Comprehensive Health History

Comprehensive Health History
Comprehensive Health History
Details: Select one patient (neighbor, family, or friend) and write-up their comprehensive health history. Include the following variables:
1.Identifying data.
2.Past medical history.
3.Health status, perceived barriers, and support.
4.Chief complaint (CC).
5.History of present illness (HPI).
6.Family and/or social history (PFSH).
7.Focused review of systems (ROS).
8.Identify age, spiritual values, and cultural variables that were considered and how these variables influenced your interviews or health history.
In a 1,000-1,250-word essay, summarize effective interview techniques for collecting a patient’s health history. Include the following:
1.Address how to elicit the patient’s interpretation of their health status, their perceived barriers, and support.
2.Critique the effectiveness of several history taking techniques with rationale from the readings.
Nurses get insight into a patient’s physical status by observation, vital sign monitoring, and self-reported symptoms during a full health assessment.
A medical history, a general review, and a thorough physical examination are all included.
A patient’s age, weight, height, build, posture, stride, and cleanliness are all part of the general survey.
Nurses utilize health assessments to gather baseline information about patients and to establish a rapport with them that can reduce anxiety and foster a trusting connection.
A comprehensive health assessment is usually performed when a patient is admitted to an acute care facility or when they attend an outpatient clinic for the first time.
When performing an evaluation, nurses may employ approaches such as:
Inspection
This is the most widely utilized assessment approach.
Nurses use their eyes, ears, and nose to seek for signs of a health concern.
They may look for strange sounds and odors, as well as examine skin color, lesions, bruises, or rashes.
Auscultation
The diaphragm or bell of a stethoscope is placed on the naked skin of a patient to listen to the noises of the abdomen.
Palpation
Nurses use various portions of their hands to apply differing degrees of pressure to the patient.
Texture, tenderness, warmth, wetness, pulsations, and the presence of masses can all be assessed by palpation.
Percussion
Nurses use the distal part of their non-dominant hand’s middle finger to firmly push on areas of a patient’s body.
To assess a patient’s level of discomfort, the procedure is applied directly to suspected tender spots.
What Are the Steps in a Comprehensive Health Examination?
Before beginning a physical exam, a comprehensive examination usually starts with documenting a patient’s medical history.
The health history covers the patient’s medical complaint, current state of health, historical health record, current lifestyle, psychological condition, and family history, according to AMN Healthcare Education Services.
The health history informs nurses about symptoms, childhood illnesses, relevant medical experiences, and the likelihood of getting particular diseases.
Following the recording of the patient’s medical history, a physical examination is performed, which includes an evaluation of the patient’s body systems.
The following items are assessed during a head to toe examination:
Neurological function of the skin
Ears, eyes, nose, and throat are the four organs that make up the human body.
Function of the lungs
System of the heart and lungs
Abdomen
Muscles and articulations
Limbs, shoulders, hips, ankles, and feet are all parts of the human body.
System of reproduction
Nutrition
A complete and precise assessment is critical since it aids in distinguishing between the patient’s normal and abnormal conditions.
A comprehensive health evaluation also determines whether a patient requires diagnostic tests or additional medical attention.
How Can a BSN Help a Nurse Improve Their Assessment Skills?
In nursing school, nurses learn how to assess patients.
Advanced Nursing Health Assessment is a course in an online RN to BSN program like Eastern Illinois University’s (EIU) that teaches students to perform exact examinations.
The curriculum expands on a nurse’s core skills in nursing assessment.
Nurses with a BSN are equipped to conduct a thorough health assessment and apply their expertise to make informed clinical decisions.
A thorough health examination is an important part of nursing practice.
Nurses may find it challenging to pinpoint a patient’s medical needs without it.
Patients must do more than simply tell nurses what is wrong.
Nurses must instead decide on a plan of action based on the observations they make during physical examinations.
Nurses can communicate with patients and assist them take steps to maintain or control their health by undertaking a comprehensive and efficient assessment.