ASSESSMENT: NURSING HEALTH HISTORY COLLECTING AND CLUSTERING SUBJECTIVE DATA (Initial Interview – Comprehensive) BASED ON GORDON’S FUNCTIONALHEALTH PATTERNS I. BIOGRAPHIC DATA Name: ____________________________________________________________ ___ Age: _______ Sex: ___________ Address: ____________________________________________________________ Race: ________________________ Marital Status: ___________ Occupation: _________________________ Religious Orientation: ________________ Health care financing and usual source of medical care: ____________________________________________________ II.
CHIEF COMPLAINT OR REASON FOR VISIT What brought you to the clinic or hospital? ____________________________________________________________ _______________________________________ What is troubling you? ____________________________________________________________ _______________________________________ III. HISTORY OF PRESENT ILLNESS Ask what was the chronological sequence of events in reference to the client’s chief complaint. When symptoms started? ________________________________________ How often? _____________________________________________________ Type of activity of client when problem occurred, etc. _______________________________________________ Was help/consultation sought? ____________________________________________________________ __________ Medication used? ____________________________________________________________ ______________________ Ask how problem has interfered with day life. If pain: 1. C-haracter 2. O-nset 3. L-ocation 4. D-uration 5. S-everity 6. P-attern 7. A-ssociated factors IV. PAST HISTORY A. Childhood diseases ___________________________ B. Immunizations ________________________________ C. Allergies (Food, Medicines) _______________________________ D. Accidents and injuries ____________________________________ E.
Hospitalizations (When? Why? )____________________________ F. Medication _______________________________________________ V. FAMILY HISTORY OF ILLNESS A. Health and ages of patients, siblings, children, or ages at death and causes B. Illness in the family similar to the patient’s C. Familial incidence of hypertension, tuberculosis, diabetes, seizures, mental illness; others especially as suggested by PI. VI. FUNCTIONAL HEALTH PATTERN A. Health Perception and Health Management Pattern 1. How has the general health been? 2. Any colds in the past? 3. Most important things done to keep health? You think these things make a difference to health? Include family folk/remedies if appropriate) 4. Use of cigarettes, alcohol, drugs? Breast examination? 5. In the past, has it been easy to find ways to follow things nurses/doctors suggest? 6. If appropriate: what do you think caused the illness? Actions taken when symptoms were perceived? Results of action? 7. If appropriate: things important to you while you are here in the hospital clinic? How can we be most helpful? 8. Traditional concepts of health and illness? Beliefs and practices? B. Nutritional and Metabolic Pattern 1. Typical daily food intake? Describe. Supplements? 2. Typical daily fluid intake? Describe. . Weight loss/gain? Amount? 4. Appetite? 5. Food or eating discomforts? Diet restrictions? 6. Heal well or poorly? 7. Skin problems? Lesions? Dryness? 8. Dental problems? C. Elimination 1. Bowel elimination pattern. Describe. Frequency? Characteristics? Discomfort? 2. Urinary elimination pattern. Describe. Frequency? Discomfort? Problem in control? 3. Excess Perspiration? Odor problems? D. Activity-exercise Pattern 1. Sufficient energy for completing desired required activities? 2. Exercise pattern? Type? Regularity? 3. Spare time: leisure activities? Child: play activities? 4. Perceived ability for (code level) Feeding •Bathing •Toileting •Bed mobility •Dressing •Grooming •General mobility •Cooking •Home maintenance •Shopping ? Level 0 – Full self-care ? Level 1 – Requires use of equipment or device ? Level II – Requires assistance or supervision from another person ? Level III – Requires assistance or supervision from another person or device ? Level IV – Is dependent and does not participate E. Sleep-Rest Pattern 1. Approximately how many hours do you sleep at night? 2. Any problem falling asleep? Do you take sleep medications? 3. Is your sleep continuous? Tired? 4. Take naps? When? (Morning/Afternoon) 5.
What do you do for relaxation? (Watch movie, read, dance, shopping, etc. ) F. Cognitive-perceptual pattern 1. Hearing? Difficulty? Aid? 2. Vision? Wear eyeglasses? 3. Any change in memory lately? 4. Easiest way for you to learn things? Any difficulty learning? 5. Any discomfort? Pain? How do you manage it? G. Self-perception 1. How do you describe yourself? Most of the time, feel good (not so good) about yourself? 2. Changes in your body or the things you can do? Problem to you? 3. Changes in way you feel about yourself or your body? (Since illness started) 4. Find things frequently make you angry? Annoyed?
Tearful? Anxious? Depressed? What helps? H. Role-relationship Pattern 1. Live alone? Family? Family structure (diagram)? 2. Any family problems you have difficulty handling? (Nuclear extended) 3. Hoe does family usually handle problems? 4. Family depends on you for things? If appropriate: How managing? 5. If appropriate: How family/others feel about your illness/hospitalization? 6. If appropriate: problems with children? Difficulty handling? 7. Belong to social groups? Close friends? Feel lonely frequently? 8. Things generally go well with you at work. 9. Feel part of (or isolated in) neighborhood where living?