Sample of Nursing Health History

Topics: Medicine, Health care, Health care provider Pages: 4 (1049 words) Published: April 22, 2011
Nursing Health History
Nursing health history is the first part and one of the mostsignificant aspects in case studies. It is a systematic collection ofsubjective and objective data, ordering and a step-by-step processinculcating detailed information in determining client’s history, healthstatus, functional status and coping pattern. These vital informationsprovide a conceptual baseline data utilized in developing nursingdiagnosis, subsequent plans for individualized care and for the nursingprocess application as a whole. In keeping the private life of my patient and in maintaining confidentiality, let me hide for with the pseudonym of Patient B. Patient B was born on December 19, 1992. She didn’t know herparents but she has relatives in Surigao del Norte. She stayed atDepartment of Welfare and Social Development or DSWD and spent her15 years of existence. Her education was funded mainly by volunteersand charitable foundations. At the same time, she compensated for it bymeans of helping in chores and accomplishing tasks in the said foundation.

The health history is a current collection of organized information unique to the individual patient. Relevant aspects of the history include biographical, demographic, physical, mental, emotional, sociocultural, sexual, and spiritual data. Purpose

The history aids the patient and health care provider by supplying essential information that will assist with diagnosis, treatment decisions, and establishment of trust and rapport between patient and medical professional. The information also helps determine the patient's baseline, or what is normal and expected for the patient. Description

The clinical interview is the most common method for obtaining a health history. When the patient or a designated representative of the patient can communicate effectively, the clinical interview is a valuable means of soliciting information. The information that comprises the health history may be obtained from the...
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