health history: | Nursing

Clinical Requirement:

healthhistory.docx Students will demonstrate knowledge of interviewing skills, the components of a health history, recording the history data, and assigning three priorities after reviewing the data. A health history will be completed and submitted according to the grading rubric and course schedule. Students will submit a detailed subjective health history of a volunteering adult over 50 on the provided form. Students should not give identifying data on the patient – only the demographics requested in the grading rubric. · The health history assignment is SUBJECTIVE - interviewing and questioning the patient. · Each student will complete a comprehensive health history following the rubric provided below: Instructions: · Comprehensive health history is all subjective data. Consider the health history a chance for the patient to tell their story. · Find a friend or relative to complete an entire health history. · After completing, a detailed health history, students will document the results of the health history APA7—information on how to complete a health history is found in  Chapter 4, pages 70 to 88. Steps for the Health History: Subject -Criteria Possible Points Patient Demographics -Gender, age, ethnicity, and other social demographics as indicated (self-pay, Insurance) 5 Chief Complaint  -Use the patient’s own words—one or more symptoms or concerns cause the patient to seek care. -Elaborate on the chief complaint; describes how each symptom developed. I-ncludes the patient’s thoughts and feelings about the illness. 5 History of Present Illness -Appropriate dimensions of cardinal symptoms are listed (including location, severity, quality, setting, chronology, aggravating/alleviating, and associated manifestations) -HPI narrative flows smoothly in a logical fashion -For those who favor mnemonics, the 8 dimensions of a medical problem can be easily recalled using OLD CARTS ( Onset,  Location/radiation,  Duration,  Character,  aggravating factors,  Relieving factors,  Timing and  Severity). 10 Past Medical History -Lists childhood illnesses  -Lists adult illnesses with dates for at least three categories: medical, surgical, and psychiatric. -Medication, Allergies -Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety. 5 Current Health Status -Summary of general health status related to the present illness. 5 Family History Narrative and Genogram https://genopro.com/genogram/medical/Links to an external site. -Outlines or diagrams of age and health or age and cause of death of siblings, parents, grandparents, and children. -Documents the presence or absence of specific illnesses in the family (e.g., hypertension, coronary artery disease) -The family pedigree shows at least three generations and involves the use of standardized symbols, which mark individuals affected with a specific diagnosis to allow for easy identification. 10 Risk assessment based on family history -Family history of a known or suspected genetic condition -Ethnic predisposition to certain genetic disorders -Consanguinity (blood relationship of parents) -Multiple affected family members with the same or related disorders -Earlier than expected age of onset of disease -Diagnosis in less-often-affected sex 10 Past Surgical History -Were they ever operated on, even as a child?  -What year did this occur?  -Were there any complications?  5 Social History -Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur? -Do they drink alcohol? If so, how much per day and what type of drink? -Any drug use, past or present, should be noted.  -Work, family, friends, community support systems,  5 Sexual Activity -Do they participate in intercourse? With persons of the same or opposite sex?  -Are they involved in a stable relationship?  -Do they use condoms or other means of birth control?  -Married? The health of the spouse? Divorced? Past sexually transmitted diseases?  -Do they have children? If so, are they healthy? Do they live with the patient? 5 Work/Hobbies/Other -What sort of work does the patient do?  -Have they always done the same thing? Do they enjoy it?  -If retired, what do they do to stay busy? Any hobbies? 5 Review of systems (ROS) -Documentation of the presence or absence of common symptoms related to each major body system. -Consider asking a series of questions going from “head to toe.” -The questions asked to reflect an array of standard and critical clinical conditions (heart disease, diabetes, arthritis) -These disorders would only be recognized if the patient were explicitly prompted. · Format · General/skin/sleep · HEENT  · Respiratory  · Cardiovascular  · Musculoskeletal  · Endocrine  · Gastrointestinal and Urinary  · Neuro/psyc 10 Prevention and Health Promotion -At least one prevention activity. -At least three health promotion recommendations. 10 APA Guidelines & Writing Style APA (title page, margins, page numbers, headings, subheadings, citations); spelling; writing straightforward, concise, and professional. 10 Total 100