NURS 146 Goldenwest College Patients Medical History Project

Health History Paper Assignment Instructions:

Chapter 2
Collecting Subjective Data: The Interview and Health History
Nursing Interview Guide to Collect Subjective Data From the Client
Questions
Findings
Biographical Data
Name
Gender
Address, phone number
Date and place of birth
Nationality or ethnicity
Marital status
Religious or spiritual practices
Primary and secondary languages spoken, written, and read; birth
language
Educational level
Occupation and working status
Who lives with the client? Identify significant others
Caregivers and support people for the client
S.R
Female
121 Rivers Road.
Apt22, Riverside, CA,
90001
5/30 /95
Santa Monica
Haspanic
Single
Catholic
English, Spanish
(spoken, written and
read) Birth language:
English
Bachelors in Pychology
Patient Acess; FullTime
Boyfriend
Boyfriend & Father &
Mother
Reason for Seeking Health Care
1. What is your major health care or concern?
2. Are you comfortable with seeking care from this organization?
Past experiences good or not?
Physical Assessment
Yes
History of Present Health Concern
(use COLDSPA when appropriate)
1. Character of symptom or condition
2. Onset (when did it begin; better? worse? same?)
3. Location (where and does it radiate?)
4. Severity (on scale of 1–10?)
None
None
None
None
Nursing Interview Guide to Collect Subjective Data From the Client
5. Pattern (what makes it better? worse?)
6. Associated factors (other associated symptoms? Effect on
leisure or exercise?)
N/A
None
Past Health History
Problems at birth?
Childhood illnesses?
Immunizations to date?
Acute or chronic adult illnesses (physical, emotional, mental)?
Surgeries?
Pregnancies? Births? Miscarriages? Abortions?
Accidents? Injuries?
Prolonged pain or pain patterns?
Medications
Allergies?
None
None
Are up to date with
immunizations records
None
None
None
Injured at 13 year old
with a broken left wrist
from snowboarding
None
Birth Control, Seasonal
Allergen
Cats, Pollen
Family Health History
Recall as many genetic relatives as possible (parents,
grandparents, siblings) with age, longevity, chronic illnesses (i.e.,
heart disease, stroke, diabetes, cancer, arthritis, Alzheimer’s).
Mother is 47 yrs of age
and healthy, Father 49
yrs of age and has prediabetes but diagnose,
Maternal Grandmother
73 years of age history
of cancer does’nt
produce cordzone,
Grandfather 71 years
old and passed away
from High Blood
pressure, High
Cholorestorl, Heart
Diease. Paternal
Grandfather 40 years
old when he passed
away from drug
additional.
Grandmother 60 years
of age and lupus.
Review of Systems
Skin, hair, and nails: Skin color, temperature, condition, excessive
sweating, rashes, lesions, balding, dandruff, condition of nails
No, Normal.
Nursing Interview Guide to Collect Subjective Data From the Client
Head and neck: Headache, swelling, stiffness of neck, difficulty
swallowing, sore throat, enlarged lymph nodes
Eyes: Vision, eye infections, redness, excessive tearing, halos
around lights, blurring, loss of side vision, moving black
spots/specks in visual fields, flashing lights, double vision, and eye
pain
Ears: Hearing, ringing or buzzing, earaches, drainage from ears,
dizziness, exposure to loud noises
Mouth, throat, nose, and sinuses: Condition of teeth and gums;
sore throats; mouth lesions; hoarseness; rhinorrhea; nasal
obstruction; frequent colds; sneezing or itching of eyes, ears,
nose, or throat; nose bleeds; snoring
Thorax and lungs: Difficulty breathing, wheezing, pain, shortness
of breath during routine activity, orthopnea, cough or sputum,
hemoptysis, respiratory infections
Breasts and regional lymphatics: Lumps or discharge from nipples,
dimpling or changes in breast size, swollen or tender lymph nodes
in axilla
Heart and neck vessels: Last blood pressure, ECG tracing or
findings, chest pain or pressure, palpitations, edema
Peripheral vascular: Swelling, or edema, of legs and feet; pain;
cramping; sores on legs; color or texture changes on the legs or
feet
Abdomen: Indigestion, difficulty swallowing, nausea, vomiting,
abdominal pain, gas, jaundice, hernias
Male genitalia: Excessive or painful urination, frequency or
difficulty starting and maintaining urinary stream, leaking of urine,
blood noted in urine, sexual problems, perineal lesions, penile
drainage, pain or swelling in scrotum, difficulty achieving an
erection and/or difficulty ejaculating, exposure to sexually
transmitted infections
Female genitalia: Sexual problems; sexually transmitted diseases;
voiding problems (e.g., dribbling, incontinence); reproductive data
such as age at menarche, menstruation (length and regularity of
cycle), pregnancies, and type of or problems with delivery,
abortions, pelvic pain, birth control, menopause (date or year of
last menstrual period), and use of hormone replacement therapy
Anus, rectum, and prostate: Bowel habits, pain with defecation,
hemorrhoids, blood in stool, constipation, diarrhea
Musculoskeletal: Swelling, redness, pain, stiffness of joints, ability
to perform activities of daily living, muscle strength
Headache due to
posture and takes
Tyenol,Advil
None
Vertigo from ears while
doing yoga.
