1. This document contains a nursing history for a patient, including demographic information and a functional health pattern assessment.
2. The functional health pattern assessment contains questions about the patient's usual and initial status in 12 areas: health perception, nutritional patterns, elimination patterns, activity level, sleep, cognitive function, self-perception, roles and relationships, sexuality and reproduction, coping and stress tolerance, values and beliefs, and other questions.
3. The assessment questions aim to understand the patient's baseline health as well as how their condition and functioning has changed since becoming ill or being hospitalized.
1. This document contains a nursing history for a patient, including demographic information and a functional health pattern assessment.
2. The functional health pattern assessment contains questions about the patient's usual and initial status in 12 areas: health perception, nutritional patterns, elimination patterns, activity level, sleep, cognitive function, self-perception, roles and relationships, sexuality and reproduction, coping and stress tolerance, values and beliefs, and other questions.
3. The assessment questions aim to understand the patient's baseline health as well as how their condition and functioning has changed since becoming ill or being hospitalized.
1. This document contains a nursing history for a patient, including demographic information and a functional health pattern assessment.
2. The functional health pattern assessment contains questions about the patient's usual and initial status in 12 areas: health perception, nutritional patterns, elimination patterns, activity level, sleep, cognitive function, self-perception, roles and relationships, sexuality and reproduction, coping and stress tolerance, values and beliefs, and other questions.
3. The assessment questions aim to understand the patient's baseline health as well as how their condition and functioning has changed since becoming ill or being hospitalized.
1. This document contains a nursing history for a patient, including demographic information and a functional health pattern assessment.
2. The functional health pattern assessment contains questions about the patient's usual and initial status in 12 areas: health perception, nutritional patterns, elimination patterns, activity level, sleep, cognitive function, self-perception, roles and relationships, sexuality and reproduction, coping and stress tolerance, values and beliefs, and other questions.
3. The assessment questions aim to understand the patient's baseline health as well as how their condition and functioning has changed since becoming ill or being hospitalized.
Download as DOCX, PDF, TXT or read online from Scribd
Download as docx, pdf, or txt
You are on page 1of 6
NURSING HISTORY
Part 1. Demographic Information
Name: ____________________________________ Nationality: _______________________________ Civil Status: _______________________________ Chief Complaint (s): ________________________ Address: __________________________________ Date and Time of Admission: _________________ Sex: _____________________________________ Diagnosis: ________________________________ Educational Attainment: _____________________ General Impression of Client (appearance upon first Religion: __________________________________ contact): Occupation: _______________________________ __________________________________________ Room and Bed No. __________________________ __________________________________________ Doctor/s in charge: __________________________ __________________________________________
Part 2. FUNCTIONAL HEALTH PATTERN ASSESSMENT
USUAL INITIAL 1. Health Perception- Health Management Pattern Usual: o How general health has been? o Any colds in the past year? o Previous hospitalizations and management/ treatment done o Check-up (regular?) o Most important things done to keep healthy (folk remedies, breast self-exam) o Use of cigarettes, alcohol, drugs o Easy to find ways to follow things nurses or doctors suggest? Initial: o What do you think caused this illness? o Actions taken when symptoms perceived? Results of actions? o Things important to you while you are here? How can we be most helpful? o Vital Signs o Medications o Labs: Hematology 2. Nutritional- metabolic pattern Usual: o Daily food intake (describe/categorized) Food taken? Consumes whole share? Supplements? o Daily fluid intake (in cc/ml) (describe) o Weight gain/ weight loss o Appetite o Discomforts in eating o Diet restrictions o Heal well/ poorly o Skin problems o Dental Problems Initial: o Daily food intake (describe/ categorized) Food taken? Consumes whole share? Supplements? o Measurement of intake: Ex: D5LR x 33 gtts/min- 500cc H2O- 300 cc Orange juice- 240 cc Soup 100 cc = 1.140 cc o Weight loss/ gain o Appetite o Diet restrictions o P.A integument, mouth, abdomen, capillary refill, Labs/ diagnostics: RBS, FBS, ultrasound of abdomen, liver, spleen. 