HISTORY COLLECTION

Biographical/Demographical Data:
• Name :
• Age :
• Gender:
• Address:
• Contact no:
• Education:
• Marital status :
• Occupation:
• Socio-economic Status:
• Religion:
• Health insurance:
• Advance directive:
• Nationality:
• Languages known :
• Ward:
• Bed No:
• Dr’s Unit:
• Diagnosis:
• Any Surgery:
• Type of anesthesia:

Chief complaint:
 Current health status:

Past health history:

• Childhood illness:

• Allergic history:

• Accidents:

• Injuries:

• Surgeries:

• Communicable diseases:

• Medications:

• Immunization:

• Recent travel history

Family history:

No Name Relation with Marital Age Education Any disease

Patient status
Family Tree:

Psychosocial profile:
• Health practices:

• Health Beliefs:

• Socio-economic status:

• Social support:

• Stress/coping patterns:

• Occupational heath :

• Environmental health patterns: (Housing, Drainage, sunlight, ventilation, water facility)

Lifestyle
• Smoking:

• Drinking:

• Drugs:

• Dietary pattern: (vegetarian /non-veg/ eggitarian / mix/ vegan)

• Frequency of food :

• Sleep:

• Exercise:
 PHYSICAL EXAMINATION

➢ General Examination
Nutritional Level: well nourished/undernourished

Health: healthy or unhealthy

Body Built: thin/obese/trim and muscular

Activity: active/dull

Posture: erect/slumped/bent/stooped/forward bent/ lordosis/kyphosis/scoliosis

Hygiene and grooming: clean/dirty/bad odor (observe hair,skin,fingernails and clothing,

excessive use of cosmetics)

Speech: moderately paused normal pitch and tone/high pitch/monotonous

Signs of distress: grimacing/ splinting painful area/difficulty breathing (shortness of breath,

sternal retractions) or anxiety

Body movements: tremors/paralysis/immobility

Consciousness: conscious /unconscious / delirious/ talking incoherently

Orientation: oriented /disoriented with time place and person

Affect and mood: Anxious/worried/depression (emotional state verbally and nonverbally,

facial expressions)

➢ Measurements:
Height:

Weight:

Abdominal girth if needed:

➢ Vital Signs:
Temperature:

Pulse:

Respiration:

Blood pressure:

➢ Skin:
Colour: Tan-Brown/fair/dark

Texture: Normally smooth and soft/dry/rough

Moisture: dullness, dryness, crusting and flaking

Temperatue: warm/ cold/clammy

Skin turgor: skin lifts easily and snaps back immediately/ poor/normal/decreased

Hydration: Edema/ swelling, pitting edema, poor/good/moderate/dehydrated

Lesions/Mass: macule/patch/papule/plaque/nodule /tumor/ wheal/ vesicle/ bulla/ pustule /

erosion / ulcer/fissure/crust/scale/keloid/scar/ excoriation/ atrophy

Discolouration: Absent/yellow/bluish/ pallor/ loss of pigmentation/yellow-orange/ Red

Vascularity: observe for petechiae

Subjective sign and symptoms:

➢ Nails:
Shape: normally convex/ spoon shaped(koilonychias)

Angle:(160 degree)between nail and its base/more than 180 degree (clubbing)

Texture: smooth / nail base should be firm and nontender /indentation/ beau’s line/

onycholysis

Colour of nail bed: pinkish nail bed with translucent white tips pallor/yellow/pink

Capillary refill(blanch test):

➢ Hair:
Distribution: evenly distributed/ baldness/ hirsutism /scanty

Colour: black/white/brittle grey/

Texture: dry/oily

Thickness and lubrication of hair:

➢ Head and Face:

Skull Shape: size /shape (gentally curved with prominence at frontal &parietal bone) /

frontannels/ symmetry/nodule/masses

Scalp: Cleanliness/Color/dryness/scaliness /lumps /lesions/ lice / nits/ dandruff/ lump/ lesion

/pediculi.