None
None
None
None
None
None
N/A
Birth Control take
everyday and at bed
time.
Menstrual Cycle:
Monthly & 3-4 days
Twice a day
None
Nursing Interview Guide to Collect Subjective Data From the Client
Neurologic: General mood, behavior, depression, anger,
concussions, headaches, loss of strength or sensation,
coordination, difficulty speaking, memory problems, strange
thoughts and/or actions, difficulty learning
None. Headache due to
posture and takes
Tyenol,Advil
Lifestyle and Health Practices Profile
Description of Typical Day
“Please tell me what an average or typical day is for you. Start
with awakening in the morning and continue until bedtime.”
Nutrition and Weight Management
• “What do you usually eat during a typical day? Please tell me the
kinds of foods you prefer, how often you eat throughout the day,
and how much you eat.”
• “Do you eat out at restaurants frequently?”
• “Do you eat only when hungry? Do you eat because of boredom,
habit, anxiety, depression?”
• “Who buys and prepares the food you eat?”
• “Where do you eat your meals?”
• “How much and what types of fluids do you drink?”
Activity Level and Exercise
• “What is your daily pattern of activity?”
• “Do you follow a regular exercise plan? What types of exercise
do you do?”
• “Are there any reasons why you cannot follow a moderately
strenuous exercise program?”
• “What do you do for leisure and recreation?”
• “Do your leisure and recreational activities include exercise?”
Sleep and Rest
• “Tell me about your sleeping patterns.”
• “Do you have trouble falling asleep or staying asleep?”
• “How much sleep do you get each night?”
• “Do you feel rested when you awaken?”
• “Do you nap during the day? How often and for how long?”
• “What do you do to help you fall asleep?”
Substance Use
• “How much beer, wine, or other alcohol do you drink on the
average?”
• “Do you drink coffee or other beverages containing caffeine
(e.g., cola)? If so, how much and how often?”
• “Do you now or have you ever smoked cigarettes or used any
other form of nicotine? How long have you been smoking/did
you smoke? How many packs per week? Tell me about any
Wake up & exercise 34 a day, run errands
and do homework and
go to work from 210pm every other
week.
Breakfast, Lunch and
Dinner. But often miss
lunch and would have a
protein shake. Yes, Eat
out 1-2 times a week.
No does not eat out of
boredom, habit,
anxiety, depression.
Between boyfriend
shares the
responsibility of
preparing meal. 64ML
of water daily.
Exercise, Hike with dog
and go walking. Weight
lifting, High intensity
days. No to moderately
strenuous exercise
program.
8 hrs of sleep often if
not sleep in extra on
the weekends. But to
help sleep essential oils
to help and promote
better sleep habits.
Drinks Beer and wine
and it depends on the
week and activity. Yes,
a cup coffee a day and
caffeine once a week.
No smoking
Nursing Interview Guide to Collect Subjective Data From the Client
• “Have you ever taken any medication not prescribed by your
health care provider? If so, when, what type, how much, and
why?” None
• “Have you ever used, or do you now use, recreational drugs?
