Sie sind auf Seite 1von 8

University of San Jose-Recoletos

College of Nursing
Cebu City
Nursing Health History and Assessment Guide
Introduction
Definition of the Diseases
Causes / Risk Factors
Signs and Symptoms
Epidemiology / Statistics (Philippine setting)
Diagnostic Procedures
Medical Treatment
Nursing Responsibilities and Preventive Measures
II. Objectives (follow the guide found on the RLE manual page 159)
III. Client Profile
Date of Assessment: ______________________
Cases #: _______________________

Time: __________________
Room / Ward & Bed #: _______

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 Complains:
Under the service of Dr. ________/ Dept of (IM, Surgery, Pedia, OB-GYNE, Ophtha)
Patient
specify: (since when, meds, other intervention)
HPN:
Y/N - ________________________________________________
DM:
Y/N - ________________________________________________
Asthma: Y/N - ________________________________________________
Smoker: Y/N - (since when, ave. # of sticks/day)_____________________
Alcohol Beverage drinker: Y/N (frequency, type of drink, # bottles/amount)________
Allergies: Y/N
Food: _________________
Drug: _________________
HFD
HPN: Y/N - Maternal / Paternal
Asthma: Y/N - Maternal / Paternal
DM: Y/N - Maternal / Paternal
Others:
Past Medical History
Immunization:
______________________________________________________________________
______________________________________________________________________
Previous Hospitalization: (include date, name of hospital, complaints, # of days confined,
medication taken: for delivery AOG, date, when, type of delivery)
Past Illness:
Illness: ___________________
Age: _____________________
Management: ______________

Present Illness:
Illness: _____________________
Age: _______________________
Management: ________________

Environment History
House & Lot: OWNED / RENT
# of storey: __________________
Building materials: LIGHT MIXED STRONG
Location: (eg. Near the road)________________
# of room/s: ______________________
# 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)

Emergency Room Blotter / Record (copy details from the patients chart)

IV. Developmental History (determine the developmental stage of the patient according to
his/her age based on the different theories: Psychosocial, Psychosexual, Moral and Faith)

V. Gordons Functional Health Pattern


1. Health Perception / Health Management
Patients rating on health (1-10): ____________________
Importance of health (1-10): _______________________
Medical / Dental check-up: (how often, physician) ___________________________
Perceived ability to control and manage health: _____________________________
Resources used: (health center, private) ___________________________________
Health Habits: (seat belt, diet, alcohol consumption, tobacco use) _______________
Expectation for outcome of current health problem: __________________________
Expectation from caregiver: _____________________________________________
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 24 hours:
Comparison to typical diet:
Breakfast time
Lunch time
Usual menu:
Usual menu:

Dinner time
Usual menu:

Usual drink: ________________________


Amount/day: _______________________
Juice/tea/coffee: _____________________

food likes: __________________


food dislike: ________________

Appetite/Gana:
PTA: ____________________________
Admission: __________________________

food restrictions: ______________

Vitamins
Brand: ______________ Compliance: ____________
Amount: _____________
Weight
Present: ________
Previous: _______

Snack time
Usual menu:

Height: ___________
IBW: _____________

3. Elimination
Voiding/day: ______________
Color: ___________
Amount: ___________
Difficulty: Y/N
Mgt: ___________________________________
Problems: _______________________________

Dentures: Y/N
where: _____________
since when: _________
Dental exam: _______
Problem w/:
mastication: Y/N
swallowing: Y/N
BM/day: _______________
usual time: ____________

Sweat: ____________________________________

color & form: ____________


difficulties: Y/N
devices:
Suppository______________
Laxatives________________
Enema__________________

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

occupation related activities:


___________________________
___________________________
___________________________

Weekend schedule:
___________________________
___________________________
___________________________

leisure activities, hobbies:


___________________________
___________________________
___________________________

Exercise regimen:
___________________________________________________________________
___________________________________________________________________
Problems w/ ADLs: Y/N
Ambulation: ________ Bathing: ________ dyspnea w/ exertion: ___________
Dressing: __________ Toileting: _______ fatigue: _____________________
Feeding: ___________
5. Sleep-rest
Hours of sleep (PTA, admission): ______ _____
Hours obtained: ______________
Wake time: __________________

Problems:
falling asleep: Y/N
staying asleep: Y/N

Naps/rest periods: Y/N


Time: am / pm
# Of min.: _________________
Sleeping aids:
Meds: ___________________
Foods: __________________
Bev. : _____________________
Sex: _______________________

Rating of sleep quality:


_______________________
Sleep Regimens:
beauty: _________________
bath: ___________________

6. Cognitive-Perceptual
Ability to understand: ________________ Self rating of intelligence: _____________
Ability to communicate w/ others: ______
Educational level:
Ability to make decisions: ____________
School: ______________________________________
Vision
Glasses: Y/N
Since when: _________________
Grade: ______________________
Check-up: ___________________

Hearing: OK Y/N
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, moderate, heavy
Thelarche: _______________________ ave. napkins/day: __________________
Dysmenorrhea: ___________________
Mgt.; _________________________________________________________
Obstetric History
G__P__ __ __ __(GTPAL) pap smear: Y/N
Complication with pregnancy: ___________________________________________
BSE: Y/N
how often: ________________
***Male
Circumcised: Y/N
Age: ___________

Age of Climacteric: _______________

Sexual activity
1st contact: ___________________
History of STD: Y/N
Whom: ______________________
Post-coital problems: __________________________________________________
Present sexual activity: ________________________________________________
Problem with intercourse: premature ejaculation, pain, blending, impotence
Contraceptives used: (type, length of use)
___________________________________________________________________

8. Self-Perception / Self-Concept
Description of self: ____________________________________________________
Strengths: ________________________________________________________
Weaknesses: _____________________________________________________
Major concerns: ______________________________________________________
Health goals: ________________________________________________________
Body image and feelings about self: ______________________________________
Emotional status: _____________________________________________________
Effect 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, organization) ____________________
Most important person for the patient: _____________________________________
Whom does she/he approach when the problems arise: ____________________
__________________________________________________________________
Family
# of children: _______________________________
Individual relationship: ______________________________________________
GENOGRAM (use proper legend: - male, female, x patient, - deceased)
Refer to LAST PAGE...
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 your self: _____________________________
What stops you: ___________________________________________________
11. Values & Belief
Most important value: _________________________________________________
What patient perceives as important in life:_________________________________
Source of strength: ___________________________________________________
Religious Preference

Importance: ______________________________________________________
Frequency: _______________________________________________________
Where: __________________________________________________________
Life goals: __________________________________________________________
__________________________________________________________
Recent Changes in values & belief: _______________________________________
__________________________________________________________
Value-belief conflicts related to health: ____________________________________
__________________________________________________________
Special religious practices: _____________________________________________
___________________________________________________________________
GENOGRAM (use proper legend: - male, female, x patient, - deceased)

College of Nursing
DISCHARGE PLAN
Name of patient: _________________________ Room/Ward & Bed no.:_________________
Age: _________ Sex: _________ Civil Status: ____________ Occupation: _______________
Address: ____________________________________________________________________
Diagnosis: ___________________________________________________________________
Physician: ___________________________________ Date of Admission: ________________
Type of& Date of Surgery, If any __________________________________________________
____________________________________________________________________________
Objectives

Nursing Interventions
a. M ( Medication )

b. E ( Environment )

c. T ( Treatment )

d. H ( Health teaching )

e. O ( Observable signs/symptoms )

f.

D ( Diet )

g. S ( Spiritual )