NCM 107

NURSING PROCESS
COMPONENTS OF NURSING HEALTH HISTORY

1. INTRODUCTION
1.1. BACKGROUND OF THE STUDY
• Purpose: Determine the background of the case
• Discuss about case (is it Antenatal? Postnatal? Pediatric Case?). Include statistics in the Philippine setting.

1.2. CLIENT PROFILE/ DEMOGRAPHIC PROFILE

• Purpose: Determine biographical data and obtain an overview of past and present medical diagnoses and treatment that
may alter a client’s response. It also helps the interviewer elicit collaborative problems.
• Should include the following:
a. Date and Time of History- Time of interview/ time that patient was evaluated.
b. Identifying Data- Name (initials), age, gender, birthday, place of birth, marital status, occupation, nationality,
address, religion
c. Source of the History- usually the patient, or an adult relative
d. Reliability- this should be documented if relevant. This varies according to the patient’s memory, trust, and mood.

2. NURSING HISTORY

2.1. CHIEF COMPLAINT

• Purpose: States the chief reason for seeking medical treatment.
• As much as possible, this should be stated in patient’s own words (current problem/ symptoms or concerns and the
frequency or duration it was experienced)

2.2. PRESENT HEALTH HISTORY (Present Pregnancy)

• Purpose: Amplifies the Chief Complaint (Upon Admission), describes how each symptom developed
• Written as a narrative report.
• Chronological onset of symptoms; Onset, duration, frequency; associated signs and symptoms; manifestations, related
history, previous treatment for the problem; pertinent positives and negatives (signs and symptoms)

• NOTE: this can be accomplished and further explored when the patient is interviewed through the Sexuality –
Reproductive Pattern

2.3. PAST HEALTH HISTORY

• Purpose: Provides report of previous health status.
• Includes list of childhood diseases; major adult illnesses with dates when contracted (medical; surgical and psychiatric);
health maintenance practices such as immunizations, screening tests, lifestyle issues, home safety, medications; any know
allergies and sensitivities
• Note: this can be accomplished and further explored when the patient is interviewed through the Gordon’s Functional
Health Pattern.

2.4. FAMILY HISTORY (Genogram)

• Purpose: Documents presence or absence of specific illnesses in family.
• Outlines or diagrams of age and health, or age and cause of death of siblings, parents, and grandparents/ medical
problems for any blood relatives.
• Remember to include a legend to define the symbols used.

2.5. MENSTRUAL HISTORY

• NOTE: this can be accomplished when the patient is interviewed through the Sexuality – Reproductive Pattern

2.6. SEXUAL HISTORY

• NOTE: this can be accomplished when the patient is interviewed through the Sexuality – Reproductive Pattern
 2.7. OBSTETRIC HISTORY
• Includes OB Score, Pregnancy Status, Age of Gestation by LMP or UTZ (ultrasound), LMP, EDD (use Naegele’s Rule),
use of family planning
• NOTE: this can be accomplished when the patient is interviewed through the Sexuality – Reproductive Pattern

2.8. GYNECOLOGIC HISTORY

• NOTE: this can be accomplished when the patient is interviewed through the Sexuality – Reproductive Pattern

2.9. DEVELOPMENTAL HISTORY

• Purpose: Determine the physical, cognitive, and psycho-social development of the client.
• Note: this can be accomplished and further explored when the patient is interviewed through the Gordon’s Functional
Health Pattern.

2.10. PSYCHOSOCIAL HISTORY

• Purpose: Describes educational level, family of origin, current household, personal interests and lifestyle
• Includes substance abuse; employment history, lifestyle (activity, hobbies, exercise/diet
• Note: this can be accomplished and further explored when the patient is interviewed through the Gordon’s Functional
Health Pattern.

3. THEORETICAL FRAMEWORK
• Purpose: Determine and discuss the applicable nursing theory for the implementation of care.

4. GORDON’S FUNCTIONAL HEALTH PATTERNS (before and during hospitalization)

*Note: ALL Subjective data should be written in verbatim (What the patient actually said)

4.1. Health Perception – Health Management Pattern:

• Purpose: Determine how the client perceives and manages her health. Compliance with current and past nursing and
medical recommendations are assessed. The client’s ability to perceive the relationship between Activities of Daily Living
(ADLs) and health is also determined.

• SUBJECTIVE – Perception of general health status and health practices used by client to maintain health (including
exercise, maintenance drugs, check ups, use of vitamins and supplements); any concern about health condition; vices
(if applicable); use of family planning method.

• OBJECTIVE – Appearance; grooming; posture; expression; vital signs; height; pertinent laboratory and diagnostic test
results

4.2. Nutritional – Metabolic Pattern:

• Purpose: Determine the client’s dietary habits and metabolic needs. The condition of hair, nails, teeth, and mucous
membranes are assessed.

