NUR 2092 HEALTH ASSESSMENT EXAM 1 STUDY GUIDE VERSION 2
Parts of a data base
o Complete (Total Health) Database
Complete Health History
Biographic Data (name, address, phone #, age, DOB, birthplace,
gender, marital status, race, ethnic origin, occupation)
Source of History
o Who furnishes info, how reliable, if person is sick or well
Reason For Seeking Care
Brief statement in person’s own words
Signs (objective data that can be seen, measured)
Symptoms (subjective data provided by client)
Present Health or History of Present Illness (HPI)
Well person: short statement about general state of health
Ill person: chronological record of reason for seeking care
o Location: specific, precise location of pain; superficial/deep
o Character/Quality: descriptive terms (burning, sharp/dull,
aching, gnawing, throbbing, shooting, viselike, etc)
o Quantity/Severity: 1-10 scale; how it effects ADLs
o Timing: Onset, Duration, Frequency
When did it start? (onset)
How long since onset?
How long does it last? (duration) constant/intermittent
Cycle of remission and exacerbation? (comes and goes)
o Setting: Where was client when it started? What brings it on?
o Aggravating/Relieving Factors: What makes pain
worse/better?
o Associated Factors: Is primary symptom related to any others?
o Patient’s Perception: How symptom affects ADLs? What do
you think it means? Any limitations because of symptom?
Past Health
o Childhood illnesses
o Accidents/injuries
o Serious/chronic illnesses
o Hospitalizations
o Operations
o Obstetric History
o Immunizations
, o Last Examination Date
o Allergies
o Current Medications
Family History
o Highlights diseases/conditions at increased risk for
Grandparents, parents, siblings, aunts/uncles, cousins
Review of Symptoms
(evaluate past/present health state of each body system, double-check
in case significant data omitted in HPI, evaluate health promotion
practices)
o General Overall Health State (present weight, fatigue,
weakness/malaise, fever/chills, sweats, weight gain/loss)
o Skin (disease, pigment/color/tone, moles, dryness/moisture,
pruritus, excessive/easy bruising, rash/lesion)
o Hair (recent loss, change in texture)
o Nails (change in shape/color/brittleness)
o Head (headache patterns, injury, dizziness (syncope) or vertigo)
o Eyes (vision difficulty, decreased acuity, blurring, blind spots,
pain, diplopia (double vision), redness, swelling, watering,
discharge, glaucoma, cataracts)
o Ears (aches, infections, discharge w/characteristics, tinnitus,
vertigo)
(hearing loss, hearing aids, environmental noise, cleaning ears)
o Nose/sinuses (discharge w/characteristics, frequent/severe
colds, sinus pain, nasal obstruction, nosebleeds, allergies, hay
fever, change in sense of smell)
o Mouth/throat (pain, sore throat, gum bleeding, toothache,
dysphagia, mouth/tongue lesion, hoarseness/voice change,
tonsillectomy, altered taste
(dental hygiene practices, dentures/bridges, last dental checkup)
o Neck (pain, limited ROM, lumps/swelling, enlarged/tender
nodes, goiter)
o Breast (pain, nipple discharge, rash, history of breast disease,
surgeries)
(breast self-exams, frequency/method used, last mammogram)
o Axilla (tenderness, lump/swelling, rash)
o Respiratory System (lung disease, asthma, emphysema,
bronchitis, pneumonia, TB, chest pain w/breathing,
wheezing/noisy breathing, SoB, cough, sputum w/description
(color, amount, viscosity), hemoptysis, toxin/pollution exposure
Parts of a data base
o Complete (Total Health) Database
Complete Health History
Biographic Data (name, address, phone #, age, DOB, birthplace,
gender, marital status, race, ethnic origin, occupation)
Source of History
o Who furnishes info, how reliable, if person is sick or well
Reason For Seeking Care
Brief statement in person’s own words
Signs (objective data that can be seen, measured)
Symptoms (subjective data provided by client)
Present Health or History of Present Illness (HPI)
Well person: short statement about general state of health
Ill person: chronological record of reason for seeking care
o Location: specific, precise location of pain; superficial/deep
o Character/Quality: descriptive terms (burning, sharp/dull,
aching, gnawing, throbbing, shooting, viselike, etc)
o Quantity/Severity: 1-10 scale; how it effects ADLs
o Timing: Onset, Duration, Frequency
When did it start? (onset)
How long since onset?
How long does it last? (duration) constant/intermittent
Cycle of remission and exacerbation? (comes and goes)
o Setting: Where was client when it started? What brings it on?
o Aggravating/Relieving Factors: What makes pain
worse/better?
o Associated Factors: Is primary symptom related to any others?
o Patient’s Perception: How symptom affects ADLs? What do
you think it means? Any limitations because of symptom?
Past Health
o Childhood illnesses
o Accidents/injuries
o Serious/chronic illnesses
o Hospitalizations
o Operations
o Obstetric History
o Immunizations
, o Last Examination Date
o Allergies
o Current Medications
Family History
o Highlights diseases/conditions at increased risk for
Grandparents, parents, siblings, aunts/uncles, cousins
Review of Symptoms
(evaluate past/present health state of each body system, double-check
in case significant data omitted in HPI, evaluate health promotion
practices)
o General Overall Health State (present weight, fatigue,
weakness/malaise, fever/chills, sweats, weight gain/loss)
o Skin (disease, pigment/color/tone, moles, dryness/moisture,
pruritus, excessive/easy bruising, rash/lesion)
o Hair (recent loss, change in texture)
o Nails (change in shape/color/brittleness)
o Head (headache patterns, injury, dizziness (syncope) or vertigo)
o Eyes (vision difficulty, decreased acuity, blurring, blind spots,
pain, diplopia (double vision), redness, swelling, watering,
discharge, glaucoma, cataracts)
o Ears (aches, infections, discharge w/characteristics, tinnitus,
vertigo)
(hearing loss, hearing aids, environmental noise, cleaning ears)
o Nose/sinuses (discharge w/characteristics, frequent/severe
colds, sinus pain, nasal obstruction, nosebleeds, allergies, hay
fever, change in sense of smell)
o Mouth/throat (pain, sore throat, gum bleeding, toothache,
dysphagia, mouth/tongue lesion, hoarseness/voice change,
tonsillectomy, altered taste
(dental hygiene practices, dentures/bridges, last dental checkup)
o Neck (pain, limited ROM, lumps/swelling, enlarged/tender
nodes, goiter)
o Breast (pain, nipple discharge, rash, history of breast disease,
surgeries)
(breast self-exams, frequency/method used, last mammogram)
o Axilla (tenderness, lump/swelling, rash)
o Respiratory System (lung disease, asthma, emphysema,
bronchitis, pneumonia, TB, chest pain w/breathing,
wheezing/noisy breathing, SoB, cough, sputum w/description
(color, amount, viscosity), hemoptysis, toxin/pollution exposure
