Normal Spontaneous Delivery

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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.
3.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
•...
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