The Complete Health History and Functional Assessment

For educational purposes only. 

This week's episode covers the complete health history and functional assessment for our adult patient, aged 18 and up. We dive into what aspects make up these assessments, how to conduct them, and why we use them. So cozy up and listen to this episode. 

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Transcript

Hello and welcome back to Rosie the Riveting RN. I hope you are having a great week and getting the most out of life today! I am Professor Poole, your friendly nursing professor to help you get through tough topics and concepts of nursing school. Today we will be discussing the complete health history and why we would need to do this. There are a couple different forms we use to collect data from the patient, and a complete health history is one of them. We do this when a patient is establishing themself with a new provider, when we admit them to the hospital, and if we have not seen the patient in a while, we might to see what has changed since we last saw them. 

Without further ado, let’s get into today’s topic. Have you ever gone to a doctor’s office and there are those long forms that ask questions about potential health issues you may have experienced, family history, your work or living environment, smoking or alcohol history? Well guess what? That is a complete health history form! The complete health history is going to be gathering both SUBJECTIVE and OBJECTIVE data. SUBJECTIVE data is what the SUBJECT says, and OBJECTIVE data is what we OBSERVE, like through inspection, palpation, percussion, and auscultation. The whole point of the complete health history is so we can gather information about their past and current health history. This way, we can help them with any health issues they have, promote healthy practices, and even anticipate potential future health problems. The complete health history is basically a screening tool for abnormalities in different areas of your background. 

The complete health history provides a very general overview of the patient’s database. And a database is a grouping of information about a patient. There are 8 different areas we gather this generalized database and it is important to know the sequence of this. First we start with the biographic data, then reasoning for care, followed by present health or history of present illness, past history, medication reconciliation, family history, review of systems, and finally functional assessment for ADLs. 

The biographical data includes the patient's name, DOB, birthplace, occupation, pronouns, contact information, marital status, gender, race, ethnicity, and primary language. We want to look at the source of the information as we are looking over the complete health history. Is the patient the one who is providing the information, a parent, translator, or a caregiver? You will have to decide the accuracy from the source. Some family members or caregivers may not know the whole health history, the patient may have a poor memory, or they may withhold information. Ask the patient what brought them in today to gather data of reason for the visit. We do not use diagnostic terms in this section since we are gathering subjective information from the patient. We can use direct quotes how the patient describes their symptoms, but we are not going to use medical diagnostic terms in this section. Be sure the patient tells you all the reasons for seeking care. To do this, ask “are there any other reasons for seeking care,” or “is there anything else you would like to discuss?”

The next step is to gather the subjective data about the patient’s health or history of illness. We will want to gather information of when symptoms started, how long the patient has had them, the location of any symptoms, how do the symptoms feel, the quality or severity, timing, setting, causative or relieving actions, associated factors, and the patient’s understanding of the symptoms. Now, what does that word salad mean? 

First you are going to start asking the patient when they started experiencing their concerned symptoms. Did they start feeling a sore throat 3 days ago and gradually they started to have pressure in their sinuses? This is something we would like to know because there are some symptoms where timing is everything. We will get into that a different day though. Where exactly the patient experiences their symptoms is going to have us hone in on potential systems involved. Character or quality are going to be the descriptors the patient uses to describe what they are feeling. Let’s go back to our previous example. The patient may say their throat feels scratchy, while the pain in the face is a dull pressure sensation. We can also use descriptors and characteristics to describe the mucus the patient may expel. They may notice thick, yellow mucus they cough up. We want to notate that. Then, we want to know the quantity or severity of their symptoms. Is the mucus scant, or is there a copious, excessive amount of mucus the patient is coughing up? Is the pressure in their face so bad that they lose balance? Are they unable to get a restful sleep because of the pain? Timing is important to know because this tells us how long the symptoms have lasted for, how frequently the patient experiences these symptoms, and the onset of the symptoms. Have the symptoms been treated, they went away, and now they have come back? Is it worse? 

We will also ask about the setting of the symptoms. Did the patient travel abroad and came back with a sore throat? Were they around others who had similar symptoms? Then assess what causes and relieves the symptoms. What makes the symptoms better and worse? The patient may have used cepacol spray to help ease the sore throat and warm compresses for the sinus pain that may have provided temporary relief. Along with all this information, we want to look at other symptoms that may have accompanied the intial complaint, which in our example was a sore throat. The patient may have a cough, headache, or a runny nose. Lastly, we look at how the patient has interpreted their symptoms. Not only does this help us get a sense of their health literacy, but it also let’s us understand how the symptoms have affected the patient. Has the patient needed to take time off work, has it made them irritable at home, have they had to cancel previously arranged engagements? Ask the patient what these symptoms mean to them. Some patients may down play or over play their symptoms. They may not have a good sense of reality of their symptoms, and their symptoms may cause anxiety. 

