ST.

ALEXIUS COLLEGE
Gen. San. Drive, City of Koronadal, South Cotabato, Philippines 09506, Tel.: (083) 228-2019, Fax: (083) 228-4015, Email: [email protected]

College of Nursing

DATABASE: PATIENT HISTORY AND NURSING INTERVIEW

HEALTH ASSESSMENT I

Biographical Data

Name :
Age :
Address :
Birthdate :
Birthplace :
Gender :
Civil Status :
Educational Attainment :
Occupation :
Religion :
Nationality :
Health Insurance :
Contact Person :

Name:
Address:
Contact Number:
Relationship to Patient:

Chief Complaint:

Main Problem:

Course of Present Illness:

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Admitting Diagnosis: ___________________________________________________________

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Past Health History

A. Childhood Illness
B. Surgeries
C. Deliveries
D. Injuries
E. Hospitalization
F. Adult Medical Problem
G. Medication (prescribed or maintenance)
H. Allergies
I. Immunization Status

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Family History

Maternal Side: ____________________________________________________________

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Paternal Side:_____________________________________________________________
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Psychosocial Profile – Gordon’s Functional Health Pattern

A. Health Perception-Health Management Pattern

1. Client’s Perceived Health Status

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2. Health Care Management

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3. Special Health Care Concerns

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B. Nutritional-Metabolic Pattern

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PHYSICAL EXAMINATION (OBJECTIVE CUES)

Current weight________ height__________

Body built_________________________________________________
Skin turgor: moist_________ dry____________
Edematous _____________ describe: __________________________
Mucous membranes: moist/dry: ________________
Breath sounds: crackles _______wheezes________ other sounds: ____________
Thyroid gland: enlarged: ______________
Condition of teeth & gums: (describe) ____________________________
Dentures: ____________ Cavities: ______________
Missing teeth: ______________________________________________
Appearance of tongue: ___________ halitosis ____ describe smell: ________________
Bowel sounds: (describe) ______________________________________
Skin lesions: (describe) ______________________________________

C. Elimination pattern

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EXAMINATION (OBJECTIVE CUES)

Abdomen: Tender______________ Rigid ___________ Soft________________

Palpable Mass: (describe) _______________________________________
Abdominal girth: ___________cm
Bowel sounds: (describe): _______________________________________
Hemorrhoids: ______________ Size: ______________
Bladder palpable: ___________
CVA tenderness: ___________

D. Activity-Exercise Pattern

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 SUBJECTIVE (REPORTS)

Occupation:______________________ Usual Activities: _____________________

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Leisure time act/hobbies:______________________________________________
Limitations imposed by condition:________________________________________
Sufficient energy for desired? required activities? (explain)
Exercise pattern? Type? Regularity? (describe)
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FUNCTIONAL LEVELS CODE: (Use Scaling for Self-care Abilities from 0 to 4)

Feeding: ___________________
Grooming: __________________
Toileting: ___________________
Bathing: ____________________
Bed Mobility: ________________
General Mobility: _____________
Dressing: ___________________
Home Maintenance: ___________

CIRCULATION: (Exhibits)

BP: R/L: Lying/ Sitting/ Standing: ____________________________

Heart sounds: Rate: ______________ Rhythm: ________________
Quality: _____________ Murmur: __________________
Extremities: Temperature: __________________
Color: _______________ Capillary Refill: _____________________
Color: General: _________________
Mucous Membranes: _____________ Lips: ___________________
Nail beds: _______________ Conjunctiva: ____________________
Sclera: __________________ Diaphoresis: ____________________

E. Sleep-rest Pattern

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 SUBJECTIVE (REPORTS)

Sleep: hours: _____________ Naps:______________

Generally rested after sleep?_________, if not, explain why___________________
Sleep onset problems? __________________
Needed aid? __________________________
Dreams? ______ Nightmares? ____________
Early awakening? __________________
Insomnia: _______ related to: _________
Feelings of boredom/dissatisfaction:_______________

F. Cognitive-Perceptual Pattern

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Neurosensory Assessment

SUBJECTIVE (REPORTS)

