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Components of Nursing Health History

Components of Nursing Health History

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Published by: renz_redoblado on Jan 29, 2010
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03/25/2013

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Components of Nursing Health HistoryBIOGRAPHIC DATA
Includes client’s name, address, age, sex, marital status, occupation, religious preference,health care financing, and usual source of medical care.
CHIEF COMPLAINT OR REASON FOR VISIT
The client’s answer to the question “What brought you to the hospital?” or “What istroubling you?” is expressed in the client’s own words
HISTORY OF PRESENT ILLNESS
This includes the onset of symptoms, when the symptoms started, if its development wassudden or gradual, severity and frequency of occurrence, the site or exact location of distress; the character of the complaint, its intensity or quality of discharge, sputum, etc.;activity of the client which may be involved in the development of the problem, phenomena or symptoms associated with the chief complaint, and the factors thataggravate or alleviate the problem.
PAST HISTORY
This includes childhood illnesses, immunizations, allergies to drugs, animals, or other environmental agents, accidents and injuries, hospitalizations for serious illnesses, andmedications currently used.
FAMILY HISTORY OF ILLNESS
This is to ascertain risk factors for diseases. Particular attention should be given todisorders such as diseases of the heart, tuberculosis, cancer, diabetes, hypertension,obesity, allergies, arthritis, bleeding, alcoholism, and any mental disorders.
LIFESTYLE
This includes personal habits, diet, sleep/ rest patterns, activities of daily living,instrumental activities of daily living, recreation or hobbies.
SOCIAL DATA
This pertains to quality of family relationships/friendships, ethnic affiliation, educational background, occupational history, economic status, home and neighborhood conditions.
PSYCHOLOGICAL DATA
 
These are major stressors experienced by the client and their perception of them, howthey cope up with these stressors, their communication to relay appropriate emotion.
PATTERNS OF HEALTH CARE
Includes all the health care resources that the client is currently using and has used in the past.
Review of Systems
The following list illustrates the content of a
complete
review of systems.
General/Constitutional
 Average weight, weight loss or gain, general state of health, sense of well-being,strength, ability to conduct usual activities, exercise tolerance
Skin/Breast
 Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growthor loss, nail changesBreast lumps, tenderness, swelling, nipple discharge
Eyes/Ears/Nose/Mouth/Throat
 Headaches (location, time of onset, duration, precipitating factors), vertigo,lightheadedness, injuryVision, double vision, tearing, blind spots, pain Nose bleeding, colds, obstruction, dischargeDental difficulties, gingival bleeding, dentures Neck stiffness, pain, tenderness, masses in thyroid or other areas
Cardiovascular
 Precordial pain, substernal distress, palpitations, syncope, dyspnea on exertion,orthopnea, nocturnal paroxysmal dyspnea, edema, cyanosis, hypertension, heartmurmurs, varicosities, phlebitis, claudication
Respiratory
 Pain (location, quality, relation to respiration), shortness of breath, wheezing,stridor, cough (time of day, of productive, amount in tablespoons or cups per dayand color of sputum), hemoptysis, respiratory infections, tuberculosis (or exposure to tuberculosis), fever or night sweats
Gastrointestinal
 Appetite, dysphagia, indigestion, food idiosyncrasy, abdominal pain, heartburn,eructation, nausea, vomiting, hematemesis, jaundice, constipation, or diarrhea,abnormal stools (clay-colored, tarry, bloody, greasy, foul smelling), flatulence,hemorrhoids, recent changes in bowel habits
Genitourinary
 Urgency, frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or change in) color of urine, stones, infections, nephritis, hesitancy, change in size of 

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