3. Elimination pattern Usual: o Bowel elimination (describe) frequency? o Character? Discomfort? o Urinary Elimination (describe) frequency? o Amount in cc/ml, character? o Discomfort? Problem in control? o Excess perspiration? Odor Problems Initial: o Bowel elimination (describe) frequency? o Character? Discomfort? o Urinary Elimination (describe) frequency? o Amount in cc/ml, character? o Discomfort? Problem in control? o Excess perspiration? Odor Problems 4. Activity- Exercise Pattern Usual: o Routine daily activities o Sufficient energy for completing desired/required activities o Exercise pattern? Type? Regularity? o Spare time? Leisure activities? Initial: o Activities in the hospital? o Level of Consciousness? o Difficulty in breathing? Restless? o Level codes for the different activities o Sufficient energy to complete activities? o P.A: cardio, respiratory, extremities o Vital signs o Diagnostics: chest x-ray, ECG 5. Sleep-rest pattern Usual: o Sleep onset? Waking time? o Generally rested or ready for daily activities after sleep? o Sleep-onset problems? Aids? (like meds, with lights on, pillows, etc.) Nightmares? o Early awakening o Nap time Initial: o Sleep onset? Waking time? o Generally rested or ready for daily activities after sleep? o Sleep-onset problems? Aids? (like meds, with lights on, pillows, etc.) Nightmares? o Early awakening o Nap time o P.A: Appearance 6. Cognitive-perceptual pattern Usual: o Hearing difficulty? o Vision? Wear glasses? Last checked? o Any change in memory? o Easiest way to learn things? Any difficulty learning? Initial: o Hearing difficulty? o Vision? Wear glasses? Last checked? o Any change in memory? o Easiest way to learn things? Any difficulty learning? o Coherence in speech/ appropriate? o Pain? How do you manage it? o Pain medications o P.A: eyes, ears, nose, neurologic system 7. Self-perception- Self-concept pattern Usual: o How would you describe yourself most of the time? (feels good, not so good) o Things that make you angry? Annoyed? o Fearful? Anxious? Depressed? What helps? Initial: o How would you describe yourself now? o Changes in your body or the things you can do? Is this a problem to you? o Changes in the way you feel about yourself or your body (since illness started) o Things that make you angry? Annoyed, fearful? Anxious? Depressed? In the hospital. What helps? 8. Role- relationship Usual: o Live alone? Family? Family structure? o Problems you have difficulty handling? o How does family usually handle problems? o Family depends on you for things? If appropriate: how managing? o Problems with children? Difficulty handling? o Income sufficient for needs? o Feel part of neighborhood? o Belong to social groups? Friendly? Lonely? Initial: o How does family feel about your illness/ hospitalization? o Presence of family members in the hospital/ support system? o How does illness hospitalization affect family roles? 9. Sexuality-Reproductive Usual o Use of contraceptives? Problems? o History of any operations involving the reproductive system? o Female: when menstruation started? Last menstrual period? Menstrual problems? Para? Gravida? Initial o Observation: gestures of intimacy between partners? o If appropriate: any change or problems in sexual relation o PA: breast, genitals (as appropriate according to patients condition) 10. Coping stress tolerance Usual o Tense all the time? What helps? Use any medicines, drugs, alcohol? o Who’s most helpful in talking things over? o Big changes in your life, how do you handle them? Most of the time, are these ways successful? Initial o Tense all the time? What helps? Use any medicines, drugs, alcohol? o Who’s most helpful in talking things over? o How does family cope with your hospitalization? o How do you cope with hospital routines and treatment procedures? With hospital personnel/ health team? 11. Value-belief Usual o Generally, get things you want out of life? Most important things? o Religion important in your life? Does this help when difficulty arises? Initial o What is of value during hospitalization? o Spiritual practices in the hospital? o Will being here interfere with any religious practices? 12. Questions (other things not mentioned)