Fainting spells/dizziness:_________________
Headaches: Location: ___________________
Frequency: ___________________________
Tingling/ numbness/weakness (location): __________________________________
Stroke/Brain injury (residual effects): _________________________________
Seizures: Type: ___________ Aura: _____________________
Eyes: Vision loss: __________
difficulty: __________________
use of glasses: _____________
last checked: _______________
Ears: Hearing loss: _________
difficulty: ___________________
use of aids: _________________
Nose: sense of smell: _________
difficulty: ___________________
Epistaxis: __________________

OBJECTIVE: (Exhibits)

Mental status (note duration of change) ____________________________________

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Oriented/disoriented: Time: ___________
Place: ___________
Person: __________
Situation: _________ 5
MENTAL STATE: Check all that apply:

Alert: ________ Drowsy:________ Lethargic:__________

Stuporous: ________ Comatose: ___________
Cooperative: _______ Combative ___________
Delusions: _________ Hallucinations _________
Affect (describe) __________________________
Pupil: Shape: __________ Size: _____________
Reaction: R/L: _________________
Facial Droop: _________ Posturing: __________
Paralysis: _________________

PAIN/ DISCOMFORT

SUBJECTIVE ( REPORTS)
Location: _________________
Intensity: (0-10 with 10=most severe)
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Quality: describe:___________________________
Duration: _____________ Relieved by: _____________
Precipitating/ aggravating factors: _____________________________________
Effect on Activities: ______________________________________
Effect on Relationships: __________________________________

OBJECTIVE (EXHIBITS)

Facial grimacing: ______________________

Guarding affected area: _________________
Posturing: ____________________________
Behaviors: ____________________________
Changes in BP ________ Pulse: ___________
Narrowed Focus: _________
Emotional Response: ____________________

RESPIRATION

SUBJECTIVE (REPORTS)
Dyspnea/related to: ___________
Cough/ Sputum: _______________
History of: Bronchitis: ___ Asthma __
Tuberculosis: ____ Emphysema: ___
Recurrent Pneumonia: ___________
Smoker: ____ Pack/day: ______
Use of Respiratory aids: What type?
_________ Oxygen: _______

OBJECTIVE (EXHIBITS)

Respiratory rate: __________ Depth: ________

Use of Accessory muscles: ________________
Nasal flaring: ___ Cyanosis: _______________
Breath sounds: __________________________
Sputum characteristics: ______________________________________
Mentation/ Restlessness: _____________________________________
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G. Self-Perception/ Self-Concept Pattern

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SUBJECTIVE (REPORTS)

Stress factors: _______________________________

Ways of handling stress: _______________________
Financial Concerns: ___________________________
Relationship Status: ___________________________
Feelings of: Helplessness: ______________________
Hopelessness: _______________ Powerlessness: _________________
Explain these feelings:
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OBJECTIVE (EXHIBITS)

Emotional status: Check those that apply:

Calm: ____ Anxious: ____ Angry: ____ Withdrawn: ____ Fearful: ____
Irritable: ___ Euphopric: ____
Observed physiologic response:
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H. Role Relationship Pattern

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SUBJECTIVE (REPORTS)

Marital status: ________________________________

Years in relationship: __________________________
Perception of Relationship: ______________________
Living with: ______________________________
Concerns/ stresses/ family problems:
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Extended family?_______________________________
Role within family structure: _______________________
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 How do family feel about your illness/ hospitalization?____________________
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Feelings of mistrust/ rejection? ______________________________
Problems with children? _______________________
Belong to social groups?_______________________
Close friends? Feel lonely? _____________________
Things go well for you at work? (school?) __________
Income sufficient for needs? ____________________

OBJECTIVE (EXHIBITS) – Please check those that apply

Speech: Clear: ______ Slurred: ______
Unintelligible: _______ Aphasic: _______
Use of Communication aids: ________
Laryngectomy/ Tracheostomy present: __________
Verbal/ Nonverbal communication with family ________________________
Family interaction (behavioral pattern): _____________________________

I. Sexuality/Reproductive Pattern

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SUBJECTIVE (REPORTS)
Sexually Active: _________ Frequency: ______
Use of condoms: _______ Birth control method:
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Sexual Concerns/ difficulties: ______________
Sexual relationships satisfying: _____________
Recent change in frequency/ interest:
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OBJECTIVE (EXHIBITS)

