3.3 Health History Introduction

“‘Sickness’ is what is happening to the patient. Listen to them.”^[1]

The profession of nursing is defined by the American Nurses Association as follows: “Nursing integrates 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 their 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. A general survey assessment is an overall observation of a patient’s general appearance, signs of distress, mood and behavior, level of consciousness and orientation, hygiene, family dynamics, range of motion, mobility, speech and communication, nutritional, and fluid status. A general survey assessment also includes analyzing height, weight, and vital signs for values that are out of range and require additional follow-up.

Attribution

Open RN Nursing Skills, 2e by Chippewa Valley Technical College is licensed under CC BY 4.0.