Question

1. A new patient has presented at a local clinic for treatment of a “red, bumpy rash” on his hands. The patient is 47 years old and is accompanied by his wife. The nurse is preparing to take a health history.

a. Which type of history, comprehensive or focused, is most appropriate and why?

b. Identify and discuss the various components of the appropriate history.

c. What sort of information will be documented by the nurse?

d. After the patient is treated for the skin problem, what type of health history will the nurse complete when the patient returns to the clinic, and why?

Answer 1

a.Comprehensive health history is appropriate.The patient's overall health status is collected by comprehensive health history.Since the patient is new to the clinic,overall health status should   be collected before the treatment.

b.Components of comprehensive health history

• Biographic data

Includes full name,age,gender,birthplace,date of birth,religion,marital status,occupation

• Reason for seeking care

The client's chief complaint is expressed in his /her own words.

• Present health status

Includes onset of symptoms,gradual or sudden development of symptoms,severity,exact location of the discomfort,factors that increases or decreases the problem,and symptoms associated with chief complaint.

• Past medical history

Includes allergies,illness in childhood,accidents,previous hospitalization for serious illness,medications taken.

• Family history

Any family history of heart diseases,tuberculosis,cancer,diabetes,hypertension,obesity,allergies and any mental illness.

• Personal and social history

Personal history includes personal habits,diet,sleeping habits,hobbies and social history includes social relationships,occupational history,economic status,educational status etc.

• Review of all body systems

Documentation of presence or absence of common symptoms affecting major body system is done.

c.Subjective and Objective information will be documented by the nurse.

d.Focused health history because it gives specific data about a health related problem.Here,since patient has returned to the clinic after the treatment, focused history should be collected.