• SUBJECTIVE – Dietary habits including patterns of daily food and fluid consumption relative to metabolic need and
pattern; indicators of local nutrient supply; dietary restrictions/aversion; meal planning and preparation; food budget;
appetite; reports of weight gain or weight loss with in the pregnancy period; episodes of nausea and vomiting; cravings;
intake of vitamins and supplements (specify); beliefs and practices concerning food preparation for a pregnant woman.

• OBJECTIVE – General physical survey; including examination of skin, mouth, teeth, hair, nails, mucous membranes,
abdomen, and cranial nerves (CN V, IX, X, and XII);weight; BMI; amount of input (oral intake, IV, etc); skinfold
measurement; pertinent laboratory and diagnostic test results

4.3. Elimination Pattern:

• Purpose: Determine the adequacy of function of the client’s bowel and bladder for elimination. The client’s bowel and urinary
routines and habits are assessed. In addition, any bowel or urinary problems and use of urinary and bowel elimination devices
are examined. Patterns of excretory function of the skin is also assessed. Includes also client’s perception of normal function.

• SUBJECTIVE – Regularity/frequency and control of bowel and bladder habits (pattern and problem experienced
such as diarrhea, constipation, increased frequency of urination etc.); perspiration pattern or problem; pain on
urination appearance of urine and stool.

• OBJECTIVE – Skin examination; rectal examination; appearance of urine and stool or any output; amount of output.
pertinent laboratory and diagnostic test results

4.4. Activity – Exercise Pattern:

• Purpose: Determine the client’s ADL, including routines of exercise, leisure and recreation. This includes activities necessary
for personal hygiene, cooking, shopping, eating, maintaining the home, and working. An assessment is made of any factors
that affect or interfere with the client’s routine ADL. Activities are evaluated in reference to the client’s perception of their
significance in her life.

• SUBJECTIVE – ADL that requires expenditure of energy; energy level; exercise pattern; health pattern; ability to do
the following: bathing, bed mobility, cooking, dressing, feeding, general mobility, grooming, home maintenance,
shopping, toileting.

• OBJECTIVE – Examination of musculo-skeletal system, including gait, posture, range of motion (ROM) of joints,
muscle tone, and strength, Cranial nerve XI; peripheral vascular examination and thoracic examination; cardiovascular
and respiratory status; mobility; functional level; pertinent laboratory and diagnostic test
results

4.5. Sleep – Rest Pattern

• Purpose: Determine the client’s patterns and perception of the quality of her sleep, relaxation, and energy level. Methods
used to promote relaxation and sleep are also assessed.

• SUBJECTIVE - Perception of effectiveness of sleep and rest habits; any sleep proble; reports of being rested or not
rested after sleep (perception of quality and quantity of sleep and energy); use of sleeping aids; routines client uses;

• OBJECTIVE – Appearance and attention span; pertinent laboratory and diagnostic test results

4.6. Sensory – Cognitive – Perceptual Pattern

• Purpose: (Sensory Perceptual) Determine the functioning status of the 5 senses: vision, hearing, touch (including pain
perception), taste and smell. Devices and methods to assist the client with deficits in any of these 5 senses is assessed.
(Cognitive) Determine ability to understand, communicate, remember and make decision.

• SUBJECTIVE – (Sensory Perceptual) including senses of hearing, vision, smell taste and touch. Perception of ability
to hear, see, smell, taste, and feel. (PQRST if there is pain) – (Cognitive) including knowledge, thought perception and
language. Perception of messages, decision making, thought processes, memory, educational status, ask how will she
feed her baby.

• OBJECTIVE – (Sensory Perceptual) Visual and hearing exams, pain perception, cranial nerve exam (cranial nerves I,
II, III, IV, V, VI, VII, VIII, IX, X, XII), testing for taste, smell and touch; pertinent laboratory and diagnostic test results –
(Cognitive) Mental status exam, level of consciousness; pertinent laboratory and diagnostic test results

4.7. Self-perception – Self-concept Pattern

• Purpose: Determine client’s perception of his or her identity, abilities, body image and self-worth. The client’s behavior,
attitude, and emotional patterns are also assessed.
 • SUBJECTIVE – Perception of self-worth/Self-esteem; personal identity; feelings about self; attitudes about self;
emotional state; perception of abilities; body comfort, body image due to changes brought by pregnancy, partner’s
opinion about the changes, any changes in life brought by pregnancy.

• OBJECTIVE – Body posture, movement, eye contact, voice and speech pattern, emotions, moods and thought
content.

4.8. Role – Relationship Pattern

• Purpose: Determine client’s perceptions of responsibilities and roles in the family, at work, and in social life. The client’s level
of satisfaction with these is assessed. In addition, any difficulties in the client’s relationships and interactions with others are
examined.

• SUBJECTIVE – Perception and level of satisfaction with family, work and social roles, living arrangement, family or
significant other(s); communication; perception of current major roles and responsibilities in the family or in the
community; changes that will be brought by the arrival of the infant to both the mother and her partner; socialization;
finance (adequate); specific plans for the coming baby; plans as future parents; effect of pregnancy to the interpersonal
relationship with the family and solutions if there are any.

