Nursing Health History and Assessment Guide

I. Objectives (follow the guide found on the RLE manual page 159)
II. Introduction
Definition of the Disease
Causes / Risks Factors
Signs and Symptoms
Epedimology / Statistics (Philippine Setting)
Diagnostic Procedures
Medical Treatment
Nursing Responsibilities and Preventive Measures

III.Client Profile
Date of Assessment:________
Room / Ward & Bed #:________

Time:________

Name:_________________________
Age:________
Sex:___
Marital Status:________
Birth date:________
Nationality:_________
Religion:________
Occupation:________
Address:_____________________________________________
Date of Admission:_________
Time:________
Traveled to Hospital via (Taxi, Private car, Ambulance):________
Accompanied by:________
Admitting Complaints:
Under the service of Dr. ________ / Dept. of (IM, Surgery, Pedia, OB-GYNE, Optha)
Patient
HPN:
DM:
Asthma:

Y/N
Y/N
Y/N

specify: (since when, meds, other interventions)

- ______________________________________________
- ______________________________________________
- ______________________________________________

Smoker:

Y/N

(since when, ave. # of sticks/day)_________________________

Alcoholic Beverage drinker: Y/N (frequency, type of drink, # no. bottles/amount)

_______________________________________________________

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Allergies: Y/N
Food: ____________________________
Drug: ____________________________
HFD
HPN:
DM:
Asthma:
Others:

Y/N Material / Paternal

Y/N Material / Paternal
Y/N Material / Paternal

Past Medical History

Immunization:
__________________________________________________________________
________________________________________________________________________
Previous Hospitalization: (include date, name of hospital, complaints, # of days confined,
medications taken)
Past illness:
Illness: ____________________
Age: ______________________
Manage: ____________________
Environmental History
House & Lot: OWNED / RENT
Building materials: LIGHT MIXED
Location: (eg, near the road)
# of rooms:

Illness: ____________________
Age: ______________________
Manage: ____________________
# of storey: ________
STRONG
# and type of toilet:__________________

Living Room:__________ Kitchen:__________ Dining Area:_________

Lives Together with:____________________________
Drainage System:______________
Garbage Disposal:_______________
Electricity:______________
Water:_______________
Domestic Animals:______________
Health Center:_______________
Market:_______________ Church:
_______________
Perception to Place (Peace & Order, relationship with neighbors)
History of Present Illness (what happened days / hours PTA)

IV.

Gordon's Functional Health Pattern (each pattern is divided into 2: PTA and during
Admission)

1. Health Perception / Health Management

Patient's rating on health (1-10):__________
Importance of health (1-10):__________
Medical / Dental check-up: (how often, physician)

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Perceive ability to control and manage health:

___________________________________
Resources used: (health center, private)
____________________________________________
Health Habits: (seat belt, diet, alcohol consumption, tobacco use)
____________________________
Expectations for outcome of current health problem:
_________________________________
Expectation from care giver:______________________________________________

Current Medications: OTC, Vitamins______________________________________________

Socio-economic factors: (financial concerns, insurance, Philhealth)
________________________________________
BSE/TSE: __________ How often:__________
Traditional Med (Hilot, Faith Healers): Y/N
Herbal Med: Y/N specify: _______________________________________________
2. Nutritional-Metabolic
Recall of food & fluid intake for past 24hours:
_________________________________________
Comparison to typical diet:
Breakfast time:
Lunch time:
Dinner time:
Usual menu:
Usual menu:
Usual menu:
Usual menu:
Usual drink:_________________________
_______________
Amount/day:________________
Milk: Y/N
Juice/Tea/Coffee:_______________
___________________
Appetite/Gana:
PTA:_______________
_____________
Admission:_______________

Snack time:

food likes:

food dislikes:

food restrictions:

Vitamins
Dentures: Y/N
Brand:_______________Compliance:________
where:________________
Amount:
Weight:
Present:________
Previous:________

since when:_______________
Dental exam:_____________
Height:
___________
Problems w/:
IBW:________
mastication: Y/N
swallowing: Y/N

3. Elimination
Voiding/day:
__________
Color: _________

BM/day: ________
usual time: ________

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Amount: ________
color & form:_______________________
Difficulty: Y/N
difficulties: Y/N
Mgt:___________________________________
devices:
Suppository __________
Problems:________________________________
laxatives ________
Enema ________
Sweat: ___________________________________

4. Activity-Exercise
Usual daily activity:
________________________________
________________________________
________________________________

occupation related activities:

___________________________________
___________________________________
___________________________________

Weekends schedule
__________________________________
__________________________________
__________________________________

leisure activities, hobbies:

___________________________________
___________________________________
___________________________________

Exercise regimen;
_________________________________________________________________________
__________________________________
Problems w/ ADLs: Y/N
Ambulation: _____
Bathing: _____
dyspnea w/ exertion: _____
Dressing: _____ Toileting: _____
fatique; _____
Feeding: _____

5. Sleep-Rest
Hours of sleep (PTA, Admission): _____ ________ Problems:
Hours obtained: ________
falling asleep: Y/N
Wake time: ________
staying asleep: Y/N
Naps/rest periods: Y/N
Time: am / pm
# of min.: _____

Rating of Sleep Quality:

__________________________________
Sleeping aids:
Meds: ___________________________
Foods: __________________________
__________________________
Bev: ____________________________
Sex: ____________________________

Sleeping Regimens:
beauty: ______________________
bath:

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6. Cognitive-Perceptual
ability to understand: _______________________
_______________

Self rating of intelligence:

Ability to communicate with others:

__________
Educational level:
Ability to make decisions:
__________________
School: _________________________________________________
Vision

