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 NURSING HEALTH HISTORY

DEMOGRAPHIC DATA D. Economic Conditions:

Name: Source of Income:
Age: Health insurance:
Sex:
Date of Birth: E. Occupation:
Address: Past employment:
Civil Status: - Working Condition:
Religion: o Working Hours –
Occupation: o Job satisfaction –
Nationality: o Exposure to noise –
Educational Attainment: o Pollution –
Height: Present employment:
Weight: - Working Condition:
Position in the Family: o Working Hours –
o Job satisfaction –
A. Consumption of: o Exposure to noise –
- Alcohol: o Pollution –
- Coffee:
- Tea: F. Familial/Hereditary disease if any:
- Drugs: Paternal side:
Maternal side:
B. Cigarette smoking: (Cancer, HPN, heart disease, DM, epilepsy, mental illness, TB, Kidney disease, arthritis,
- Form: asthma, alcoholism, obesity)
- Pack per day:
- How long: Date & Time of Admission: __________________________________________
Attending Physician(s): __________________________________________
C. Home Conditions: __________________________________________
Nature of family relationship: Chief Complaints:
Role in the family: ___________________________________________________________________________
# of living children: ___________________________________________________________________________
Living arrangement & housing: ___________________________________________________________________________
- Owned: ___________________________________________________________________________
- Renting: Admitting diagnosis: __________________________________________________________
- Pets: Diet: __________________________________________
History of Present Illness:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

General Impression of Client (appearance upon first contact):

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

PAST HEALTH HISTORY

 Immunization status
 Known allergies – food, medication, etc.
 Childhood illness
 Adult illness
 Psychiatry illness
 Injuries – burns, fractures, head injuries
 Hospitalization
- Date:
- Diagnosis:
- # of days:
- Treatment:
 Surgical procedures
- Procedure:
- Date:
 Diagnostic procedures
- Procedure:
- Date:
 Medication history
 Use of alcohol
 USUAL FUNCTION PATTERNS INITIAL APPRAISAL ( )
1. HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN
asked by the nurse to provide an overview of the individual's health status and health VITAL SIGNS:
practices that are used to reach the current level of health or wellness T=
Clients perceived pattern of health and well-being and how health is managed. P=
Examples: Compliance with medication regimen, use of health-promotion activities such as R=
managed, regular exercise, annual check-ups. BP=
How has general health been?
 Any colds in the past year? MEDICAL DIAGNOSIS:
 Does this make a difference to your health?
 Management MEDICATIONS:
 Medications
 Alternative treatments

Most important things done to keep self healthy:

 Does this make a difference to your health?
 Folk remedies:
 Alcoholic beverages:
 Cigarette smoking: form: ______ pack/day: _____ how long: _____________
 Drug addiction:
 Breast self-exam
 Testicular self-exam

LAB EXAMS:
 Accidents at home, work, school, driving?

 If appropriate: any absences from work/school?

 In past, has it been easy to find ways to carry out doctor’s or nurse’s suggestions?
What do you think caused current illness?
What actions have you taken since symptoms started?
Have your actions helped?

(If appropriate) What things are most important to your health?

How can we be most helpful?

2. NUTRITIONAL – METABOLIC PATTERN
describes nutrient intake relative to metabolic need IVF BOTTLE:
Pattern of food and fluid consumption relative to metabolic need and pattern; indicators of DIET:
local nutrient supply. FOOD INTAKE:
Examples: Condition of skin, teeth, hair, nails, mucous membranes; height and weight. Breakfast –
Typical daily food intake? (Describe) Lunch –
Dinner –
 Use of supplements, vitamins Snacks –

 Typical daily fluid intake? (Describe) SUPPLEMENTS:

 Appetite: good ____ fair ____poor ____ FLUID INTAKE:

 Breastfeeding
 Infant feeding HEIGHT: WEIGHT:
 Weight loss? ALLERGIES:
 Weight gain?
DIET RESTRICTIONS:
Food or eating:
 Discomfort, swallowing difficulties, diet restrictions, able to follow?
 Skin problems:
 Diet restrictions  Lesions  jaundice
 Complied?  Dryness  cyanosis
 Wounds:  Pitting edema  scars
 Heal well?  Skin turgor  Temperature
 Heal poorly?
 Skin problems:
 Lesions  jaundice
 Dryness  cyanosis
 Pitting edema  scars
 Skin turgor  Temperature

 Dental problems
OBJECTIVE DATA:
 Skin assessment
 oral mucous membranes, teeth
 actual weight/height
 temperature.
Abdominal assessment
3. ELIMINATION PATTERN
Describes the function of the bowel, bladder and skin. Through this pattern the nurse is able to
determine regularity, quality, and quantity of stool and urine.
Patterns of excretory function (bowel, bladder, and skin). Includes clients perception of
"normal" urine and stool.
Examples: Frequency of bowel movements, voiding pattern, pain on urination, appearance of
function.
BOWEL BOWEL  Colostomy
Frequency – Frequency –
Character – Character –
Discomfort – Discomfort –
Problem with control – Problem with control –
URINARY URINARY  Catheter
Frequency – Frequency –
Discomfort – Discomfort –
Problem with control – Problem with control –
 Excess perspiration  Excess perspiration
 Body Odor  Body Odor
OBJECTIVE DATA:
 Drainage Characteristics, color, consistency

