This paper is being submitted on April 15, 2019, for Kimberly Korneck’s NUR2092 Section P2 Health Assessment – Residential and Online course.
The health history is one of the most crucial assessment to know about our patients. The main purpose of the health history is to gather data what the person says and what we observe through assessment such as inspection, palpation, percussion, and auscultation. The health history format represents many sequences that the primary care settings may use but since we need to know the partial health history I would go with present, past and family history (Jarvis, 2016).
I chose to write this health history on my husband Mr.P.R, 32 years old male, with his permission for this assignment. I started with my hand hygiene and introduced myself and my role and the purpose of taking a health history. I started asking his current health information on how he was feeling. He said he was feeling good and healthy now but the last week he felt very tired and he had a migraine occasionally. He said he has been diagnosed with minor depression and had pain and weakness in his left side of the body. I asked him to describe more deeply about his pain. I asked him to point to the location where he felt pain.
He pointed to head pain and left upper extremities pain. I asked him how he would describe the pain in his left upper arm, he replied dull aching pain. I asked him to describe the quality of pain in his head, and he described it as a sharp pain. I then asked what his migraine pain was like and he replied a sharp pain behind his eye. Then I asked him to describe the severity of overall pain from pain scale 0-10, 0 is no pain, 10 is worst pain, 4-6 is moderate pain, and 1-3 is mild pain. He replied to me 7 was overall pain. I asked him how long the pain lasts, and how often and he said his head pain is always there every day, his migraines appear approximately 2-3 times per week and vary in duration from a few hours to eight hours and up, and the pain in the upper left extremities start when he lift more weight or push weights. I asked him what do you do anything if you are suffering from pain such as any relieving remedies pain pills, cold or heat pack or distraction or aromatherapy. He said he always takes some Tylenol for his headache. He said the headaches tend to go away without any treatment as well.
The migraines, on the other hand, are more difficult; he takes migraine medication sumatriptan when the signs are there that a migraine is coming on, and goes into the bedroom where it is dark, and there is no light, puts an ice pack on his head and lights a lavender candle. This helps a little with calming himself down he says, and the ice pack helps with the pain a little, the sumatriptan works sometimes, and other times it doesn’t seem to. I asked him if he has any known allergies to any medicines, any substances or environmental factors and he said he does not have any allergy as he knows. I asked him that any alcohol or smoking history. He said he occasionally drinks like once in a month, he does not smoke, and never use any substance drugs. The current medications that he is taking are Bupropion, Gabapentin, Lamotrigine, Melatonin, Sertraline, and Sumatriptan. The sumatriptan is for aiding in the relief of migraine pain, fish oil is for cholesterol, gabapentin is for nerve pain relating to his palm, lamotrigine is for mood, bupropion is for mood, and sertraline is for energy according to his prescription labels. He doesn’t have any major serious conditions such as hypertension or diabetes.
After collecting the present health history, I turned my attention to ask him about his past health pieces of information. He said he had the chickenpox, flu couple times, and had low platelets in his blood problem. During his childhood, he had not any minor surgeries, accidents, hospitalizations. A few years ago, he had slipped onto the ice and he had minor bleeding from the head. He was stitched up at the Saint Cloud Hospital. He was also diagnosed with migraine in 2012, and major depression in 2009. He had been treated for both at the Centracare Clinic. He is very regularly to follow up with his vaccination throughout his like.
Mr. P.R.’s family history was a little tough to find because he doesn’t talk much about anyone other than immediate family. His mom has hypertension and diabetes. His father has knee and hip issues as well as degenerative bone disease in his lower back. His father had a stroke a couple of years ago. His brother he said is pretty much healthy. His younger sister had gestational diabetes with her first-born baby, other than that he doesn’t know if she has any others. His older sister has depression. His grandmother on his mother’s side has heart disease, his grandfather died when he was a kid but was an alcoholic and died of a heart attack in his sleep. Mr.P.R and I have been in a marital relationship for about eight years so now he is pretty much comfortable sharing about his family history. Since I am his wife, as a family history I would like to tell a little bit about myself. I do not have any health problem. I would say I am pretty healthy and active. I do not have any illness or any past health problems.
1. Was the person willing to share the information? If they were not, what did you do to encourage them?
Yes, the person I did the health history on was willing to share the information. I was comfortable taking the health history of Mr. P.R. because we are married since 2010 and I know pretty much all the health issues that he and his family have. P.R had no issue in sharing health information with me. He was very supportive and respectful while sharing this information. The problem I had to struggle was talking about his family health history because he does not know too much about any health issues his family has, they tend to keep those things to themselves. He definitely asked his parents before sharing their information.
2. Was there any part of the interview that was more challenging? If so, what part and how did you deal with it?
I do not feel any challenging part while taking his health Information except taking his family and past information. He did not know much about his family history. He asked a couple of times to his parents while I was gathering all the information. He was diagnosed with major depression so he did not want to recall that information. He told me that not to ask more detail about his past health but he kind of gave me the important information related to his health.
3. How comfortable were you taking a health history?
Well, that was my first time taking partial health history so I was kind of nervous and overwhelmed. I was trying to remember that what should I asked him before I started but as I go through the present, past and family health data, I kind of know all the important information I need to know.
4. What interviewing techniques did you use? Were there any that were difficult and if so, how did you overcome the difficulty?
I chose to use open-ended questions to be able to get more information to work with instead of just using questions with just a yes or a no answer. A yes or no question I didn’t think would be able to provide enough information. I also use an active listening technique to carefully listen to what he wanted to tell me. I clarified a couple of data to make sure that I got the correct information. I did not judge his thoughts and respected all the information that he shared with me. I rotated between the questions types depending on what I thought would get the best result for an answer.
5. Now that you have taken a health history to discuss how this information can assist the nurse in determining the health status of a client.
Once a health history has been taken a nurse should be able to determine any nursing diagnosis based on the information. The nurse should also able to determine any potential illnesses by the symptoms they are showing that day, they can also see any potential hereditary diseases they may be at risk for as well as risk factors associated with those diseases. The past health history is important to know because it can have a left over effect or effects on an individual throughout their lifetime, so it may help to determine problems arising from prior health issues. I believe that health history interviews are a very important part of health promotion, and it helps the nurse to gather subjective data about the client to help treat them in the present and the future. After that, the nurse should able to develop a plan of care and provide interventions in the plan of care. At last, the nurse should evaluate the outcome based on the re-assessment of interventions (Jarvis, 2016).
Jarvis, C. (2016). Physical examination and health assessment (7th Ed.). St. Louis, Missouri:
Elsevier. Retrieved from https://ambassadored.vitalsource.com/#/books/9781455728107/