When assessing pain, we use the acronym PQRSTU. P is provocative or palliative which what causes the pain, what makes it worse or better. Q is qualitative where we ask the patient if they heard any popping sounds when their ankle broke, is the pain severe where they are doubled over, does it affect movement? Then we want to know the region of the pain and if it radiates. Then we assess the severity by asking the patient “on a scale of 0-10 10 being the worse pain, how would you rate your pain?  If there is a patient who does not speak English, is a child, or has comprehensive disabilities, we can use the faces pain scale to gather this data. Timing is where we ask when the pain started, how long it lasts for, and how frequently does it occur? Is the pain constant, or does it come and go? Lastly, how do the patient understand their pain? What does their pain mean to them? And that is what goes into the pain assessment. 

Next we go into the past medical history where we as about vaccinations, past or current accidents, serious or chronic illnesses, hospitalizations, and operations. If the patient is female, we will want to gather her obstetric history. How many pregnancies has she had (gravidity), number of pregnancies the have gone to TERM, number of pregnancies prior to week 37 (preterm), number of incomplete pregnancies (ABORTIONS), and the number of LIVING children. Gathering gynecological information is also important such as, is the patient sexually active, are they using contraception, when was their last menstrual cycle, and any abnormalities that may be associated with their cycle. 

Since we usually take a complete medical history when we are first seeing the patient or when we have not seen them in a while, you will want to ask when was their last check-up, imagings, or labs. 

Does the patient have any ALLERGIES, if so, what are they and what happens when they are exposed to their allergen. 

Then we look at their MEDICATION LIST. We call this MEDICATION RECONCILIATION because we are going over the meds the patient is taking. This includes prescribed, over-the-counter medication, and herbals and supplements. Take note if the patient is still taking those substances, how frequently, and the dosage. You can also ask them why they are taking it because there may be an off label use for the medication. 

Now we will look into family history. We want to know this information because there are genetic factors that play a role in a patient’s health. This can be either inherited health factors, or learned behaviors that affect our health. In some instances you can have create a genome or a family tree that depicts the members of your family, their gender, if they are alive, married, have children, and what health disparities they may have. If a patient or family member has any ailments you will want to note the age of onset.

After you have gathered all this data, we move on to the review of systems. This is where we look at each body system at a time and ask the patient specific questions about the discussed body system. This way, if the patient forgot to mention something, this is where they may remember to mention something that is current or a past history. When writing out what the patient says, you still want to avoid medical diagnoses and just write if symptoms are present or absent. With each system, be sure to provide health promotion for each system as you go along. 

When doing a complete health history on the elderly population, it is important to note that the process of the complete health history is very much the same as it would be for other generations. The elderly adults are those who are ages 65 or older. Elderly patients may downplay their symptoms because they do not think their symptoms are worth mentioning. The complete health assessment can take longer because they are likely to have chronic diseases. We do not need to gather a family health history on the patient, since they are in the later stages of their life, family history will no longer be needed to predict what they may experience. Chances are, if they were going to have something in their family history, they would have experienced it by now. We still want to perform the other steps of the complete health history though just as we would for our younger patients. For elderly female patients, still obtain an obstetrics history. 

We know that as we age, our vision, memory, hearing, and overall function declines. This can affect the patient’s ability to drive, move, maintain finances, or even be social. All of these can impact their health holistically. 

Elderly adults are likely to have polypharmacy, which is where they are taking a lot of medications, and it can take time to go through the medication reconciliation. We may need to detox some elderly patients because they are on so many medications that could be interacting with one another, but that’s a story for a different time. 

There are some differences though. We really look at the patient’s ability to perform activities of daily living, ADLs. We can perform a geriatric assessment which includes cognitional, spirituality, physical home environment for safety hazards, pain, economic, functional, and emotional status. There are a couple of key terms to know what we assess about the function of the patient. Functional ABILITY- THe patient’s ability to perform ADLs such as bathing, shopping, housework, and eating. FUNCTIONAL STATUS= ability to perform self-care, perform functions needed for independent living, and the ability to navigate social and physical environments. 

The Functional Assessment and Activities of Daily Living are an important part of the complete health history because we want to assess if they are able to complete common tasks themselves. This can give us a quick insight into quality of life as well. We want our patients to do all appropriate functions in their daily life. There are different aspects that make up the overall functional assessment and they are: a physical examination, self-care (activities of daily living), self-maintenance (instrumental activities of daily living OR IADL), and physical mobility. First you will ask the patient if they are able to perform specific ADLs, then we observe them performing those ADLs. 

