Lyceum of the Philippines University

COLLEGE OF NURSING
Intramuros, Manila

GUIDE FOR NURSING PROCESS

COMPLETE NURSING HEALTH HISTORY: WELL/SICK PEDIATRIC AND ADULT
CLIENT
Name: ____________________________________Section/Group: ________Date: _________
Place of Experience: ________________________
A, ASSESSMENT
NURSING HEALTH HISTORY
(7 Components)
1.

Identifying Data and Source of History

Psychosocial and Cultural History

Age:
_______________
Marital Status: _______________
Occupation:
_______________
Religious affiliation: ____________
Country of Origin ______________
Military Service ________________

2.

Gender:
__________________
Number of Children:
__________________
Highest Level of Education: __________________
Place of residence:
__________________
Primary Language
__________________
Foreign Travel/residence
__________________

Date and Time of History _______________________________

Source of the History___________________________________

Reliability ___________________________________________

Reason for seeking health care / or the Chief Complaint(s) Why was the client admitted?
(the one or more symptoms or concerns causing the patient to seek care)

_______________________________________________________________________________
_______________________________________________________________________________

3.

History for seeking health care/ or of the Present Illness ( Why is this client still hospitalized?)
(describes how each symptoms develop: pulls in relevant portions of the ROS called pertinent positives and negatives:
may include medication allergies, habits of smoking, and alcohol which are frequently pertinent to the present illness.)

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Medications
(name, dose, route, frequency of use, home remedies, non-prescription drugs, vitamins and herbal supplements, oral
contraceptives and medicines borrowed from family members or friends.)

________________________________________________________________________
________________________________________________________________________
Allergies including specific reaction to each medication: _________________________________
_______________________________________________________________________________

Tobacco Use
(report in pack-years a person who has smoke 1 pack of cigarettes a day for 12 years has an 18-pack year history. If
someone has quit note for how long.)

Alcohol and Drug Use

_______________________________________________________________________________
_______________________________________________________________________________

4.

PAST HEALTH HISTORY

Childhood Illnesses:
(communicable and chronic illnesses)

_________________________________________________________
_________________________________________________________
Injuries/Accidents:

_________________________________________________________
_________________________________________________________

Previous Hospitalizations:__________________________________________________________
_________________________________________________________
Adult Illnesses:
Medical:________________________________________________________________________
(include hospitalizations; and risky sexual practices)

Surgical: _______________________________________________________________________
(dates, indications, and types of operations)

OB/Gyne:_______________________________________________________________________
(obstetrical history, menstrual history, methods of contraception)

Psychiatric: _____________________________________________________________________
(illness, and time frame, diagnosis, hospitalizations, and treatments)

Health Maintenance Practices

Immunizations: __________________________________________________________________
Screening test: ___________________________________________________________________
Tuberculin test, pap smear, mammography, blood exams, results and when they were last performed)

5.

Family Health History

(documents presence or absence of specific illnesses in the family, such as hypertension, CAD, etc.)

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Family Genogram with Family Illnesses
(outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents)

6.

Personal and Social History

(describe the patients personality and interest, sources of support, coping style, strengths, and fears. Include lifestyle habits that
promote health or create risk such as exercise and diet, safety measures and alternative health care practices.)

7. Review of Systems (ROS)

General:
(usual weight, recent weight change, weakness, fatigue and fever)

__________________________________________________________________________________________
__________________________________________________________________________________________
Skin:
(rashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails and color/sizes of moles)

__________________________________________________________________________________________
__________________________________________________________________________________________
Head, Eyes, Ears, Nose Throat (HEENT)
(headache, head injury, vision, glasses or contact lenses, last eye exam, glaucoma, cataract, hearing, vertigo, hearing aids, frequent colds,
nosebleeds, bleeding of gums, dentures, last dental exam, sore throat; hoarseness)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Neck:
(swollen glands, goiter, lumps, pain, stiffness in the neck) ___________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________
Breast:
(lump, pain, discomfort, nipple discharge, BSE)

__________________________________________________________________________________________
__________________________________________________________________________________________
Respiratory:
(cough, sputum, hemoptysis, dyspnea, last chest x-ray)

__________________________________________________________________________________________
__________________________________________________________________________________________
Cardiovascular
(high blood pressure, chest pain, palpitation, dyspnea, edema, past ECG or other heart test results)

__________________________________________________________________________________________
__________________________________________________________________________________________
Gastrointestinal
(difficulty swallowing, heartburn, appetite, nausea, vomiting, indigestion, bowel movements, abdominal pain, food intolerance, belching, or
passing of gas, jaundice.)