Comfort level with the subject matter

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 FEMALE (SUBJECTIVE REPORTS):

Age at Menarche: ___________ Length of cycle: ______________

Duration: __________ No. of pads/ day: _________________
Last Menstrual Period: ___________ Pregnant now: ________
Bleeding between periods: ______________________
Menopause: ___________ Vaginal lubrication: _________________
Vaginal Discharge: _______ Describe: _______________________
Reproductive Surgeries: ___________________
Para: _________ Gravida: ____________
Practices BSE: _______ Last Pap Smear: ______

OBJECTIVE ( EXHIBITS)
Genital warts/lesions: __________________________
Unusual Discharge/ Odor: _______________________

MALE (SUBJECTIVE- REPORTS)

Penile Discharge: ___________ Prostate disorder: __________
Circumcised: ___________ Vasectomy: _____________
Practice TSE: _______________________

OBJECTIVE (EXHIBITS)
Breast: __________ Testicles: ___________
Genital Lesions: _______________________
Unusual discharges/ Odor: __________________________________
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J. Coping / Stress Tolerance Pattern

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K. Value-belief Pattern

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Summary of the Interview:

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Interviewer

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 ST. ALEXIUS COLLEGE
Gen. San. Drive, City of Koronadal, South Cotabato, Philippines 09506, Tel.: (083) 228-2019, Fax: (083) 228-4015, Email: [email protected]

College of Nursing

HEALTH ASSESSMENT II

Name: Ward No. /Room No.:

Age: Department:
Sex: Civil Status:
Address:
Nationality: Religion:
Occupation:
Educational Level:
Admitting Diagnosis:
Date of Admission:
Time of Admission:
Blood Type:

Allergies (specify in Red Ink):

Mental State Activities Bladder/Bowel

 Conscious  Ambulate  With I & O monitoring
 Drowsy  Dangle/Sit-up  Urinary Incontinence
 Unconscious  Bed Rest with toilet Privilege  Foley Catheter
 Comatose  Complete Bed Rest  Colostomy
Mood and Affect Hygiene and Comfort Diet and Nutrition
 Calm  Oral Care  NPO
 Anxious  Perineal Care  Clear Liquid
 Soft/Full
 Computed/Osteorized
 Appetite
 Ability to eat
Motor Status Bed Bath Tubes
 Normal  Partial  Thoracostomy
 Slurred speech  Complete  Tracheostomy
 Hemiplegia Grooming  Penrose
 Paraplegia
 Paresis  Good
 Fair
 poor

Other Information

Weight: ______ Weight: _______ 24 hour Urine Collection: _______

BP: ________ Temp: ________ PR: ______ RR: _______

Neurological Vital Signs: _______________

ABG Reading:

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Assessor
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 NURSING REVIEW CHART

Name:_________________________________ Room Number: __________ Date: ________

General Description:
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Instruction: SIGNIFICANT
Use “N” to indicate “NORMAL” condition. DATA
Use “A” to indicate “ABNORMAL” condition
Indicate your comments on the column for
“SIGNIFICANT DATA”
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Head _____
Skin _____ ________________
Lymph _____ ________________
Eyes _____ ________________
Ears _____ ________________
Nose _____ ________________
Mouth _____ ________________
Neck _____ ________________
Breasts _____ ________________
Chest ________________
Inspection _____ ________________
Palpation _____
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Percussion _____
Auscultation _____ ________________
Cardiovascular System ________________
Pulses ________________
Carotid _____ ________________
Brachial _____ ________________
Radial _____ ________________
Polpliteal _____ ________________
Dorsalis Pedis _____ ________________
Posterior Tibial _____ ________________
Heart ________________
Inspection _____
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Palpation _____
Percussion _____ ________________
Auscultation _____ ________________
Kidney _____ ________________
Uterus _____ ________________
Abdomen _____ ________________
Genitalia _____ ________________
Back and spine _____ ________________
Rectum _____ ________________
Extremities _____ ________________
Bones and joint _____ ________________
Neurologic
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Behavior _____
Mental Status _____ ________________
Reflexes _____ ________________
Motor Coordination _____ ________________
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Assessor
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