BOX 7-1 Nursing History and Assessment Tool

I. General Information

Client name: _________________________________________ Allergies:

__________________________________________

Room number: _______________________________________ Diet:

______________________________________________

Doctor:______________________________________________ Height/weight:
_____________________________________

Age: ________________________________________________ Vital signs: TPR/BP

________________________________

Sex: __________________ Name and phone no. of significant other:

____________________________________________

Race:
_____________________________________________________________________________________
______________

Dominant language: __________________________________ City of

residence:___________________________________

Marital status:________________________________________ Diagnosis (admitting & current):

______________________

Chief
complaint:____________________________________________________________________________
______________

_____________________________________________________________________________________
______________________

Conditions of admission:

Date:________________________________________________ Time:
_____________________________________________

Accompanied
by:__________________________________________________________________________________
_______

Route of admission (wheelchair; ambulatory; cart):

___________________________________________________________

Admitted from:
_____________________________________________________________________________________
______
II. Predisposing Factors

A. Genetic Influences

1. Family configuration (use genograms):

Family of origin: Present family:

Family dynamics (describe significant relationships between family members):

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

2. Medical/psychiatric history:

a. Client:
_____________________________________________________________________________________
______

_____________________________________________________________________________________
____________

_____________________________________________________________________________________
____________

b. Family members:
_________________________________________________________________________________

_____________________________________________________________________________________
____________

_____________________________________________________________________________________
____________

3. Other genetic influences affecting present adaptation. This might include effects specific to gender,
race,

appearance, such as genetic physical defects, or any other factor related to genetics that is affecting the

client’s adaptation that has not been mentioned elsewhere in this assessment.

_____________________________________________________________________________________
_______________
_____________________________________________________________________________________
_______________

B. Past Experiences

1. Cultural and social history:

a. Environmental factors (family living arrangements, type of neighborhood, special working conditions):

_____________________________________________________________________________________
____________

_____________________________________________________________________________________
____________

b. Health beliefs and practices (personal responsibility for health; special self-care
practices):________________

_____________________________________________________________________________________
____________

_____________________________________________________________________________________
____________

c. Religious beliefs and

practices:_____________________________________________________________________

_____________________________________________________________________________________
____________

_____________________________________________________________________________________
____________

d. Educational background:
__________________________________________________________________________

_____________________________________________________________________________________
____________

_____________________________________________________________________________________
____________

e. Significant losses/changes (include dates):

____________________________________________________________

_____________________________________________________________________________________
____________

_____________________________________________________________________________________
____________
f. Peer/friendship relationships:
________________________________________________________________________

_____________________________________________________________________________________
____________

_____________________________________________________________________________________
____________

g. Occupational history:
_______________________________________________________________________________

_____________________________________________________________________________________
____________

_____________________________________________________________________________________
____________

h. Previous pattern of coping with stress:

______________________________________________________________

_____________________________________________________________________________________
____________

_____________________________________________________________________________________
____________

i. Other lifestyle factors contributing to present

adaptation:______________________________________________

_____________________________________________________________________________________
____________

_____________________________________________________________________________________
____________

C. Existing Conditions

1. Stage of development (Erikson):

a. Theoretically:
____________________________________________________________________________________

b. Behaviorally:
_____________________________________________________________________________________

c. Rationale:
_____________________________________________________________________________________
__

_____________________________________________________________________________________
____________
_____________________________________________________________________________________
____________

2. Support systems:
___________________________________________________________________________________

_____________________________________________________________________________________
______________

3. Economic security:
__________________________________________________________________________________

_____________________________________________________________________________________
______________

4. Avenues of productivity/contribution:

_____________________________________________________________________________________
____________

a. Current job
status:________________________________________________________________________________

_____________________________________________________________________________________
____________

b. Role of contributions and responsibility for others:

___________________________________________________

_____________________________________________________________________________________
____________

III. Precipitating Event

Describe the situation or events that precipitated this

illness/hospitalization:____________________________________

_____________________________________________________________________________________
________________________

IV. Client’s Perception of the Stressor

Client’s or family member’s understanding or description of stressor/illness and expectations of

hospitalization:

_____________________________________________________________________________________
__________________________

_____________________________________________________________________________________
__________________________
_____________________________________________________________________________________
__________________________

_____________________________________________________________________________________
__________________________

V. Adaptation Responses

A. Psychosocial

1. Anxiety level (circle level and check the behaviors that apply): mild moderate severe panic

calm_____ friendly_____ passive_____ alert_____ perceives environment correctly_____

cooperative_____

impaired attention_____ “jittery”_____ unable to concentrate_____ hypervigilant_____ tremors_____

rapid speech_____ withdrawn_____ confused_____ disoriented_____ fearful_____

hyperventilating_____

misinterpreting the environment (hallucinations or delusions)_____ depersonalization_____

obsessions_____

compulsions______ somatic complaints_____ excessive hyperactivity_____

other_________________________

_____________________________________________________________________________________
_______________

2. Mood/affect (circle as many as apply): happiness sadness dejection despair elation

euphoria suspiciousness apathy (little emotional tone) anger/hostility

3. Ego defense mechanisms (describe how used by client):

Projection:
_____________________________________________________________________________________
_____