Describe any usage.” None
• “Do you take vitamins or herbal supplements? If so, what?” No
Self-Concept and Self-Care Responsibilities
• “What do you see as your talents or special abilities?” Caring for
others or people and the environment as well as empathetic towards
others
• “How do you feel about yourself? About your appearance?”
Comfortable in own skin
• “Can you tell me what activities you do to keep yourself safe,
healthy, or to prevent disease?” Good hygiene, Keep a steril
environment
• “Do you practice safe sex?” Yes
• “How do you keep your home safe?” By locking doors and
observing my surrounding.
• “Do you drive safely?” Yes
• “How often do you have medical checkups or screenings?” Every
year to two years
• “How often do you see the dentist? Every 6 months. Eyes
(vision) examined?” Twice a year
Social Activities
“What do you do for fun and relaxation?” Loves going to the
beach, going outdoors and having dinner with friends.
• “With whom do you socialize most frequently?”Boyfriend, Friends
and family
• “Are you involved in any community activities?” Volunteer at a
Soup Kitchen in San Fransico.
• “How do you feel about your community?” Love my Community
and feels safe
• “Do you think that you have enough time to socialize?” Yes
• “What do you see as your contribution to society?” Being
considerated towards others and impacting my community.
Relationships
“Who is (are) the most important person(s) in your life? Describe
your relationship with that person.” My Mom and I are very close.
• “What was it like growing up in your family?” Very Traditional
household and loving.
• “What is your relationship like with your spouse?” Don’t have
one
• “What is your relationship like with your children?” No children
• “Describe any relationships you have with significant others.”
Loving, caring and good communication
• “Do you get along with your in-laws?” Yes
• “Are you close to your extended family?” Yes
• “Do you have any pets?” Yes a dog
Nursing Interview Guide to Collect Subjective Data From the Client
• “What is your role in your family? Is it an important role?” To keep
everyone together
• “Are you satisfied with your current sexual relationships? Have
there been any recent changes?” No recent changes I’ve been
with my boyfriend for 9 years.
Values and Belief System
“What is most important to you in life?” God, Family and Friends
• “What do you hope to accomplish in your life?” To impact others
and become a nurse
• “Do you have a religious affiliation? Is this important to
you?”Yes, Catholic. Yes
• “Is a relationship with God (or another higher power) an
important part of your life?” Yes
• “What gives you strength and hope?” Family
Education and Work
• “Tell me about your experiences in school or about your
education.” I love my school experience but there’s always room
to grow and learn.
• “Are you satisfied with the level of education you have? Do you
have future educational plans?” Yes, but there’s always room to
grow and learn and better yourself.
• “What can you tell me about your work? What are your
responsibilities at work?” Register patient in ER and their beds
and assign paitent assignments.
• “Do you enjoy your work?” Yes
• “How do you feel about your coworkers?” Yes, I love my
coworkers
• “What kind of stress do you have that is work related? Any
major problems?” No
• “Who is the main provider of financial support in your family?”
Parents and Boyfriend
• “Does your current income meet your needs?” No
Stress Levels and Coping Styles
• “What types of things make you angry?” Inconsider people,
People who litter
• “How would you describe your stress level?” Normal stresser
when it comes to bills, life activity and responsibility
• “How do you manage anger or stress?” By bathing in the sun
and going to the beach, bike riding.
• “What do you see as the greatest stressors in your life?” Money
and having a career.
• “Where do you usually turn for help in a time of crisis?” My mom
Environment
• “What risks are you aware of in your environment such as in
your home, neighborhood, on the job, or any other activities in
which you participate?” Safe in my home and my community.
• “What types of precautions do you take, if any, when playing
contact sports, using harsh chemicals or paint, or operating
Nursing Interview Guide to Collect Subjective Data From the Client
machinery?” Saftey is a high piorty and Hygiene
• “Do you believe you are ever in danger of becoming a victim of
violence? Explain.” No and I hope to never become either.
