Nursing History

Nursing History

  • Subject Data
    • Important Health Information
      • Past health history
        • Major childhood and adult illnesses, injuries, hospitalizations, and surgeries
      • Medications
        • Past and current medications, including prescription and illicit drugs, over-the-counter drugs, vitamins, herbs, and dietary supplements.
        • Question older adult and chronically ill patients about medication routines.
      • Allergies
        • Fully explore the patient’s history of allergies to drugs, latex, contrast media, food, and the environment
      • Surgery or other treatments
        • Record all surgeries, along with the date of the event, reason for the surgery, and outcome
    • Functional Health Patterns
      • Health perception–health management pattern
        • Ask the patient to describe his or her personal health and any concerns about it
        • Explore the patient’s feelings of effectiveness at staying healthy by asking what helps and what hinders his or her well-being.
        • Ask the patient to rate his or her health as excellent, good, fair, or poor, and record this information in the patient’s own words, if possible
        • The questions for this pattern also seek to identify risk factors by obtaining a thorough family history (e.g., cardiac disease, cancer, genetic disorders), history of personal health habits (e.g., tobacco, alcohol, drug use), and history of exposure to environmental hazards (e.g., asbestos).
      • Nutritional-metabolic pattern
        • If a problem is identified, ask the patient to keep a 3-day food diary for a more careful analysis of dietary intake.
        • Assess the impact of psychologic factors such as depression, anxiety, stress, and self-concept on nutrition.
        • Determine socioeconomic and cultural factors such as food budget, who prepares the meals, and food preferences.
      • Elimination pattern
      • Activity-exercise pattern
      • Sleep-rest pattern
      • Cognitive-perceptual pattern
      • Self-perception–self-concept pattern
      • Role-relationship pattern
      • Sexuality-reproductive pattern
      • Coping–stress tolerance pattern
      • Value-belief pattern
        • Document the patient’s ethnic background and effects of culture and beliefs on health practices

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