Abdominal assessment

4. ACTIVITY – EXERCISE PATTERN

This pattern centers on activity level, exercise program, and leisure activities.
Patterns of exercise, activity, leisure, and recreation.
Examples: Exercise, hobbies. May include cardiovascular and respiratory status, mobility, and
activities of daily living.
 Sufficient energy for desired and/or required activities?  Sufficient energy for desired and/or required activities?
Exercise pattern: Exercise pattern:
o Type o Type
o Regularity o Regularity
 Spare time (leisure) activities?
Perceived ability for Perceived ability for
 feeding  grooming  bathing  feeding  grooming  bathing
 general mobility  toileting  home maintenance  general mobility  toileting  home maintenance
 bed mobility  dressing  shopping  bed mobility  dressing  shopping
0 – full self care
 1 – use of equipment/device
2 – requires assistance/supervision
3 – dependent

OBJECTIVE DATA: OBJECTIVE DATA:

 Demonstrate ability for above criteria  Demonstrate ability for above criteria
 Gait  Gait
 Posture  Posture
 Absent body part  Absent body part
 Range of motion (ROM) joints  Range of motion (ROM) joints
 Hand grip - can pick up pencil?  Hand grip - can pick up pencil?
 Respiration  Respiration
 Blood pressure  Blood pressure
 General appearance  General appearance
 Musculoskeletal, cardiac and respiratory assessments.  Musculoskeletal, cardiac and respiratory assessments.

5. SLEEP – REST PATTERN

Assesses sleep and rest patterns
Patterns of sleep, rest, and relaxation.
Example: Clients perception of quality and quantity of sleep and energy, sleep aids, routines
client uses.
 Generally rested and ready for activity after sleep?  Generally rested and ready for activity after sleep?
 Sleep onset problems?  Sleep onset problems?
 Sleeping Aids?  Sleeping Aids?
 Dreams  Dreams
 Nightmares  Nightmares
 Early awakening? Sleep routine? Sleep apnea symptoms?  Early awakening? Sleep routine? Sleep apnea symptoms?
 Sleeping pattern:  Sleeping pattern:
o Hrs of sleep ____ o Hrs of sleep ____
o Nap: o Nap:
o Insomnia: yes ____ no ____ o Insomnia: yes ____ no ____

 Rest / relaxation periods?  Rest / relaxation periods?

 Special preferences  Special preferences
Sleep apnea symptoms? Sleep apnea symptoms?
 Waking up with a very sore or dry throat  Waking up with a very sore or dry throat
 Loud snoring  Loud snoring
 Occasionally waking up with a choking or gasping sensation  Occasionally waking up with a choking or gasping sensation
 Sleepiness or lack of energy during the day  Sleepiness or lack of energy during the day
 Sleepiness while driving  Sleepiness while driving
 Morning headaches  Morning headaches
 Restless sleep  Restless sleep
 Forgetfulness, mood changes  Forgetfulness, mood changes
 Recurrent awakenings or insomnia  Recurrent awakenings or insomnia
OBJECTIVE DATA OBJECTIVE DATA
 Evidences of sleep disturbance  Evidences of sleep disturbance

6. COGNITIVE – PERCEPTUAL PATTERN

Assesses the ability of the individual to understand and follow directions, retain information,
make decisions, and solve problems. Also assesses the five senses.
Sensory-perceptual and cognitive patterns.
Example: Vision, hearing, taste, touch, smell, pain perception and management; cognitive
functions such as language, memory, and decision making.
 Hearing difficulty?  Hearing aid?  Hearing difficulty?  Hearing aid?
 Vision problems?  Wears glasses?  Vision problems?  Wears glasses?
Last checked? When last changed? Last checked? When last changed?
 Any change in memory?  Concentration?  Any change in memory?  Concentration?

 Important decisions easy/difficult to make?  Important decisions easy/difficult to make?

 Easiest way for you to learn things? Any difficulty?  Easiest way for you to learn things? Any difficulty?

 Pain? ---management:  Pain? ---management:

Pain Scale: Pain Scale:
OBJECTIVE DATA OBJECTIVE DATA
 Orientation  Orientation
 Hears whispers?  Hears whispers?
 Reads newsprint?  Reads newsprint?
 Grasps ideas and questions (abstract, concrete)?  Grasps ideas and questions (abstract, concrete)?
 Language spoken.  Language spoken.
 Vocabulary level.  Vocabulary level.
 Attention span.  Attention span.