NANDA NURSING DIAGNOSIS
Last updated August 2009, *=new diagnosis 2009-2011
•
Nutrition: imbalanced, less than body
Personal identity, disturbed
requirements
Post trauma syndrome
•
Nutrition: imbalanced, more than body
Post trauma syndrome, risk for
requirements
Power, readiness for enhanced
•
Nutrition: imbalanced, risk for more
Powerlessness
than body requirements
Powerlessness, risk for
•
Nutrition, readiness for enhanced
Rape-trauma syndrome
•
Oral mucous membrane, impaired
Relocation stress syndrome
•
Swallowing, impaired
Relocation stress syndrome, risk for
*Resilience, impaired individual
Gastro
*Resilience, readiness for enhanced
•
*Jaundice, neonatal
*Resilience, risk for compromised
•
Liver function, impaired, risk for
Self concept, readiness for enhanced
•
Nausea
Self-esteem, chronic low
Activity/Rest-ability to engage in
necessary/desired activities of life (work and
leisure) and to obtain adequate sleep/rest
•
Activity intolerance
•
Activity intolerance, risk for
•
Disuse syndrome, risk for
•
Divisional activity, deficit
•
Fatigue
•
Insomnia
•
Mobility: bed, impaired
•
Mobility: physical, impaired
•
Mobility: wheelchair, impaired
•
Sedentary lifestyle
•
Sleep deprivation
•
*Sleep pattern disturbed
•
Sleep, readiness for enhanced
•
Transfer ability, impaired
•
Walking, impaired
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Circulation- ability to transport oxygen and
nutrients necessary to meet cellular needs
•
*Bleeding, risk for
•
Cardiac output, decreased
•
*Tissue perfusion, decreased cardiac
tissue, risk for
•
*Tissue perfusion, ineffective,
cerebral, risk for
•
*Tissue perfusion, ineffective, renal,
risk for
•
*Tissue perfusion, ineffective
gastrointestinal, risk for
•
Tissue perfusion, ineffective,
peripheral
•
*Shock, risk for
Endo
•
Blood glucose, risk for unstable
Ego Integrity- ability to develop and use
skills and behaviors to integrate and
manage life experiences
•
Anxiety
•
Anxiety, death
•
Body image, disturbed
•
Coping, community, ineffective
•
Coping, community, readiness for
enhanced
•
Coping, defensive
•
Coping, family, compromised
•
Coping, family, disabled
•
Coping, family, readiness for enhanced
•
Coping, (individual), readiness for
enhanced
•
Coping, ineffective
•
Denial, ineffective
•
Energy field disturbance
•
Fear
•
Grieving
•
Grieving, complicated
•
Grieving, risk for complicated
•
Health behavior, risk prone
•
Human dignity, risk for compromised
Self-esteem, situational low
Self-esteem, risk for situational low
Sorrow, chronic
Stress, overload
Elimination- ability to excrete waste
products
•
Bowel incontinence
•
Constipation
•
Constipation, risk for
•
Constipation, perceived
•
Diarrhoea
•
*Motility, dysfunctional
gastrointestinal
•
*Motility, risk for dysfunctional
gastrointestinal
•
Urinary elimination, readiness for
enhanced
•
Urinary elimination, impaired
•
Urinary incontinence, functional
•
Urinary incontinence, overflow
•
Urinary incontinence, reflex
•
Urinary incontinence, stress
•
Urinary incontinence, urge
•
Urinary incontinence, risk for urge
•
Urinary retention
Food/fluid- ability to maintain intake of and
utilize nutrients and liquids to meet
physiological needs
•
Breastfeeding, effective
•
Breastfeeding, ineffective
•
Breastfeeding, interrupted
•
*Electrolyte imbalance, risk for
•
Failure to thrive, adult
•
Fluid balance, readiness for enhanced
•
Fluid volume, deficient
•
Fluid volume, deficient risk for
•
Fluid volume excess
•
Fluid volume, imbalanced, risk for
•
Infant feeding pattern, ineffective
Growth and development
•
Dentition, impaired
•
Development delayed, risk for
•
Growth, disproportionate, risk for
•
Growth and development, delayed
Health promotion/Education
•
Health maintenance, ineffective
•
Health management, self, ineffective
•
Health-seeking behaviors (specify)
•
Immunization status, readiness for
enhanced
•
Knowledge deficient (specify)
•
Knowledge (specify), readiness for
enhanced
•
Therapeutic regime management:
family ineffective
•
Hygiene- ability to perform activities of
daily living
•
*Neglect, self
•
Self care, readiness for enhanced
•
Self-care deficit, feeding
•
Self-care deficit, bathing
•
Self-care deficit, dressing
•
Self-care deficit, toileting
Life Principles
•
*Activity planning, ineffective
•
Decisional conflict
•
Decision making, readiness for
enhanced
•
Moral distress
•
Noncompliance (specify)
•
Hope, readiness for enhanced
•
Hopelessness
•
Religiosity, impaired
•
Religiosity, readiness for enhanced
•
Religiosity, risk for impaired
•
Spiritual distress
•
Spiritual distress, risk of
•
Spiritual well being, readiness for
enhanced
Neurosensory- ability to perceive, integrate
and respond to internal and external cues
•
Autonomic dysreflexia
•
Autonomic dysreflexia, risk for
•
Communication, impaired verbal
•
Communication, readiness for
enhanced
•
Confusion, acute
•
Confusion, acute, risk for
•
Confusion, chronic
•
Environmental interpretation
syndrome, impaired
•
Infant behavior, disorganized
•
Infant behavior, disorganized, risk for
•
Infant behavior, organized, readiness
for enhanced
•
Intracranial adaptive capacity,
decreased
•
Memory, impaired
•
Neurovascular dysfunction, peripheral
risk for
•
Sensory perception disturbed
(specify):visual, auditory, kinesthetic,
gustatory, tactile, olfactory
•
Unilateral neglect
Pain/discomfort- ability to control
internal/external environment to maintain
comfort
•
*Comfort, impaired
•
Comfort, readiness for enhanced
•
Pain, acute
•
Pain, chronic
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Perioperative positioning injury, risk
for
Poisoning, risk for
Protection, ineffective
Self mutilation
Self mutilation, risk for
Skin integrity, impaired
Skin integrity, impaired, risk for
Sudden infant death syndrome, risk for
Suffocation, risk for
Suicide, risk for
Surgical recovery, delayed
Thermoregulation, ineffective
Tissue integrity, impaired
Trauma, risk for
*Trauma, risk for vascular
Violence, self-directed risk for
Violence, other-directed, risk for
Wandering
Sexuality (component of ego integrity and
Social interaction)- Ability to meet
requirements/characteristics of male/female
role
•
*Childbearing process, readiness for
enhanced
•
Sexual dysfunction
•
Sexuality patterns, ineffective
Social Interaction- ability to establish and
maintain relationships
•
Attachment, parent/infant/child, risk
for impaired
•
Care giver role strain
Respiration- ability to provide and use
•
Care giver role strain, risk for
oxygen to meet physiological needs
•
Family processes, dysfunctional
•
Airway clearance, ineffective
•
Family processes, interrupted
•
Aspiration, risk for
•
Family processes, readiness for
•
Breathing pattern, ineffective
enhanced
•
Gas exchange, impaired
•
Loneliness, risk for
•
Spontaneous ventilation, impaired
•
Parenting, impaired
•
Ventilatory weaning response,
•
Parenting, readiness for enhanced
dysfunctional (DVWR)
•
Patenting, risk for impaired
Safety- ability to provide safe, growth•
*Relationships, readiness for enhanced
promoting environment
•
Role conflict, parental
•
Body temperature, imbalanced, risk for •
Role performance, ineffective
•
Contamination
•
Social interaction, impaired
•
Contamination, risk for
•
Social isolation
•
Falls, risk for
•
Home maintenance, ineffective
•
Hyperthermia
•
Hypothermia
•
Infection, risk for
•
Injury, risk for
•
*Maternal/fetal dyad, risk disturbed
•
Latex allergy response
•
Latex allergy response, risk for
Activity/Rest
Activity intolerance: insufficient
physiological or psychological energy to
endure or complete required or desired daily
activities
Activity intolerance, risk for: at risk for
experiencing insufficient physiological or
psychological energy to endure or complete
required or desired daily activities
Walking, impaired: limitation of
independent movement within the
environment on foot (or artificial limb)
Circulation
*Bleeding, risk for: at risk for a decrease in
blood volume that may compromise health
Cardiac output, decreased: inadequate
blood pumped by the heart to meet
metabolic demands of the body
Disuse syndrome, risk for: at risk for
deterioration of body systems as the result of *Tissue perfusion, decreased cardiac
tissue, risk for: risk for a decrease in
prescribed or unavoidable musculoskeletal
cardiac (coronary) circulation
inactivity
Diversional activity, deficient: decreased
stimulation from or interest or engagement
in recreational or leisure activities
*Tissue perfusion, ineffective, cerebral,
risk for: risk for decrease cerebral tissue
circulation
Fatigue: an overwhelming, sustained sense
of exhaustion and decreased capacity for
physical mental work at usual level
*Tissue perfusion, ineffective, renal, risk
for: at risk for a decrease in blood
circulation to the kidney that may