Face: pale/puffiness/ periorbital edema /tics /tremor/ pain/ enlargement of parotid

gland/moon face/bell’s palsy

Subjective sign and symptoms:

➢ Eyes:
Eye brows: normal evenly distributed /absent/lesion/symmetrical/scanty

Eye Lashes: infection/sty (curl outward)/inversion/ Eversion/absent/ equally

distributed/presence of dandruff

Eye lids: oedema/lesions/ectropion/entropion/ ptosis/normal

Pupillary reflex (consensual reflex):constricts/unequal response (normal;negative, abnormal:

positive)

Pupil accommodation: Pupils constricts when looking at near objects & dilate when

looking at far object/ One/both pupils fail to constrict/ dilate

Pupil: dilated/constricted/black colour/equal in size(3 to 7 mm)/cloudiness

Pupil shape: round/oval/irregular/pinpointed

Sclera: Jaundice/white/ slight yellowish/red/lesions/nodule

Conjunctiva: pale/ red/pink/purulent/transparent smooth and shiny,

Cornia and iris: irregularities/abrasions/smooth

Corneal reflex(sensitivity test):blink/absent blink

Vision: normal/abnormal ( myopia, hyperopia)

Peripheral vision:

Eye muscles : strabismus(squint)/extraocular movements

Fundus: congestion/hemorrhagic spots

Subjective sign and symptoms:

➢ Ears:
Pinna/auricles: normal size shape and texture/tenderness/anotia/microtia/melotia/macrotia

Cerumen:Present/Absent

Otorrhoea: Absent/purulent/serous/bloody/ sanginous

Hearing:Normal/decreased/use of hearing aids

• Weber’s Test :
• Rinne Test :

Tympanic membrane: Pearly gray color, semi transparent / Pink to red, some

opacity, yellow-amber, white, blue or deep red & dull surface

Subjective sign and symptoms:

➢ Nose:
External Nose: Symmetric & straight / Asymmetric /tenderness/lesions

Nasal cavity: Pink/clear watery discharge / Mucosa red/ edematous/ abnormal discharge

Septum: septum deviated to right / Left or midline and intact

Passage: Air movement is Normal/ restricted , patent/obstructed/ nasal polyp

Smell: normal/absent

Rhinorrhea: present/absent
Frontal/maxillary sinuses: not tender/ tenderness on one or more sinuses

Infection: no infection/ frequent cold/allergies/ Epistaxis

Subjective sign and symptoms:

➢ Mouth
Lips: Dry/ crakes/ crusts/ symmetrical /ulcer in the mucous membrane/ angular stomatits/
swelling/ lesions
Colour: pallor/cyanosis/redness
Gums:Normal gums/bleeding gums/score gums/infection present/pyorrhea/gingivitis
Tongue: Normal/ulcers/cyanotic/ Pallor/dry/ furrows/ tongue tie/white coated/bright
red/black
Teeth: Dental caries/Decay/ Dentures
Taste:Normal/absent
Mucous membrane: ulceration/bleeding/ swelling/ pus formation/leukoplakia
Breath odour: foul smell
Gag reflex: present/absent
Tonsils:inflamed/ not inflamed/enlarged
Voice: Clear/Harsh aphonic/Dysphonic/ Mute
Subjective sign and symptoms:

➢ Neck:
ROM: co-ordinated smooth movement possible/ Painful/ Absent/lumps/injury/short muscles

Lymph nodes:not enlarged/ enlarged/painful

Trachea: centrally aligned/right or left deviated/ tracheostomy/scar

Thyroid Gland: not enlarged/enlarged/palpable

Jugular vein: distension/

Carotid artery: pulsations are felt/

Subjective sign and symptoms:

➢ Chest:
INSPECTION:

Shape: Symmetrical/Asymmetrical/flat/ barrel chest/ funnel chest/pigeon chest/visual

pulsation

Thorax expansion: Normal/equal/unequal/delayed/shallow

Any scar and lesion: Present/Absent

PALPATION: Pain/tenderness/mass/fremitus

AUSCULTATION:

Heart sounds:S1,S2/ Murmor/gallop sounds

Breath sounds: Normal(bronchial/bronchovesicular/vesicular) /wheeze/stridor/friction rub/

crackles/ rhonchi

Apical pulse: pulse/min

PERCUSSION: resonance/dullness/flat/ hyper resonance

Cough and sputum: absent /present( specify colour/odour/consistency-sticky, purulent,

McCord, Frothy)

Subjective sign and symptoms:

➢ Breast and Axilla

Size and shape: Symmetrical/asymmetrical/soft/round and smooth/ skin depression/ dimpling

Areola and nipple:Any discoloration/retraction/inverted/ Dimpling/ crust

Discharge: absent/milky/yellowish/purulent

Lesion: Absent/Ulceration/Swelling/moving/painful/tender

Axillary node: Not palpable/Palpable/moving painful

Hair Distribution: evenly distributed/absent/scant

Subjective sign and symptoms:

➢ Abdomen
Appetite: normal/increased/diminished

Abdominal Girth:

ON INSPECTION:

Umbilicus: skin rashes, scar, hernia /flat/ prominent veins/ incision/ scar/ distension/ ascitis
/peristaltic movements /striae/keloid /pregnancy/ other signs

AUSCULTATION: bowel sounds, foetal heart sounds

ON PERCUSSION:

Bowel sounds:dullness/tympany (fluid/masses/air)

ON PALPATION: soft/ painful/tender/rigidity/liver margin, palpable spleen, tenderness at the

area appendix, inguinal hernia

Inguinal lymph nodes: Palpable/not palpable

Subjective sign and symptoms

➢ Musculo –skeletal system:

Posture: erect/slumped/bent/stooped/forward bent/ lordosis/kyphosis/scoliosis

Muscle tone: atrophy, tremors, flaccidity, unco- ordinated movements, swelling and pain,
spasticity

Muscular strength:normal/good/fair/poor/trace/zero

➢ Upper Extremities:
Symmetry: symmetrical/asymmetrical

Finger Nail: capillary refill -seconds

Range of motion:possible/impossible-specify

Peripheral pulse( radial and brachial) : rate, rhythm, volume, normal/ abnormal specify

Reflexes (Biceps and triceps): normal/abnormal

Oedema/swelling: Absent if present specify

Cyanosis: Absent if present specify

Joints: No complaints/swollen/pain limitation of movement/stiffness/ tenderness//crepitus

Deformity: Absent if present specify

Subjective sign and symptoms:

BACK AND SPINE:

Shape: Normal/ kyphosis/ lordosis/scoliosis

Posture of neck: torticollis, asymmetry of neck movement

Bony Contour: Tenderness in spine & muscles

➢ Lower Extrimities:
Symmetry: symmetrical/asymmetrical

Toe Nails: capillary refill -seconds

Range of motion:possible/impossible-specify

Peripheral pulse( Dorsalis pedis, posterior tibial, popliteal) : rate, rhythm, volume, normal/
abnormal specify

Reflexes (Patellar/Plantar/Achilles): normal/abnormal

Oedema/swelling: Absent if present specify

Cyanosis: Absent if present specify

Joints: No complaints/swollen/pain limitation of movement/stiffness/ tenderness//crepitus

Deformity: Absent if present specify

Gait: Normal/limp/step page/ dystonic//ataxia/ scissoring

Varicose Veins: Absent if present specify

Subjective sign and symptoms:

➢ Genito-Urinary system
Flank region Lesion/scar:absent/if present specify/swelling/ brusing/ redness

Discharge/infection: absent/ if present specify

Voiding: retention/ incontinence/ catheterized

Colour of urine: Normal/ haematuria

Urine output: Normal/polyurea/oliguria/frequency/urgency/hesistency /dysuria/burning

micturition

Subjective sign and symptoms:

➢ Rectum and Anus:

Perianal skin integrity: color, texture, lumps and rashes, scars, erythema, fissures and

external hemorrhoids

Bowel elimination pattern: frequency

Subjective sign and symptoms:

➢ Reproductive System (Female)

Menstruation: Regular/if irregular then specify

Number of pregnancies or miscarriage:

History of LSCS and reason:

Abortion:

Inspection: pubic hair distribution, labia majora, labia minora, clitoris

Vaginal discharge: absent/ if present specify

Vaginal examination: if performed specify cervix and os for size, color shape, lesion,

discharge.(pink color, round indentation or slit)

Infection: Absent/ if present specify

Subjective symptoms if any:

➢ Reproductive System (Male)

Inspection: pubic hair distribution, penile shaft and glans penis, urethral meatus

Palpation: (penis,scrotum &testes): lesion/ nodules/masses/tenderness

Inguinal area: swelling/bulges

Infection: Absent/ if present specify

Subjective symptoms if any:

➢ Central Nervous System:

Level of consciousness: Conscious/ semiconscious/ unconscious

Orientation: Oriented to time/place and person

Glasgow coma scale total score:

Memory(immediate/recent/remote) : intact/impaired

Speech: clear/slurring/stammering/not clear/maintains eye contact

Sensory functions: touch/pain/ temperature/numbness/weakness/paralysis/ hearing/ vision/

smell/taste

Subjective symptoms if any:

➢ Reflexes:(+4,+3,+2,+1,0)

Biceps: Flexion of Elbow

Triceps: Extension of Elbow

Patellar: Extension of Lower Leg

Achillies: Planter Flexion

Babinski Reflex: Dorsiflexion Of Great Toe, With Extension

➢ Conclusion:
➢ NURSING DIAGNOSIS AS PER PRIORITY