So what is the actual definition of ADLs? They are necessary for self-care. This includes, eating, cooking, cleaning, grooming, walking, getting out of the chair, toileting, and so forth. 

There is an assessment known as the Katz Index of Independence in ADL and this assesses the physical ability of those who are affected by illnesses and those who are elderly. This is a screening tool where we assess if the patient is dependent for an ADL or independent. This can help us refer home services or PT/OT for the patient if needed. 

Instrumental Activities of Daily Living (IADL) include shopping, utilizing transportation, taking medications, cooking, managing your house and finances. Basically things that can make us independent and shows we are okay to live by ourselves. 

Lawton Instrumental Activities of Daily Living is basically the Instrumental Activities of Daily Living, but it tells what living situation would be best for the patient. The IADL is a prerequisite to the Lawton IADL. What sets the Lawton IADL apart is that it is a self-reported assessment. It is not about the patient’s ability, but their report of if they can do the tasks. We use this more when a patient is going to be discharged and we need to decide what kind of setting they should be in. Are they okay to go home, should they go to a rehabilitation facility, a Skilled nursing facility (SNF), or somewhere else? The areas we assess in Lawton IADL are the same as the IADL. We still look at the patient’s ability to use a phone, manage finances, shop, meal prep, do laundry, housekeeping tasks, use transportation, and take medications themself. 

Advanced Activities of Daily Living or AADLs is commonly used by Occupational Therapists. The parameters of this assessment looks at the patient’s ability to do their work (this can include paid work or volunteer work), hobbies, and socialization.

A lot of these ADL assessments are self-reported and the patient may not be as forthcoming as we would like them to be. This can make it difficult to get an accurate account of what is going on in the patient’s life. However, we can do a functionality assessment called the Timed Up and Go Test which assesses the patient’s ability to get up from a chair, walk 10 feet, and walk back to the chair to sit down. We want the patient to do this in 12 seconds or less. Those who take longer are at a higher risk of falls. As the patient is performing this assessment, we are watching their balance, gait, and ability to complete the assessment. 

Other things we want to assess for the elderly patient is their cognition, screen them for dementia, delirium, or depression, socialization skills, and caregiver burnout. Now, why do we look at these? Patients who have chronic illnesses or decrease physical ability are at a high risk for delirium and depression. They’re not able to do things themself as they used to, and it is sad to watch time go by around you. Also, patients who have dementia tend to have depression as well. Those who have chronic illnesses are likely to withdrawal from social settings and become more recluse. One reason is the fact they cannot get up and see people, another reason is the patient does not feel good, they do not look the same as they once did, and they do not want their loved ones to see them in the state they are in. We also want to see the if the patient has any type of support group, whether that is with family, friends, church, or any support group. Those who have a good support group tend to do better than those who have no support system. 

Cognition is important to assess with the aging adult because we often see this decline in later decades. For patients who have cognitive disabilities, keep questions and statements simple to yes or not questions. Present one question at a time, and allow the patient time to respond. You may need to have a caregiver answer questions if the patient’s cognition is poor. We can assess cognition with tools such as the Mini-mental state examination or the Montreal Cognitive Assessment. These both assess difference cognitive domain for patients can help identify not only cognitive decline, but also progression of dementia. 

As we lose the ability to take care of ourselves, we rely on caregivers to help us. This can lead to caregiver burden or burn out. The caregiver is not only trying to take care of themself, but they are also doing everything for the patient that they themself cannot do. We want the caregiver to also have a good support system too. This is beneficial to both the caregiver and the patient as well. This can improve patient outcomes and the health of the caregiver. 

Ways we can promote health and safety for our patients is to teach them how to prevent falls, how to get adequate sleep, and safe driving. To prevent falls, we want to remove any throw rugs, remove clutter, make sure the patient can walk safely at home, adequate lighting, and even use fluorescent tape on steps which can help with depth perception. Sleep is a concern because our bodies need sleep. Our minds need sleep for proper function. We can promote proper sleep by limiting caffeine intake, creating a sleep routine, no electronics an hour before bed, and restrict irritating foods and fluids prior to bedtime. 

As we age, our reaction time decreases and this can affect our driving skills. When patients are getting lost frequently, have increased accidents or close calls, issues with depth perception, or difficulty seeing the road signs or lights, then it is time to stop driving. 

Lastly, we can assess the patient for spirituality needs which can strengthen as we age. As the patient if they are spiritual and if there are any spiritual needs you can help with. You can have the Chaplain come see the patient, or contact their minister, priest, or rabai if the patient wishes. This can bring in a holistic approach to healing the patient. 

That is going to wrap up our complete health history assessment and functional assessment segment today. I hope you were able to take away something today and I was able to guide you in your studies. Have a great day, please like, rate, and subscribe, and remember: the best medication is patient education.