Hearing: OK (Y/N)

Glasses: Y/N
Since when: __________
Grade: ___________
Check-up: _____________

hearing aid: ___________

since when: ____________
pain: ____________
discharges: ______________

Smell: OK (Y/N)
Speech: clear, stutter, slur
Touch: OK (Y/N)
Memory:
Long term: _______________________________________________
Short term: _______________________________________________
Learns best by: _______________________________________________
7. Sexuality-Reproductive
Level of Satisfaction with male/female role:
**Female
Menstrual History
Menarche:
______ ______ menstrual period; (regular, irregular)
Menopause:__________ flow: light, mode, ate, heavy
Thelarche: ____________
ave. napkins/day: __________
Dysmenorrhea: __________
Mgt.: _____________________________________
Obstetric History
G__P__ __ __ __ (GTPAL)
pap smear: Y/N
Complications w/ pregnancy:
___________________________________________________
BSE: Y/N
how often: ___________
**Male
Circumcised: Y/N
Age of Climacteric: __________
Age: ___________
Sexual Activity
1st contact:
___________
History of STD: Y/N
Whom: __________________
Post-coital problems: ___________________________________________________
Present sexual activity: _________________________________________________

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Problems with intercourse: premature ejaculation, pain, bleeding, impotence

Contraceptives used: (Type, length of use)
8. Self-Perception / Self-Concept
Description of Self:
Strenghts:
__________________________________________

Weaknesses:
__________________________________________
Major concerns:
__________________________________________
Health
Goals: ___________________________________________________________________
Body image and feelings about self:
__________________________________________
Level of satisfaction at current age:
__________________________________________
Emotional status:
_____________________________________________________________________
Effects of illness on self-perception:
___________________________________________________________________________
___________
___________________________________________________________________________
___________
9. Role-Relationship
Role in the family: ______________
Married life: _____________
Number of years: _____________

communication pattern: ____________

Interpersonal relationship within the family:

____________________________________________
Support system within the family:
__________________________________________
Family related problems:
__________________________________________________
Problems at work:
_________________________________________________________
Societal relationship:
___________________________________________________
Participation in social groups: (church, clubs, organizations)
__________________________________________________
Most important person for the patient:
_________________________________________________
Whom does he/she approach when problems arise:
_________________________________________________

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Family
# of children: _________________________________________
Individual relationship: __________________________________________
GENOGRAM (use proper legend: - male,
- female, X patient, + - decreased)
10. Coping & Stress Tolerance
Decision making: ____________________________________________________
Stressor
Minor: __________________________________________________

Major: __________________________________________________
Most stressful event: __________________________________________________________
Stress management techniques: (15 S, eating, self-medication, counseling, exercise)
Effectiveness:
____________________________________________________________
___________________________________________________________________________
Availability and Effectiveness of support system:
__________________________________________________________________
What would you like to change about yourself: _________________________________
What stops you:
______________________________________________________________
11. Values & Belief
Most important value: ____________________________________________________
what patient perceives as important in life: ______________________________________
Source of strenght:________________________________________________________
Religious Preference
Importance: _____________________________________________________________
Frequency: ______________________________________________________________
Where: _________________________________________________________________
Life Goals:
_________________________________________________________________________
__________________________________________________________________________
Recent Changes in Values & belief:
______________________________________________
__________________________________________________________
Values-belief conflicts related to health:
______________________________________________
_________________________________________________________
Special religious practices:
__________________________________________________________________________

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V. Mental Status Exam

A. Client's Profile
Name of Patient:
Age:
Sex:
Civil Status:
Religion:
Occupation:
Chief complaints:
B. General Appearance:
(type and condition of clothing, cleanliness, physical condition and posture)

C. Behavior:
Note the following:
(Expression of anger: covert, overt, verbal, or physical)
(Degree of cooperation: resistance, or evasiveness)
(Social skills: positive, unpleasant habits, shyness, withdrawal)
(Amount/type of motor activity: psychomotor retardation, agitation, restlessness, tremors,
lack of activity)
D. Orientation:
(Orientation to time, place, and person and level of consciousness)
E. Memory:
(Note presence of amnesia, blackouts and confabulation)
F. Thought Clarity
(Coherence, confusion, vagueness)
G. Thought Process Reflected in Speech:
(Flight of ideas, blocking, loose associations, neologism, word salad)
H. Thought Content
(Suicidal ideas, homicidal ideas/plans, suspicious, phobias, obsessions, blaming of others,
denial, helplessness, hopelessness, worthlessness, guilt)
I. Hallucinations:
(visual and/or auditory)
J. Delusions:
(of reference, persecution, grandeur, religious, or somatic)
K. Affect/Mood
(Blunted, flat effect; inappropriate affect; anxiety level; elevated or depressed mood; specific
feelings expressed)
L. Insight
(Degree of awareness of problems and their causes)
M. Judgment
(Soundness of problem solving and decisions)
N. Motivation
(Degree of motivation for treatment)

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VI. Anatomy and Physiology (Have a brief introductory statement before each system stating its
relevance in the case)
VII.

Psychopathophysiology (use Host-Agent-Environment Model)

VIII.

Psychodynamic (Eik Erikson, Jean Piaget, Sigmund Freud and Harry Stack Sullivan's

theories)
IX. Nursing Care Plan (at least ten 10 Problems actual or potential) Refer to format on page 153

and 161 of the RLE

Manuals. Prioritized Identified problems)
X. Drug Study (Indicate prescribed dosage)
XI. Discharge Plan (METHODS) Refer to page 157 and 161 of RLE manual
XII.

Bibliography

XIII.

Learning Insights (Individual)

//jveracruz

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