Nursing Process – Additional Inputs o Avoidance of legal action

o Hold the nurse accountable and responsible for the complete,

Nursing (ANA) – the diagnosis and treatment of human responses to actual or accurate and relevant steps in the nursing process.
potential health problems.
Nursing Health History
Process – a course of action or proceedings, a continuous progression from one
point to another to achieve a specific goal. • Refers to data collected about the client’s current level of wellness,
including a review of body systems, family and health history, socio-cultural
Nursing Process history, spiritual health, mental and emotional reactions to illness
• Obtained during an interview
• a dynamic, continuous process which allows for a nurse to modify care as
• Includes:
needed.
1. Biographical info
• a deliberate intellectual activity whereby the practice of nursing is
2. Reason for seeking health care – CHIEF COMPLAINT
approached in an orderly, systematic manner that focuses on identifying
3. Client expectations
and treating unique responses
4. Present illness or health concerns
• a systematic, rational method of planning and providing nursing care.
5. Health history
• a cyclical; that is, its components follow a logical sequence, but more than 6. Family history
one component may be involved at one time. 7. Review of systems
Purpose of Nursing Process 8. Environmental history
9. Psychosocial history
• To organize and deliver nursing care. 10. Spiritual health
• Allows the nurse to integrate elements of critical thinking to make
judgements and take actions based on reason. 1. Biographic/Demographic data
• It is a variation of scientific reasoning that allows nurses to organize and • Personal data: name, address, age, sex, marital status, occupation, religion,
systematize nursing practice. health care financing, insurance
• To identify client’s health status, actual or potential health problems. 2. Chief complaint
• To establish plans and to meet identified needs. • Reason for seeking health care
• To derive specific nursing interventions to address client’s needs. • Should be recorded in the client’s own words
• It encourages identification and utilization of client’s strength. o Fell off 4-foot ladder and landed on right shoulder
• It enhances communication and continuity of care, thus reducing omissions o Cough with yellowish phlegm for 4 days
and duplication of patient care.
3. History of Present Illness
Importance of the Nursing Process • When the signs/symptoms started
• Whether the onset was sudden or gradual
• For the Client
• How often the problem occurs
o Quality client care
o Continuity of care • Exact location of distress
o Participation by the clients in their health care • Character of the complaints
• For the Nurse • Activity of client when problem occurred
o Consistent and systematic nursing education • Phenomena or signs/symptoms associated with the CC
o Job satisfaction • Factors that aggravate or alleviate the problem
o Professional growth
4. Past History 9. Patterns of health care
• Childhood illnesses
• Health care sources used in the past and present
• Childhood immunizations
o E.g. Membership in health management organizations
• Allergies
• Accidents and injury 10. Review of systems (ROS)
• Hospitalization for serious illness
• Medications • Brief account from the client of any recent signs or symptoms associated
with any of the body systems.
5. Family History of Illnesses • ROS relies on subjective information provided by the client rather than on
the nurse’s own PE
• Current state of health of the family, or if deceased and its reasons
• Determine any genetic, familial or environmental patterns of health or
illness that might affect the client’s health
• Documented through a family tree or genogram

6. Lifestyle

• Personal habits
• ADLs (Activities of Daily Living)
o Nutrition – food, diet, fluids, food preparation
o Elimination – urinary and bowel elimination, frequency, pattern
o Rest and sleep – number of hours of sleep, nap, bedtime rituals
(children)
o Activity and exercise – type of exercise, need for assistance in
walking, standing, grooming
o Recreation/hobbies

7. Social Data

• Family and friends relationship

• Ethnic affiliation
• Educational history
• Occupational history
• Economic status
• Home and neighborhood conditions

8. Psychologic Data

• Stressors experienced
• Usual coping pattern
• Communication style
• Sources of support – family, significant others religion, support groups