


The National Center for Health Services Research of the U.S. Department of Health and Human Services and other groups from the public and private sectors have focused on assessing not only biologic health but also other dimensions of health. These dimen-sions include physical, functional, emotional, mental, and social health. Modern efforts to assess health status have focused on the manner in which disease or disability affects the patient’s functional status—that is, the ability of the person to function normally and perform his or her usual physical, mental, and social activities. An emphasis on functional assessment is viewed as more holistic than the traditional health or medical history. Instruments to assess health status in these ways may be used by nurses along with their own clinical assessment skills to determine the impact of illness, dis-ease, disability, and health problems on functional status.


Health concerns that are not complex (earache, tonsillectomy) and can be resolved in a short period of time usually do not require the depth or detail that is required when a person is experiencing a major illness or health problem. Additional assessments that go beyond the general patient profile may be used when the patient’s health problems are acute and complex or when the illness is chronic. Individuals should be asked about their continuing health promotion and screening practices. Patients who have not been in-volved in these practices in the past are educated about their im-portance and are referred to appropriate health care providers.


Regardless of the assessment format used, the nurse’s focus during data collection is different from that of the physician and other health team members; however, it complements these ap-proaches and encourages collaboration among the health care providers, as each member brings his or her own expertise and focus to the situation.


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