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)