Section II: Nursing Health History
Most commonly reported complains of patients during outpatient and emergency consultations are respiratory problems and concerns. The way you conduct your health history will depend on the client’s situation. The first session of the course focuses on how you will conduct nursing health history especially with the use of Gordon’s Functional Health Patterns Assessment. There are many questions that you can ask to the client and their significant others, however, you have to make it relevant and comprehensible to obtain the most needed information. Common or concerning respiratory symptoms are:
- Chest pain or chest discomfort which can also be associated with problems with the heart.
- Dyspnea or shortness of breath is a painless but uncomfortable awareness of breathing that is inappropriate to the level of exertion.
- Wheezes are musical respiratory sounds that may be audible to the patient and to others.
- Cough is a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi. These stimuli include mucus, pus, blood, as well as external agents such as allergens, dust, foreign bodies, or even extremely hot or cold air. Cough can be acute (< 3 weeks), subacute (>3 to 8 weeks), or chronic (>8 weeks). It can be dry or productive with sputum or phlegm.
- Hemoptysis refers to blood coughed up from the lower respiratory tract; it may vary from blood-streaked sputum to frank blood.
- Daytime sleepiness or snoring and disordered sleep. Ask about problems with snoring, witnessed apneas (defined as breathing cessation for ≥10 seconds), awakening with a choking sensation, or morning headache.
The art of questioning is a skill that is developed throughout the time by practice. Your questions should be thought critically and sensitively for you to analyze what is happening to the client and at the same time, demonstrate respect and comfort. Imagine if the client is having difficulty of breathing but still you want to perform comprehensive history of the client’s complain. Another scenario is because of nervousness attending an unconscious client, you are not able to think appropriate questions. Remember to always to frameworks to guide you in assessing the client. One of the most commonly taught assessment frameworks in school is the OLDCART method.
- Onset: Identify when the symptoms are first experienced. Determine if it is acute or chronic.
- Location: Ask the patient to locate the affected area to determine single or multiple site affectations.
- Duration: Determine how long has been the symptoms. Determine if it is intermittent or persistent.
- Characteristics: Ask the patient to describe the symptoms and its level of discomfort.
- Associated factors: Determine associated factors and what aggravates the symptom.
- Relieving factor: Determine what relieves the patient from the symptoms.
- Treatment: Ask the patient if consultation has been made, and what medications has been taken.
Smoking is one of the most common risk factors in the development of respiratory diseases. Part of your health history is to determine whether your patient is smoking or not. If the patient is smoking, you will need to compute for pack years.
Pack year is a way to measure the amount a person has smoked over a long period of time. It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years of smoking. The formulas for computing pack years are:
- Number of cigarettes per day / 20 x number of years of smoking = number of pack years
- Number of packs per day x number of years of smoking = number of pack years