This document outlines the process and components of a health assessment for Mr. Binu Babu and Mrs. Jincy Binu. It discusses collecting a health history, which includes biographic data, chief complaints, present health history, past health history, family history, personal history, and socioeconomic history. The purposes of a health assessment are to collect physical, mental, social, and health-related problem data to determine a client's health status, the cause and extent of any diseases, the necessary treatment, and to formulate an appropriate nursing care plan. A health assessment involves collecting a health history and performing a physical examination.

1. HEALTH HISTORY
Mr. Binu Babu
Asst. professor
MSN (N)
Mrs. Jincy Binu
Lecturer
MSN (N)

2. HEALTH ASSESSMENT
Health assessment is the collection of data
about client’s health status.

3. PURPOSES
 To collect data about physical, mental and social
well being of client.
 To get clear picture of the client’s health status
and health related problems.
 To determine the cause and extent of disease.
 To determine the nature of treatment required
for client.
 To collect data systematically.
 To get a holistic (complete) view of the client.
 To formulate appropriate nursing care plan.

4. PROCESS OF HEALTH ASSESSMENT
Health history
Physical examination

5. HEALTH HISTORY
Health history is the collection of data
regarding client’s health in an chronological
order.

6. COMPONENTS OF HEALTH HISTORY
1. Biographic data
2. Chief complaints
3. Present health history
4. Past health history
5. Family history
6. Personal history
7. Socio economic history

7. 1. Biographic data
This includes information regarding client’s
name, age, gender, marital status, occupation,
education, I.P no, treating doctor & diagnosis.

8. 2. Chief complaints
It is the brief statement of client’s problem
for which client needs care.
Eg: Client is complaining of cough since 2
weeks, fever since yesterday and headache
since today.

9. 3. Present health history
Present health history is the expansion
of chief complaints. It should include location,
quality, quantity, exaggerating and relieving
factors.
Eg: Client is admitted to the hospital with the
complains of cough with mucus secretion since 2
weeks, cough increases during night and decreases
with rest, fever with temperature 100⁰F since
yesterday and headache at forehead since today
which decreases with rest and rates 7 in pain scale.

10. Present medical history
Present surgical history

11. 4. Past health history
It is the information about client’s previous
experience with any disease or surgery. This
health history includes the detail of
 Childhood illness
 Adult illness
 Psychiatric illness
 Injuries, burns, fractures etc.
 Hospitalization
 Surgical & diagnostic procedures
 Current medications

12. Past medical history
Past surgical history

13. 5. Family history
This is the information about the client’s family
members and their health status.
Family tree
This is the diagrammatic representation of
family members. Three generations has to be
denoted in family tree. Family tree is also
known as genogram.

14. - Male
- Female
- Male patient
- Female patient
- Male dead
-Female dead

15. Index
- Male
- female
Name, ageName, age
Name, ageName, ageName, ageName, age
Name, ageName, ageName, ageName, age

16. Index
- Male
- Female
- Patient
- Dead
Name, ageName
Name, ageName, ageName, ageName, age
Name, ageName, ageName, ageName, age

17. 6. Personal history
It includes client’s personal details such as
dietary pattern, sleep pattern, activity level,
elimination pattern, alcoholism, smoking habits
etc

18. 7. Socio economic history
Collecting data regarding client’s life style,
working environment, personal relationship
with other human beings, monthly or annual
income, housing facilities.

19. Health
assessment
Socio
economic
history
Health
history
Personal
history
Family
history
Present
health
history
Past health
history
Chief
complaints
Biographic
data
Medical
Surgical
Medical
Surgical
Physical
examination