I.

Components of Nursing History a. BIOGRAPHIC DATA i. Name: ii. Address iii. Sex iv. Marital Status v. Occupation vi. Religious Preference vii. Health Care Financing b. CHIEF COMPLAIN OR REASON FOR VISIT i. What brought you to the hospital? c. HISTORY OF PRESENT ILLNESS i. When did you arrive here? ii. When did the symptoms started? iii. Is it sudden or gradual? iv. How often did the problem occur? v. Where is the exact location of distress? vi. How long have you had this problem? vii. Is there anything that makes this problem worse? viii. Is there anything that makes this problem better? ix. What were the interventions given to you? (medications, Laboratory and Diagnostic exams,etc) d. PAST HEALTH HISTORY i. What are your childhood illnesses? Have experienced chicken pox,mumps,measles ii. Do you still remember of you have completed all the immunization required during childhood? iii. Do you have any known allergies to food, drugs or animals? iv. Have you had any injuries or accidents before? 1. How, When and Where the incidence occurred 2. What type of injury? 3. What treatment was given? 4. Is there any complication with regards to that? v. Have you been hospitalized before? 1. What is the reason of Hospitalization 2. Do you still remember the date when youve been hospitalized? 3. What treatment was given to you? 4. Is there any complication with regards to that?

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vi. May I know the medication that youre taking right now? 1. OTC meds and prescribed FAMILY HISTORY i. May I know the ages of your siblings, parents and grandparents and their current state of health (If they are diseased, ask for the reason of death) ii. Is there anyone in your family that is suffering from Heart disease, cancer,diabetes,hypertension,obesity,allegies,arthritis,tuberculosis,bleedi ng,alcoholism and any mental health disorders LIFESTYLE i. What are your personal habits? ii. What consist your usual diet? iii. Do you smoke? 1. How many packs are consuming per day 2. When did you start smoking? iv. Do you drink alcoholic Beverages? 1. How often to you drink? 2. How much do you consume? v. What is your usual day sleep or wake time? 1. Do you have any problems with regards to sleeping? 2. Are you experiencing any difficulty in sleeping? a. What are your remedies for this? vi. What do you usually do? 1. Do you have any difficulty in basic activities of eating,grooming,dressing,elimination and locomotion? vii. Do you exercise? 1. What kind of exercise? 2. How much time are you allotting for this? viii. What are your hobbies? SOCIAL DATA i. What is your highest level of educational attainment? ii. How can you describe your family relationship? iii. Who helps you in times of need? iv. Who shoulders your hospitalization bills? v. Do you believe in cultural practices/ pamahiin? What are those? vi. What do you do for a living? PSYCHOLOGIC DATA i. What causes stress to you right now? ii. How do you cope up with this

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FUNCTIONAL HEALTH PATTERNS a. Health perception and Health Management i. How do you define Health ii. Do you consider health as one of your priorities? If so, what do you do to maintain your health status? b. Nutritional/Metabolic i. What is your Height? ii. What is your weight? iii. How often do you eat a day? iv. What do you usual eat? v. How many glasses of water do you consume a day? c. Elimination i. Have you experience any pain and discomfort in urinating? ii. Do you have regular bowel movement? 1. If you are constipated, what do you usually do? iii. Do you perspire easily? d. Activity/Exercise i. Are you physically active? ii. What type of exercise do you usually do? iii. How much time do you a lot for this? iv. DO you do household chores? (Like what?) e. Cognitive/Perceptual i. What is the day today? ii. Where are you now? iii. Who is our president? iv. What did you eat for breakfast? v. Where have you been last Sunday? f. Roles and Relationship i. Are you married? ii. Are you still together? iii. Do you have children? iv. Who takes care of them when you are not around? v. Hows your relationship with your friends, neighbours and co- workers? g. Self Perception/ Self Concept i. How do maintain your physical appearance? h. Coping/Stress i. How do you feel today? ii. What causes stress to you right now?

iii. How do you cope up with this? i. Values/Beliefs i. What is your religion? ii. Where do you prefer to go? (Doctor, Faith Healer, Hilot) iii. What class do you consider yourself? iv. Do you believe in God v. Do you go to church every Sunday? j. Medication/History i. Do you have any maintenance drugs? ii. Are you taking Over the Counter Meds? k. Nursing Physical Assessment i. Perform Head to Toe assessment to the client 1. If applicable: Inspect,palpate,ausculate and percuss 2. Give emphasis to the following area: a. Skin b. Nails c. Head d. Mouth e. Nose f. Eyes g. Ears h. Neck and Lymph Nodes i. Thorax j. Heart k. Breast l. Abdomen m. Genitals n. Upper and Lower extremities