__________________________________________________________________________________________
__________________________________________________________________________________________
Peripheral Vascular
(intermittent claudication, leg cramps, varicose veins, color changes in finger tips and toes during cold weathers, swelling with redness ot
tenderness)

__________________________________________________________________________________________
__________________________________________________________________________________________
Urinary
(changes in the pattern of urination, flank pain, kidney stones, suprapubic pain, incontinence)

__________________________________________________________________________________________
__________________________________________________________________________________________
Male Reproductive
(hernias, discharge from or sores on the penis, scrotal swelling, history of STD and treatment, sexual habits, birth control methods-condom)

__________________________________________________________________________________________

__________________________________________________________________________________________
Female Reproductive
(age at menarch: regularity, frequency, and duration of periods: amount of bleeding: LMP, dysmenorrhea: PMS, age at menopause and
symptoms: if born before 1971 exposure to DES: number of pregnancies and type of deliveries, number of abortions, birth control methods,
sexual preference)

__________________________________________________________________________________________
__________________________________________________________________________________________
Musculoskeletal
(muscle or joint pain, stiffness, arthritis, gout, backache)

__________________________________________________________________________________________
__________________________________________________________________________________________
Psychobiologic
(nervousness, tension, mood and memory change, suicide attempts)

__________________________________________________________________________________________
__________________________________________________________________________________________
Neurological
(fainting, blackouts, seizures, paralysis, numbness, tingling, tremors)

__________________________________________________________________________________________
__________________________________________________________________________________________
Hematologic/immunologic
(easy bruising, or bleeding, past transfusions and reactions, autoimmune disorders)

__________________________________________________________________________________________
__________________________________________________________________________________________
Endocrine
(thyroid trouble, heat intolerance, excessive sweating, diabetes, excessive thirst or hunger, polyuria, change in glove or shoe size)

__________________________________________________________________________________________
__________________________________________________________________________________________

PHYSICAL ASSESSMENT
Using IPPA record findings following the attributes, body functions and system:
General Survey
(physical appearance, age, hygiene, grooming, posture, mobility, use of ambulatory devices, weight, height and vital signs)

__________________________________________________________________________________________
__________________________________________________________________________________________

Skin
________________________________________________________________
________________________________________________________________
Head Eyes, Ears Nose, Throat (HEENT)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Neck
________________________________________________________________
________________________________________________________________
Back
________________________________________________________________

________________________________________________________________
Posterior Thorax and Lungs
________________________________________________________________
________________________________________________________________
Breast and Axilla
________________________________________________________________
________________________________________________________________
Anterior Thorax and Lungs
________________________________________________________________
________________________________________________________________
Cardiovascular System
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Abdomen
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Lower Extremities
________________________________________________________________
________________________________________________________________
Nervous System
Mental Status

________________________________________________________________
________________________________________________________________

Cranial Nerves

________________________________________________________________
________________________________________________________________

Motor System

________________________________________________________________
________________________________________________________________

Sensory System

________________________________________________________________
________________________________________________________________

Reflexes

________________________________________________________________
________________________________________________________________

Additional Examination
Rectal Exam for Men
________________________________________________________________
________________________________________________________________
Genital and Rectal Exam in Women
________________________________________________________________
________________________________________________________________

OTHER SOURCES
Laboratory Data
Laboratory Test

Indication to the
Patient

Normal Value

Clients Value

Diagnostic Test
- Non-Invasive
- Invasive

On-Going Appraisal
(Significant changes negative or positive on a daily basis)
Date
Time

Progress Notes

Nurses Notes

Reference:
Bickley, Lynn S. Bates Guide to Physical Examination 2009 10 th Edition
Timby, Barbara K. Introductory Medical-Surgical Nursing, 2010 10th Edition
ADPCN BSN Resource Unit 2008. 3rd Edition

Interpretation