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