Chapter 2: Patient Assessment
2.2 Health History
Critical Thinking Exercises: Questions, Answers, and Sources / References
Critical thinking questions are in bold type, and the answers are italicized. Additional resources or references are provided below.
- Why is it important to obtain a complete description of the patient’s present illness?
Obtaining a description of the patient’s present illness includes:
- Chief complaint
- Onset and duration of present health concern
- What caused the health concern to occur?
- Signs, symptoms, and related problems
- Alleviating and aggravating factors
- How the concern affects life and activities of daily living?
- Previous history and episodes of this condition
All of these help the healthcare provider to gather data so the healthcare team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions.
Source:
Wilson, S. F., & Giddens, J. F. (2013) Health assessment for nursing practice (5th ed.) Mosby.
2. Identify one reason why it is important for the nurse to obtain a complete description of the client’s lifestyle and exercise habits?
The data gathered about lifestyle and exercise habits helps the nurse and healthcare team to understand the patient in a more holistic way. Lifestyle and exercise habits may or may not play a role in the patient’s current health concerns. Such information may prove valuable when discussing health promotion practices, providing patient education, and working collaboratively to build a plan to address any health concerns.
Source:
Stephen, T. C., Skillen, D. L., Day, R. A., & Jensen, S. (2012). Canadian Jensen’s nursing health assessment: A best practice approach. Wolters Kluwer-Lippincott.
Sample Learning Activities
The following activities are intended to assist learners develop their skill with obtaining a health history.
1. The faculty member will create a case study script that will allow one student to play the role of patient. Ask students to simulate a patient nurse interview, with one student playing the role of the patient, the other student playing the role of the nurse. The student playing the role of nurse will conduct the interview and document it. The student playing the role of patient will provide feedback on their partner’s interview performance.
2. Obtain a nursing history or admission history document from your local health authority or online, and have students complete this on an assigned patient when they are in practice.
3. Students create their own nursing history document by determining a set of questions to ask a prospective patient. Students can work individually or in small groups, followed by a larger group discussion.