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

Share:

More Posts

Shoulder Injuries and Disorders

Summary Your shoulder joint is composed of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone). Your shoulders are

Stroke Signs and Symptoms

Learn what to do if you or someone else is having a stroke. During a stroke, every minute counts! Fast treatment can lessen the brain damage

The Emotional Benefits of Exercise

Research shows the benefits of exercise go beyond just physical well-being. Learn how physical activity helps support emotional and mental health. Share this infographic and