7. SELF-PERCEPTION – SELF-CONCEPT PATTERN

Clients’ self-concept pattern and perceptions of self.
Examples: Body comfort, body image, feeling state, Attitudes about self, perception of
abilities, objective data such as body posture, eye contact, voice tone.
How do you describe yourself? Most of the time, feel good (or not so good) about self? How do you describe yourself? Most of the time, feel good (or not so good) about self?

Changes in body or things you can do? Problems for you? Changes in body or things you can do? Problems for you?

Changes in the way you feel about self or body (generally or since illness started)? Changes in the way you feel about self or body (generally or since illness started)?

Things frequently make you: Things frequently make you:

Angry Mgt: Angry Mgt:
Annoyed Mgt: Annoyed Mgt:
Fearful Mgt: Fearful Mgt:
Anxious Mgt: Anxious Mgt:
Depressed Mgt: Depressed Mgt:
OBJECTIVE DATA: OBJECTIVE DATA:
 Eye contact.  Eye contact.
 Attention span (distraction?)  Attention span (distraction?)
 Voice and speech pattern  Voice and speech pattern
 Body posture  Body posture
 Client nervous (5) or relaxed (1) (rate scale 1-5)  Client nervous (5) or relaxed (1) (rate scale 1-5)
 Client assertive (5) or passive (1) (rate scale 1-5)  Client assertive (5) or passive (1) (rate scale 1-5)

8. ROLE – RELATIONSHIP PATTERN

Clients pattern of role engagements and relationships.
Example: Perception of current major roles and responsibilities (e.g., father, husband,
salesman); satisfaction with family, work, or social relationships.
 Lives alone  Feel lonely
 with Family
Family structure: Who is with him/her?
 Nuclear Family - The nuclear family is considered the “traditional” family and consists of
a mother, father, and the children.
How does your family feel about your illness?
 Single Parent - a parent who cares for one or more children without the assistance of
the other biological parent.

 Childless families consist of a husband and wife living and working together. The
childless family is sometimes the "forgotten family” because they don’t have children.

 Step Families - Over half of all marriages end in divorce, and many of these individuals
choose to get remarried. This creates the stepfamily, it consists of a new husband and wife
and their children from previous marriages or relationships. Who visited you here?

 Grandparent Family Many grandparents today are raising their grandchildren for a
variety of reasons and the parents are not present in the child's life.

 Extended Family - consists of grandparents, aunts, uncles, and cousins. In some

circumstances, the extended family comes to live either with or in place of a member of the
nuclear family.

 Any family problems you have difficulty handling (nuclear/extended family):

 Family or others depend on you for things?

How well are you managing?

If appropriate – How families/others feel about your illness?

 Problems with children?

 Belong to social groups?
 Close friends?
 Feel lonely? (Frequency)

 Things generally go well at work / school?

 If appropriate – income sufficient for needs?
 Feel part of (or isolated in) your neighborhood / participate in neighborhood activities

OBJECTIVE DATA:
Interaction with family members or others if present.

9. SEXUALITY – REPRODUCTIVE PATTERN

Patterns of satisfaction and dissatisfaction with sexuality pattern; reproductive pattern.
Example: Number and histories of pregnancy and childbirth; difficulties with sexual
functioning; satisfaction with sexual relationship.
 Sexual relationships satisfying?  Sexual relationships satisfying?
 Changes?  Changes?
 Problems?  Problems?
 If appropriate – Use of contraceptives?  If appropriate – Use of contraceptives?
 Problems?  Problems?
Female Female
When did menstruation begin (menarche)? When did menstruation begin (menarche)?
Last menstrual period (LMP)? Last menstrual period (LMP)?
Any menstrual problems? Any menstrual problems?

Regularity: Days: Amount: (soaked?) Regularity: Days: Amount: (soaked?)

# of pads per day: # of pads per day:
Color: Color:
 Menopause  Menopause
Gravida: Para: Abortion: Miscarriage:

10. COPING – STRESS TOLERANCE PATTERN

General coping pattern and effective of the pattern in terms of stress tolerance.
Example: Clients usual manner of handling stress, available support systems, perceived ability
to control or manage situations.
Common Stressors? Stressors?
Big problems now?

Coping Mechanisms: Coping Mechanisms:

 Any big changes in your life in last year or two? Crisis?  Support system
 Available now?
Who is most helpful in talking things over? Available to you now?

 Tense most of the time?

When tense, what helps?
 Relaxed most of the time?
 Use any medications, drugs, alcohol to relax?
Big changes in your life in the past two years?

When (if) there are big problems in your life, how do you handle them?

 Most of the time, are these ways successful?

 Support system

11. VALUE – BELIEF PATTERN

Patterns of values, beliefs (including spiritual), and goals that guide clients choices or
decisions.
Examples: Religious affiliation, what client perceives as important in life, value-belief conflicts
related to health, special religious practices.
Religion: Religion:
 Important to you?  Important to you now?
 Does this help when difficulties arise?
 Any religious groups?
 Church or any regular rituals Most important things?
 Pray
 Generally get things you want from life? Pray?
 Important plans for future?

 If appropriate – will being here interfere with any religious practices?

 Health beliefs