• OBJECTIVE – Communication with significant others and visits from significant others and family; family genogram.

4.9. Sexuality – Reproductive Pattern

• Purpose: Determine the client’s fulfillment of sexual needs and perceived level of satisfaction. The reproductive pattern and
developmental level of the client is determined, and perceived problems related to sexual activities, relationships, or self-
concept are elicited. The physical and psychological effects of the client’s current health status on her sexuality or sexual
expression are examined.

• SUBJECTIVE: OB history (OB Score; Pregnancy Status; Age of Gestation by LMP or UTZ; LMP, EDD, outcome of
previous pregnancies, symptoms of pregnancy experienced; discomforts experienced and measures done to alleviate
it; danger signs of pregnancy)
• Gynecologic history (reproductive illness and surgery with dates; history of intermenstrual/ postcoital/
postmenopausal bleeding; vaginal discharge: color, smell, amount, presence of itch; abdominal or pelvic pain site,
duration, radiation, associated factors)
• Menstrual history (menarche, cycle, any changes in the cycle, flow, number of pads used; discomforts; remedies
used)
• Sexual history (coitarche; sexual identity; activities and relationships; expression of sexuality and level of satisfaction
or dissatisfaction with sexual patterns; number of sexual partners; is the patient sexually active; dyspareunia; timing of
coitus and desire for pregnancy; concerns or worries about sexual relationship during pregnancy; any history of
STD’s)
• Reproductive planning method (is pregnancy planned; details about the method used; duration of use; acceptance;
current method; side effects; and plan for future pregnancies)

• OBJECTIVE – Female genitalia examination, breast examination, leopolds maneuver, fetal assessment, signs of
pregnancy, abdominal examination, BUBBLESHE; pertinent laboratory and diagnostic test results

4.10. Coping – Stress – Tolerance Pattern

• Purpose: Determine the areas and amount of stress in client’s life; general coping patterns and the effectiveness of coping
methods used in terms of stress tolerance. Availability and use of support systems such as family, friends, and religious
beliefs are assessed.
• SUBJECTIVE – Stressors; usual manner of handling stress; perception of stressful life events and ability to cope;
coping mechanisms; major life changes; problem management; perceived ability to control or manage situations; source
of emotional/material support; effect of pregnancy to her (and her partner); will the pregnancy make a difference in the
financial status.
• OBJECTIVE – Behavior, thought process, psychological test
4.11. Value – Belief Pattern
• Purpose: Determine client’s life values and goals, philosophical beliefs, religious beliefs, and spiritual beliefs that influence
his or her choices and decisions. Conflicts between these values, goals, beliefs and expectations that are related to health are
assessed.

• SUBJECTIVE – Perception of what is good, correct, proper, and meaningful; what the client perceives as important
in life; philosophical beliefs; values and beliefs that guide choices, satisfaction with life; spirituality and religious beliefs;
special religious practices; religious affiliations; value-belief conflicts related to health; health beliefs; beliefs and
practices concerning pregnancy; thoughts and feelings about pregnancy; view and feelings about sex during
pregnancy.

• OBJECTIVE – Presence of religious articles, religious actions and routines, visits from clergy.

5. PHYSICAL ASSESSMENT
• Purpose: Determine presence or absence of common symptoms related to each major body system
• Head- to-Toe assessment. Pertinent results should be included in the objective data of the corresponding Gordon’s
Functional Health Pattern.

SYSTEM NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS

6. ANATOMY AND PHYSIOLOGY (Review of the Reproductive System)

• Purpose: Determine the normal anatomy and physiology of the body system involved.
 Should be presented with illustration

7. LABORATORY REPORT/ DIAGNOSTIC TEST RESULTS (Table)

• Purpose: Determine exams done to confirm pregnancy and other pregnancy related problems
• Include purpose of the Laboratory/Diagnostic Test, result, interpretation/indication and analysis in relation to the case of the
patient.
Laboratory/Diagnostic Normal Values Result Interpretation/Indication Analysis
Test

8. DRUG ANALYSIS (Table)

• Purpose: Determine all medications, vitamins, supplements taken by the patient in relation to her case
• Include generic name, brand name, classification, dosage, frequency, route, indication, mechanism of action, side effects,
adverse effects, contraindications of the medication in relation to the case of the patient and the nursing responsibilities.
9. PATHOPHYSIOLOGY (Diagram) (To be included in the 2nd Semester)
• Purpose: Determine how the disease developed.
• Includes all modifiable, non-modifiable factors, course of the disease with corresponding signs and symptoms as well as
results of laboratory and diagnostic tests.

10. NURSING CARE PLAN

10.1. 2 Actual Nursing Problem, 1 Risk/Potential Problem

Format (Note: All data should be CONGRUENT with one another)

ALL data from the Assessment until Evaluation should be congruent. If one area of the Nursing process is incorrect,
EVERYTHING IS CONSIDERED INCORRECT.
*to be submitted at the end of the 4 weeks rotation.