Suppression:
_____________________________________________________________________________________
___

Undoing:
_____________________________________________________________________________________
______

Displacement:
_____________________________________________________________________________________
__
Intellectualization:______________________________________________________________________
______________

Rationalization:
_____________________________________________________________________________________
_

Denial:_______________________________________________________________________________
_______________

Repression:
_____________________________________________________________________________________
____

Isolation:_____________________________________________________________________________
_______________

Regression:
_____________________________________________________________________________________
____

Reaction Formation:
_________________________________________________________________________________

Splitting:______________________________________________________________________________
______________

Religiosity:
_____________________________________________________________________________________
_____

Sublimation:
_____________________________________________________________________________________
___

Compensation:
_____________________________________________________________________________________
_

4. Level of self-esteem (circle one): low moderate high

Things client likes about

self:________________________________________________________________________

_____________________________________________________________________________________
_____________

Things client would like to change about self:

_________________________________________________________
_____________________________________________________________________________________
_____________

Objective assessment of self-esteem:

Eye contact:
_____________________________________________________________________________________
_

General appearance:
_______________________________________________________________________________

_____________________________________________________________________________________
_____________

Personal
hygiene:______________________________________________________________________________
____

Participation in group activities and interactions with

others:____________________________________________

5. Stage and manifestations of grief (circle one):

denial anger bargaining depression acceptance

Describe the client’s behaviors that are associated with this stage of grieving in response to loss or
change:

_____________________________________________________________________________________
_____________

_____________________________________________________________________________________
_____________

_____________________________________________________________________________________
_____________

6. Thought processes (circle as many as apply): clear logical easy to follow relevant confused

blocking delusional rapid flow of thoughts slowness in thought suspicious

Recent memory (circle one): loss intact Remote memory (circle one): loss intact

Other:
_____________________________________________________________________________________
_________

_____________________________________________________________________________________
_______________

7. Communication patterns (circle as many as apply): clear coherent slurred speech incoherent
neologisms loose associations flight of ideas aphasic perseveration rumination tangential speech

loquaciousness slow, impoverished speech speech impediment (describe):

_____________________________

Other:
_____________________________________________________________________________________
_________

_____________________________________________________________________________________
_______________

8. Interaction patterns (describe client’s pattern of interpersonal interactions with staff and peers on the
unit, e.g.,

manipulative, withdrawn, isolated, verbally or physically hostile, argumentative, passive, assertive,

aggressive,

passive-aggressive, other):
___________________________________________________________________________

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

9. Reality orientation (check those that apply):

Oriented to: time_________________ person

_______________________________________________________

place_________________ situation ______________________________________________________

10. Ideas of destruction to self/others? Yes No

If yes, consider plan; available means:

_______________________________________________________________

_____________________________________________________________________________________
_____________

_____________________________________________________________________________________
_____________

_____________________________________________________________________________________
_____________

B. Physiological
1. Psychosomatic manifestations (describe any somatic complaints that may be stress-related):
________________

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

2. Drug history and assessment:

Use of prescribed drugs:

Name Dosage Prescribed for Results

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

Use of over-the-counter drugs:

Name Dosage Used for Results

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

Use of street drugs or alcohol:

Amount How Often When Last Effects

Name Used Used Used Produced

_____________________________________________________________________________________
_______________
_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

_____________________________________________________________________________________
_______________

3. Pertinent physical assessments:

a. Respirations: normal_____ labored_____

rate_______ rhythm_________

b. Skin: warm _________ dry_________ moist_________ cool_________ clammy_________

pink__________

cyanotic_________ poor turgor_________ edematous_________

Evidence of: rash_________ bruising_________ needle tracts_________ hirsutism_________

loss of hair_________
other_______________________________________________________________________

_____________________________________________________________________________________
___________

c. Musculoskeletal status: weakness_________ tremors_________

Degree of range of motion (describe limitations):

____________________________________________________

_____________________________________________________________________________________
__________________

Pain
(describe):____________________________________________________________________________
______

_____________________________________________________________________________________
__________________

Skeletal deformities (describe):

____________________________________________________________________

Coordination (describe limitations):

________________________________________________________________

d. Neurological status:

History of (check all that apply): seizures__________ (describe method of

control):_______________________
_____________________________________________________________________________________
__________________

headaches (describe location and

frequency):_______________________________________________________

fainting spells____________ dizziness____________

tingling/numbness (describe location):

_____________________________________________________________

e. Cardiovascular: B/P______ Pulse______

History of (check all that apply):

hypertension_____ palpitations_______

heart murmur_______ chest pain_______

shortness of breath_______ pain in legs_______

phlebitis_______ ankle/leg edema______

numbness/tingling in extremities
__________________________________________________________________

varicose
veins_________________________________________________________________________________
__

Gastrointestinal:

Usual diet pattern:

_______________________________________________________________________________

Food allergies:
__________________________________________________________________________________

Dentures? upper_____ lower_____

Any problems with chewing or swallowing?

