Health Assessment Nursing BSN

SUBJECTIVE:

BIOGRAPHICAL DATA:

Patient Initials_________ Sex____Age____ Marital Status_____Occupation________Insurance_______

Source of History / Reliability____________ Advance Directives __________ (DNR / DNI / Health care proxy)

CHIEF COMPLAINT (CC):

 

 

HISTORY OF PRESENT ILLNESS (HPI):

Chronology: Update a stable patient	Symptom Analysis: explore a symptom
Onset, symptoms over time since onset Treatment from onset to present time Hospitalizations, surgeries r/t this condition Current Status Symptoms, pertinent review of systems (ROS) Medications, other treatments May include habits, allergies, PMH, LMP Functional status Follow up	OLDCART Onset Location Duration Characteristics: Quality Quantity / severity Timing, frequency Setting Aggravating / relieving Associated factors: pertinent ROS, PMH, medications, habits, allergies, LMP

 

 

PAST MEDICAL HISTORY (PMH):

Childhood Illnesses:   

Adult Illnesses:

Hospitalizations:          

Surgeries/Accidents/Injuries:

Immunizations:

Allergies:          

Medications:

Drug name (trade)	Generic name	Indication	Dose	Route	Frequency

Habits: (tobacco, alcohol, illicit drugs)                                                                          

                                                              

FAMILY HISTORY (FMX): (specify family member affected/age at death):                     

SOCIAL HISTORY:                

Born in:

Education:

Occupation:

Family Situation:

Interests/Hobbies:

 

 REVIEW OF SYMPTOMS (ROS): List findings, or check as negative. (If you have a positive finding, then describe its 7 attributes in the HPI or PMH)

REVIEW OF SYSTEMS

	Concerning Symptom	Findings
General	Wgt Δ; weakness; fatigue; fevers
Skin	Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails
Head	Headache; head injury; dizziness
Eyes	Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma
Ears	Hearing Δ; tinnitus; earaches; infections; discharge
Nose/ Sinuses	Colds; congestion; discharge; itching; hay fever; nosebleeds
Throat	Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse
Neck	Lumps; swollen glands; goiter; pain; neck stiffness
Breasts	Lumps; pain; discomfort; nipple discharge
Pulmonary	Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains
Cardiac	Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema
G/I	Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance
Urinary	Frequency; nocturia; urgency; dysuria; hematuria; incontinence MALES:  caliber of urinary stream; hesitancy; dribbling
G/U (General)	Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposure
Male G/U	Discharge from or sores on penis; testicular pain/masses
Female G/U	Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP Vaginal discharge; itching; sores; lumps Menopause; hot flashes; post-menopausal bleeding;
Peripheral Vascular	Claudication; leg cramps; varicose veins; hx of blood clots
Musculo-skeletal	Muscle or joint pain; joint stiffness
Neuro	Syncope; seizures; weakness; paralysis; numbness/tingling; tremors; involuntary movements
Heme	Hx of anemia; easy bruising or bleeding; blood transfusions
Endo	Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria;  glove or shoe size
Psych	Nervousness/anxiety; depression; memory changes; suicide attempts

FUNCTIONAL HEALTH PATTERNS :

Health Perception/Health Management Pattern

Describe current illness: how did this illness present? What treatment have you had? How are you managing today? How will you manage when you get home?

Describe usual state of health. Ask about healthy behaviors: diet, exercise, tobacco, alcohol. Do you have regular checkups?

Nutrition/ Metabolic Pattern

Usual pattern of food, fluid intake, appetite, preferences, swallowing, chewing, eating problems, weight gain or loss

How is your appetite? Has it changed recently? Decreased or increased? Do you get the foods you like? How is your energy level?

Elimination Pattern

Bowel and urinary elimination pattern, changes. Control problems, use of assistive devices, medications

I&O for past 24 hours

How often do you urinate? have a bowel movement? Is this a change for you? Do you use laxatives?

What help do you need to get in and out of the bathroom?

Exercise and Activity Pattern

Pattern of exercise, activity, and recreation; Ability to perform activities of daily living (ADLs).

What help do you need to move around? Bathe? Dress? Prepare food? Eat? What do you do in a routine day?

Cognitive and Perceptual Pattern

Pain / discomfort/ vision / taste / touch / smell / memory / language / learning / decision making ability

Are you in pain? Where is it located? Describe the pain. What makes it worse? What helps?

How is your memory?

Sleep/Rest Pattern

Patterns of sleep, rest; perceptions of quality, quantity

How much sleep do you need every night? Do you wake up feeling refreshed? Daytime naps? Do you have difficulty in falling asleep? Do you awaken early? Get up during the night for any reason?

Roles and Relationship Pattern

Patterns of relationships / Role responsibilities/ satisfaction with relationships, responsibilities

Who lives with you? What is your role in your family? How does your family respond to stress? What changes has this illness caused in your family relationships?

Where do you work? Is it a safe environment? Does your work affect your health? Does your health problem or illness affects your work?

Coping and Stress Management Pattern

Ability to manage stress, sources of support

Knowledge of stress tolerance, number of stressful events in past year

What helps you handle stress? To whom do you turn when you have a problem? Is there someone to help you when you go home?

Self-Perception/ Self- Concept

Attitudes about self, sense of worth, body image, identity. Perception of abilities

Emotional patterns

How would you describe your self? What are you looking forward to? How has this illness changed your thoughts about yourself? Do you think this illness has changed how others see you?

Sexuality/Reproductive Pattern

Menstrual, reproductive history

Satisfaction with sexual relationship, sexual identity

Pre or post menopausal problems

Has your illness or health problem contributed to any change in your sexual pattern? Do you have any concerns in relation to your sexual functioning?

Values and Beliefs

Values, goals, beliefs, spiritual practices; perceived conflicts in values

What is important to you: people, possessions, education, privacy, space? What values and beliefs do you rely on to help you make decisions about your health? What are your religious or spiritual practices? Are you involved in a religious group?

OBJECTIVE:

PHYSICAL EXAMINATION

Height _______ % _______ Weight ________ % _________

BMI % _________

Temp _________ RR _________ HR ______ BP ____________

General Appearance:

Skin:

Head/Face/Neck

LNs:

Eyes:

Ears:

Nose:

Mouth/Throat:

Heart/PV:

Lungs:

Breast:

Abdomen:

GU:

Musculoskeletal:

Neuro:

ASSESSMENT/IMPRESSION:

PLAN:

Diagnostics:

Pharmacologic:

Immunizations/Screening:

Education:

Anticipatory Guidance: