NUR2092 WRITE-UP—HEALTH HISTORY Classroom Project Week Two
Date __________________________ Examiner ______________________
1. Biographic Knowledge Title _______________________________________________ Phone________________________ Address____________________________________________________________________________ Birthdate ________________________________ Birthplace _________________________________ Age __________ Gender __________ Marital Standing ______________ Occupation _______________ Race/ethnic origin __________________________________ Employer ________________________
2. Supply and Reliability
three. Motive for In search of Care
4. Present Health or History of Present Illness
Previous Health
Describe normal well being ______________________________________________________________ Childhood sicknesses __________________________________________________________________ Accidents or accidents (embody age) ______________________________________________________ Critical or power sicknesses (embody age) ________________________________________________ Hospitalizations (what for? location?) ____________________________________________________ Operations (title process, age) ______________________________________________________ Obstetric historical past: Gravida ____________ Time period ____________ Preterm ____________ (# Pregnancies) (# Time period pregnancies) (# Preterm pregnancies) Ab/incomplete _____________________ Kids residing _____________________ (# Abortions or miscarriages) _____
Course of pregnancy__________________________________________________________________ (Date supply, size of being pregnant, size of labor, child’s weight and intercourse, vaginal supply or cesarean part, problems, child’s situation) Immunizations_____________________________________________________________________
Final examination date: Bodily ________________
Dental ________________ Imaginative and prescient ________________ Allergy symptoms _________________________________ Response __________________________________
Present medicines _________________________________________________________________ _
6. Household History—Specify Which Relative(s)
Coronary heart disease___________________________ Excessive blood pressure______________________ Stroke_________________________________ Diabetes_______________________________
Blood disorders_________________________ Breast or ovarian cancer___________________
Most cancers (different)__________________________ Sickle cell______________________________ Arthritis_______________________________ Allergies_______________________________ Bronchial asthma _______________________________ Obesity________________________________ Alcoholism or drug dependancy ______________
Psychological sickness ___________________________ Suicide ________________________________
Seizure dysfunction ________________________ Kidney illness __________________________ Tuberculosis _____
Assessment of Methods (Circle/spotlight each previous well being issues which were resolved and present issues, together with date of onset.)
Common General Health State: Present weight (achieve or loss, interval of time, by weight loss plan or different components), fatigue, weak point or malaise, fever, chills, sweats or night time sweats
Pores and skin: History of pores and skin illness (eczema, psoriasis, hives), pigment or shade change, change in mole, extreme dryness or moisture, pruritus, extreme bruising, rash or lesion
Hair: Current loss, change in texture
Nails: Change in form, shade, or brittleness
Health Promotion: Quantity of solar publicity, methodology of self-care for pores and skin and hair
Head: Any unusually frequent or extreme headache, any head harm, dizziness (syncope), or vertigo
Eyes: Issue with imaginative and prescient (decreased acuity, blurring, blind spots), eye ache, diplopia (double imaginative and prescient), redness or swelling, watering or discharge, glaucoma or cataracts
Health Promotion Eyes: Wears glasses or contacts, final imaginative and prescient test or glaucoma check, how dealing with loss of imaginative and prescient, if any
Ears: Earaches, infections, discharge and its traits, tinnitus, or vertigo
Health Promotion Ears: Listening to loss, listening to Help use, how loss impacts every day life, any publicity to environmental noise, methodology of cleansing ears
Nostril and Sinuses: Discharge and its traits, any unusually frequent or extreme colds, sinus ache, nasal obstruction, nosebleeds, allergic reactions or hay fever, or change in sense of odor
Mouth and Throat: Mouth ache, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered style
Health Promotion/Mouth & Throat: Sample of every day dental care, use of prostheses (dentures, bridge), and final dental checkup
Neck: Ache, limitation of movement, lumps or swelling, enlarged or tender nodes, goiter
Breast: Ache, lump, nipple discharge, rash, historical past of breast illness, any surgical procedure on breasts Axilla: Tenderness, lump or swelling, rash
Health Promotion Breast: Performs breast self-examination, together with frequency and methodology used, final mammogram and outcomes
Respiratory System: History of lung illness (bronchial asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest ache with respiration, wheezing or noisy respiration, shortness of breath, how a lot exercise produces shortness of breath, cough, sputum (shade, quantity), hemoptysis, toxin or air pollution publicity Health Promotion Respiratory: Final chest x-ray examination
Cardiovascular System: Precordial or retrosternal ache, palpitation, cyanosis, dyspnea on exertion (specify quantity of exertion it takes to provide dyspnea), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, historical past of coronary heart murmur, hypertension, coronary artery illness, anemia
Health Promotion Cardiovascular: Date of final ECG or different coronary heart checks and outcomes
Peripheral Vascular System: Coldness, numbness and tingling, swelling of legs (time of day, exercise), discoloration in palms or ft (bluish pink, pallor, mottling, related to place, particularly round ft and ankles), varicose veins or problems, intermittent claudication, thrombophlebitis, ulcers Health Promotion Peripheral Vascular: If work entails long-term sitting or standing, keep away from crossing legs on the knees; put on Help hose.
Gastrointestinal System: Urge for food, meals intolerance, dysphagia, heartburn, indigestion, ache (related to consuming), different belly ache, pyrosis (esophageal and abdomen burning sensation with bitter eructation), nausea and vomiting (character), vomiting blood, historical past of belly illness (ulcer, liver or gallbladder, jaundice, appendicitis, colitis), flatulence, frequency of bowel motion, any latest change, stool traits, constipation or diarrhea, black stools, rectal bleeding, rectal circumstances, hemorrhoids, fistula)
Health Promotion Gastrointestinal: Use of antacids or laxatives
Urinary System: Frequency, urgency, nocturia (the quantity of instances awakens at night time to urinate, latest change), dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine shade (cloudy or presence of hematuria), incontinence, historical past of urinary illness (kidney illness, kidney stones, urinary tract infections, prostate); ache in flank, groin, suprapubic area, or low again
Health Promotion Urinary: Measures to keep away from or deal with urinary tract infections, use of Kegel workouts
Male Genital System: Penis or testicular ache, sores or lesions, penile discharge, lumps, hernia
Health Promotion Male Genital: Carry out testicular self-examination? How continuously?
Feminine Genital System: Menstrual historical past (age at menarche, final menstrual interval, cycle and period, any amenorrhea or menorrhagia, premenstrual ache or dysmenorrhea, intermenstrual recognizing), vaginal itching, discharge and its traits, age at menopause, menopausal indicators or signs, postmenopausal bleeding.
Health Promotion Feminine Genital: Final gynecologic checkup, final Pap check and outcomes
Sexual Health: Presently in a relationship involving intercourse? Are facets of intercourse passable to you and associate, any dyspareunia (for feminine), any adjustments in erection or ejaculation (for male), use of contraceptive, is contraceptive methodology passable? Use of condoms, how continuously? Conscious of any contact with associate who has sexually transmitted an infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/AIDS, syphilis)?
Musculoskeletal System: History of arthritis or gout. Within the joints: ache, stiff-ness, swelling (location, migratory nature), deformity, limitation of movement, noise with joint movement. Within the muscle groups: any ache, cramps, weak point, gait prob-lems or issues with coordinated actions. Within the again: any ache (location and radiation to extremities), stiffness, limitation of movement, or historical past of again ache or disk illness.
Health Promotion Musculoskeletal: How a lot strolling per day? What’s the impact of restricted vary of movement on every day actions, reminiscent of on grooming, feeding, toileting, dressing? Any mobility aids used?
Neurologic System: History of seizure dysfunction, stroke, fainting, blackouts. In motor perform: weak point, tic or tremor, paralysis, coordination issues. In sensory perform: numbness and tingling (paresthesia). In cognitive perform: reminiscence dysfunction (latest or distant, disorientation). In psychological standing: any nervousness, temper change, melancholy, or any historical past of psychological well being dysfunction or hallucinations.
Hematologic System: Bleeding tendency of pores and skin or mucous membranes, extreme bruising, lymph node swelling, publicity to poisonous brokers or radiation, blood transfusion and reactions. Endocrine System: History of diabetes or diabetic signs (polyuria, polydipsia, polyphagia), historical past of thyroid illness, intolerance to warmth or chilly, change in pores and skin pigmentation or texture, extreme sweating, relationship between urge for food and weight, irregular hair distribution, nervousness, tremors, want for hormone remedy.
Useful Assessment (Together with Actions of Each day Residing)
Self-Esteem, Self-Idea: Training (final grade accomplished, different vital coaching) ______________
Monetary standing (earnings enough for life-style and/or well being issues) __________
Worth-belief system (non secular practices and notion of private strengths) ___________
Self-care behaviors ______________________
Exercise and Train: Each day profile, standard sample of a typical day ________________________________
Unbiased or wants help with ADLs, feeding, bathing, hygiene, dressing, toileting, bed-to-chair switch, strolling, standing, climbing stairs _________________________________
Leisure actions ________________________________________
Train sample (kind, quantity per day or week, methodology of warm-up session, methodology of monitoring
Sleep and Relaxation: Sleep patterns, daytime naps, any sleep aids used ___________________
Diet and Elimination: Report 24-hour weight loss plan recall. _______________________________________ _____________________________________________________________________________________
Is that this menu sample typical of most days? ___________________________________________________
Who buys meals? ____________________________
Who prepares meals? __________________________
Funds enough for meals? __________________________________
Who’s current at mealtimes? __________________________________
Interpersonal Relationships and Assets: Describe personal position in household _________________________
How getting together with household, associates, co-workers, classmates ______________________
Get Help with an issue from? ______________________________________________
How a lot every day time spent alone? _______________________________________________________ Is that this pleasurable or isolating? ___________________________________________________________
Coping and Stress Administration: Describe stresses in life now __________________________________ _____________________________________________________________________________________ Change(s) in previous yr ______________________________________________
Strategies used to alleviate stress _______________________
Are these strategies useful? ___________________________
Private Habits:
Each day consumption caffeine (espresso, tea, colas) ______________________________________
Smoke cigarettes? ____________________________ Quantity packs per day ______________
Each day use for what number of years __________________ Age began ___________
Ever tried to give up? ____________________________ How did it go? _____________________________
Drink alcohol? ____________________ Date of final alcohol use _______
Quantity of alcohol that episode __________________________________________________________
Out of final 30 days, on what number of days had alcohol? ____________________________________
Ever advised had a ingesting drawback? ________________________________________________________ Any use of road medicine? ___________Marijuana? _________________________________
Cocaine? __________________________________ Crack cocaine? ______________________________ Amphetamines? _____________________________ Heroin? __________________
Prescription painkillers? _____________________ Barbiturates? _______________________________ LSD? _____________________________________
Ever been in therapy for medicine or alcohol? ________________________________________________
Surroundings and Hazards: Housing and neighborhood (kind of construction, stay alone, know neighbors) _____________________________________________________________________________________
Security of space _________________________________________________________________________ Satisfactory warmth and utilities ____________________________________________________________
Entry to transportation ____________________________________________________________
Involvement in group companies _______________________________________________________ Hazards at office or dwelling ___________________________________________________________ Use of seatbelts ____________________________________________________________________
Journey to or residence in different international locations ___________________________________________________ Navy service in different international locations ________________________________________________________ Self-care behaviors _____________________________________________________________________ Intimate Accomplice Violence: How are issues at dwelling? Do you’re feeling secure? __________________
Ever been emotionally or bodily abused by your associate or somebody essential to you___-
Ever been hit, slapped, kicked, pushed, or shoved or in any other case bodily damage by your associate or ex-partner? _____________________________________________________________________________________ Accomplice ever drive you into having intercourse? ____________________________________________________ Are you afraid of your associate or ex-partner? ________________________________
Occupational Health:
Please describe your job. ______________________________________________
Work with any well being hazards (e.g., asbestos, inhalants, chemical substances, repetitive movement)? ___________________________________________________________________________________
Any tools at work designed to scale back your publicity?
Any work applications designed to watch your publicity? _________________________________
Any well being issues that you just suppose are associated to your job? _____________________________
What do you want or dislike about your job? _________________________________________________
Notion of Personal Health:
How do you outline well being? ________________________________________
View of personal well being now ________________________________________________________________
What are your issues? ________________________________________________________________
What do you anticipate will occur to your well being in future? _
———-
NUR2092 WRITE-UP—HISTORY OF HEALTH Week Two of the Classroom Project
1. Title of the biographical knowledge Handle Gender Marital Standing ______________ Occupation _______________ Race/ethnic origin __________________________________ Employer ________________________
2. Supply and Reliability
three. Motive for In search of Care
4. Present Health or History of Present Illness
Previous Health
Describe normal well being ______________________________________________________________ Childhood sicknesses __________________________________________________________________ Accidents or accidents (embody age) ______________________________________________________ Critical or power sicknesses (embody age) ________________________________________________ Hospitalizations (what for? location?) ____________________________________________________ Operations (title process, age) ______________________________________________________ Obstetric historical past: Gravida ____________ Time period ____________ Preterm ____________ (# Pregnancies) (# Time period pregnancies) (# Preterm pregnancies) Ab/incomplete _____________________ Kids residing _____________________ (# Abortions or miscarriages) _____
Course of being pregnant
__________________________________________________________________ (Date supply, size of being pregnant, size of labor, child’s weight and intercourse, vaginal supply or
_____________________
Your well being targets ______________________________________________________________________
Your expectations of nurses, physicians ___________________________________________________
——–
