NURSING HEALTH HISTORY Is obtained by interviewing the patient, his family, and /or significant others.

. Reveals the patients level of wellness, changes in his life patterns, sociocultural role, mental, emotional and spiritual reaction to illness. Objectives in Taking Nursing Health History: - This will enables nurse to develop complete nursing care plan. Identify patterns of health and illness
Identify Risk factors Identify Physical and behavioural

Precipitating factors Relief measures Expectations from health caregivers

5. Past Health History

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Covers prior illness throughout development (infancy, childhood, adolescence, adulthood.) Previous hospitalizations Allergies Immunizations Idiosyncrasies Vices: Smoking (When did it starts, how many sticks/packs per day) caffeine intake, alcohol or drug abuse Use of prescribed and self prescribed medications Work habits Relaxation activities Exercise and sleep pattern

problems
Identify Deviation from normal and

available resources which the patient can use. Basic Components of Nursing Health History 1. Biographical and Social Profile - Includes age, sex, marital status, address, nationality, region, and ethnic group, dialects spoken, and occupation. 2. Classification Pay ward (Private) Service ward (Charity) Health Insurance (E.g: Medicare)

6. Family History
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This includes the health of parents, siblings, spouse and children Risk factors such as cancer, diabetes, heart disease, kidney disease, bleeding tendencies, asthma, hypertension, mental disorders and etc.

3. Mode of Admission
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Ambulatory, Stretcher-borne, Wheel- chair Alone or accompanied Emergency or walk in Name and address of companion if any

7. Emotional Profile

Attitude towards hospitalization Speech (whether clear or slurred) Concerns regarding treatment, illness, hospitalization and body imag

4. Present Illness or Health Concerns OFM

8. Environmental History Cleanliness of surroundings Hazards and pollutants Physical safety

Reason for seeking hospitalization Onset of illness whether gradual or sudden

9. Review of Systems
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Role- relationship pattern Sexuality- reproductive pattern Coping- stress tolerance pattern Value and belief pattern

Mental Status: level of consciousness and orientation Neuromuscular/ skeletal status: mobility, weakness and aid if any Sensory status: vision, hearing, aid if any Integumentary status: wound healing, condition of skin, color, warmth, turgor, presence of rashes, lesions and allergies Cardio- vascular/ respiratory status: quality of pulse, respiration rate, rhythm, activity of tolerance and need for assistance Nutritional Status: Type of diet, ability to chew, swallow; allergies if any, religious restrictions Gastrointestinal/ Genito-urinary Status: Major problems/ concerns in function, appetite, incontinence, infection, diarrhea, constipation, use of laxatives Reproductive Status: o Females- pregnancies, number of children, abortions, vaginal discharge, latest pap smear examination and result, self breast examination Males- any prostate problems, swelling, discharges, history of venereal disease
o

10. Functional Health Patterns Health perception- health management pattern Nutritional metabolic pattern Elimination pattern Activity- exercise pattern Cognitive- perceptual pattern Sleep- rest pattern Self- perception-self concept pattern

OFM