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Information

The nursing history obtains data for planning and implementing nursing actions.

  1. GENERAL HEALTH INFORMATION: reason for admission; duration of present illness; previous hospitalization; history of illnesses; diagnostic procedures before admission; allergies—type and severity of reactions; medications taken at home—over-the-counter (OTC) and prescription medications, and alternative/complementary therapies.
  2. INFORMATION RELATIVE TO GROWTH AND DEVELOPMENT: age; menarche—age at onset; heavy menses; dysmenorrhea; vaginal discharge; date of last Pap smear; pregnancies; abortions; miscarriages; last menstrual period; history of sexually transmitted infections (STIs).
  3. INFORMATION RELATIVE TO PSYCHOSOCIAL FUNCTIONS: feelings (anger, denial, fear, anxiety, guilt, lifestyle changes); language barriers; cultural needs; family support; spiritual needs; religious preference; history of trauma/rape; job status; current stressors.
  4. INFORMATION RELATIVE TO NUTRITION: appetite—normal, changes; dietary habits; food preferences or intolerances; difficulty swallowing or chewing; dentures; use of caffeine/alcohol; weight changes; excessive thirst, hunger, sweating.
  5. INFORMATION RELATIVE TO FLUID AND GAS TRANSPORT: difficulty breathing; shortness of breath; home O2 use; history of cough/smoking; colds; sputum; swelling of extremities; chest pain; palpitations; varicosities; excessive bruising; blood transfusions; excessive bleeding.
  6. INFORMATION RELATIVE TO PROTECTIVE FUNCTIONS: skin problems—rash, itch; current treatment; unusual hair loss.
  7. INFORMATION RELATIVE TO COMFORT, REST, ACTIVITY, MOBILITY: usual activity (activities of daily living [ADLs]); present ability and restrictions; rest and sleep pattern; weakness; joint or muscle stiffness, pain, or swelling; occupation; interests.
  8. INFORMATION RELATIVE TO ELIMINATION: bowel habits; changes—constipation, diarrhea; ostomy; emesis; nausea; voiding—retention, frequency, dysuria, incontinence.
  9. INFORMATION RELATIVE TO SENSORY/PERCEPTUAL FUNCTIONS: pain—verbal report, acute/chronic, treatment, quality, location, precipitating factors, duration; limitations in vision (glasses), hearing, touch, smell; orientation to person, place, time; confusion; headaches; fainting; dizziness; convulsions.