_________________________________________________________

Any recent change in weight?

_____________________________________________________________________

Any problems with:

Indigestion/heartburn?
_________________________________________________________________________

Relieved by:
_________________________________________________________________________________
Nausea/vomiting?
_______________________________________________________________________________

Relieved by:
_________________________________________________________________________________

History of ulcers?
________________________________________________________________________________

Usual bowel pattern:

_____________________________________________________________________________

Constipation?_______ Diarrhea?________

Type of self-care assistance provided for either of the above

problems:_____________________________

_____________________________________________________________________________________
________

g. Genitourinary/Reproductive:

Usual voiding
pattern:____________________________________________________________________________

Urinary hesitancy?__________________________ Frequency?

_________________________________________

Nocturia?______________________________Pain/burning?
____________________________________________

Incontinence?
___________________________________________________________________________________

Any genital lesions?

_____________________________________________________________________________

Discharge?_____________________ Odor?
______________________________________________________

History of sexually transmitted disease?

____________________________________________________________

If yes, please explain:

_________________________________________________________________________

_____________________________________________________________________________________
__________________

Any concerns about sexuality/sexual activity?

______________________________________________________
_____________________________________________________________________________________
_________________

Method of birth control used:

_____________________________________________________________________

Females:

Date of last menstrual cycle:

___________________________________________________________________

Length of cycle:
______________________________________________________________________________

Problems associated with menstruation?

________________________________________________________

_____________________________________________________________________________________
________

Breasts: Pain/tenderness?
_______________________________________________________________________

Swelling?_____________________ Discharge?
___________________________________________________

Lumps?_______________________ Dimpling?
____________________________________________________

Practice breast self-examination?

_________________________________________________________________

Frequency?
__________________________________________________________________________________

Males:

Penile discharge?
____________________________________________________________________________

Prostate problems?
___________________________________________________________________________

h. Eyes: Yes No Explain

Glasses? ________________ ________________ ________________________________________

Contacts? ________________ ________________ ________________________________________

Swelling? ________________ ________________ ________________________________________

Discharge? ________________ ________________ ________________________________________

Itching? ________________ ________________ ________________________________________

Blurring? ________________ ________________ ________________________________________

Double vision? ________________ ________________

i. Ears Yes No Explain

Pain? ________________ ________________ ________________________________________

Drainage? ________________ ________________ ________________________________________

Difficulty hearing? ________________ ________________

________________________________________

Hearing aid? ________________ ________________ ________________________________________

Tinnitus? ________________ ________________ ________________________________________

j. Medication side effects:

What symptoms is the client experiencing that may be attributed to current medication usage?

_____________________________________________________________________________________
_________________

_____________________________________________________________________________________
_________________

k. Altered lab values and possible significance:

_________________________________________________________

_____________________________________________________________________________________
____________________

_____________________________________________________________________________________
____________________

l. Activity/rest patterns:

Exercise (amount, type,

frequency):________________________________________________________________

_____________________________________________________________________________________
___________________

Leisure time activities:

___________________________________________________________________________

_____________________________________________________________________________________
___________________

Patterns of sleep: Number of hours per night:

______________________________________________________
Use of sleep aids?
_______________________________________________________________________________

Pattern of awakening during the night?

____________________________________________________________

_____________________________________________________________________________________
___________________

Feel rested upon awakening?

_____________________________________________________________________

m. Personal hygiene/activities of daily living:

Patterns of self-care: independent

________________________________________________________________

Requires assistance with: mobility

________________________________________________________________

hygiene ________________________________________________________________

toileting ________________________________________________________________

feeding_________________________________________________________________

dressing________________________________________________________________

other___________________________________________________________________

Statement describing personal hygiene and general appearance:

_____________________________________

_____________________________________________________________________________________
___________________

_____________________________________________________________________________________
___________________

n. Other pertinent physical assessments:

_______________________________________________________________

_____________________________________________________________________________________
____________________

_____________________________________________________________________________________
____________________

VI. Summary of Initial Psychosocial/Physical Assessment:

Knowledge deficits identified:

Nursing diagnoses indicated: