Question

A nurse is gathering data related to the health history of an elderly female patient. When completing a health history, describe pertinent information that should be obtained from the patient.

Answer 1

Gathering data from an elderly patient usually differs. Interviewing the health history of a female patient should focus on more specific things which reduces the hospitalization of an elderly patient. It helps to identify the health issues and to improve the quality of life. While gathering data from female patients the following information should be obtained

Subjective data:

Client current problems and symptoms of the chronic disease such as diabetes, hypertension, Alzheimer's disease should be gathered. Her chief complaints should be assessed by asking the relevant questions. EX: Complaints of chest pain, nervousness, palpitation.

Objective data:

Patient should be assessed thoroughly. Focus on age-related sickness and geriatric problems. EX: restricted motion, joint swelling. Special attention should be given for bone-related diseases such as osteoporosis. Females are high risk because of calcium deficiency and hormonal imbalance.

Sensory deficits:

Gather data related to use of eyeglasses, vision, hearing deficit, and dentures. Collect history of vision problem, hearing problems.

Other symptoms:

Collect data about gait disturbance, dizziness, falls, memory problem, breathing problem, fatigue, confusion, weight loss.

Functional status:

Collect history about the activities of daily living and recent changes in the daily routines. Identification of Functional decline helps to prevent further decline and to maintain the current functional level. Assess the feeding status and need of any support.

Age-related disorder:

Gather data about the difficulty in walking, joint pain, swelling, stiffness, fear, depression, confusion, disorientation, and other associated problems. Collect history of hormone related changes and associated symptoms.

Family History:

Collect a thorough family history of the patient which helps to detect some chronic problems at early. For Ex: family history of breast cancer.

Past Medical History:

Collect the history of previous medical conditions and its treatment. Past history of any surgery and hospitalization. Collect history of immunizations, and allergic to any medications. Collect old reports and gather data completely. Collect history of menopause begins and ends and habits of breast self-examination. Collect data of any bleeding or flushes.

Drug History:

Collect current medications, dosage, frequency, side effects, and interaction. Gather data about use of any topical medications, Over the counter medications, herbal products. Include use of any dietary supplements.

Nutritional History:

Assess dietary patterns, diet intake, eating habits, and eating behavior. Assess the carbohydrate, fat, and fiber level in the diet. Assess the appetite pattern, bowel patterns, and gut-related disorder. Assess the history of fluid intake and urinary incontinence. Assess the history of weight loss or weight gain.

Mental Health History:

Collect the history of cognitive function, depression, and mental health disorders. Gather data of use of any antipsychotic drugs and Psychotherapy. Collect history of sleeping patterns and insomnia, snoring, or breathing difficulty during sleep.

Life history:

Collect data about lifestyle patterns, recreational activities, physical activities, and her relationship with the family members, friends, and neighbors. Assess her level of decision making and consciousness. Collect the history of financial independence and support.

Social history:

Assess the history of using tobacco, alcohol, or smoking. Assess her level of climbing upstairs, transportation, and other physical support. Gather history about her participation in social activities.