compromise health
Insomnia: a disruption in amount and
quality of sleep that impairs function
Mobility: bed, impaired: limitation of
independent movement from one bed
position to another
Mobility: physical, impaired: limitation in
independent, purposeful physical movement
for the body or of one or more extremities
Mobility: wheelchair, impaired: limitation
of independent operation of wheelchair
within the environment
Sedentary lifestyle: reports a habit of life
that is characterized by a low physical
activity level
Sleep deprivation: prolonged periods
without sleep (sustained natural, periodic
suspension of relative unconscious)
*Sleep pattern disturbed: time-limited
interruptions of sleep amount and quality
due to external factors
Sleep, readiness for enhanced: a pattern of
natural, periodic suspension of
consciousness that provides adequate rest,
sustains a desired lifestyle, and can be
strengthened
Transfer ability, impaired: limitation of
independence movement between two
nearby surfaces
*Tissue perfusion, ineffective,
gastrointestinal, risk for: at risk for
decrease I gastrointestinal circulation
Tissue perfusion, ineffective, peripheral:
decrease in blood circulation to the
peripheries that may compromise health
*Shock, risk for: at risk fro an inadequate
blood flow to the body’s tissues which may
lead to life-threatening cellular dysfunction
Ego Integrity
Anxiety: vague, uneasy feeling of
discomfort or dread accompanied by an
autonomic response, with the source often
nonspecific or unknown to the individual; a
feeling of apprehension caused by
anticipation of danger. It is an alerting signal
that warns of impending danger and enables
the individual to take measures to deal with
threat.
Anxiety, death: vague uneasy feeling of
discomfort or dread generated by
perceptions of a real or imagined threat to
one’s existence
Body image, disturbed: confusion in
mental picture of one’s physical self
Coping, community, ineffective: pattern of
community activities (for adaptation and
problem solving) that is unsatisfactory for
meeting the demands or needs of the
community
Coping, community, readiness for
enhanced: pattern of community activities
for adaptation and problem solving that is
unsatisfactory for meeting the demands or
needs of the community but that can also be
improved for management or current and
future problems/stressors
Grieving: a normal complex process that
includes emotional, physical, spiritual,
social and intellectual responses and
behaviors by which individuals, families and
communities incorporate an actual,
anticipated or perceived loss into their daily
lives
Coping, defensive: repeated projection of
falsely positive self-evaluations based on
self-protective pattern that defends against
perceived threats to positive self regard
Grieving, complicated: a disorder that
occurs after the death of a significant other,
in which the experience of distress
accompanying bereavement fails to follow
normative expectations and manifest in
functional impairment
Coping, family, compromised: usually
supportive primary person (family member
or close friend) provides insufficient,
ineffective, or compromised support,
comfort, assistance, or encouragement that
may be needed to manage or master
adaptive tasks related to heath challenge
Coping, family, disabled: behavior of
significant person (family member or other
primary person) that disables his or her
capacity to effectively address tasks
essential to either person’s adaptation to
health challenges
Coping, family, readiness for enhanced:
effective management of adaptive tasks by
family member involved with client’s health
challenge, who now exhibits desire and
readiness for enhanced health and growth
with regard to self in relation to client
Coping, (individual), readiness for
enhanced: pattern of cognitive and
behavioral efforts to manage demands that is
sufficient for wellbeing and can be
strengthened
Coping, ineffective: inability to form a
valid appraisal of internal or external
stressors, inadequate choices of practical
responses, and/or to access or use available
resources
Denial, ineffective: conscious or
unconscious attempt to disavow anxiety the
knowledge or meaning of an event, to
reduce anxiety/fear, but leading to the
detriment of health
Energy field disturbed: a disruption of the
flow of energy surrounding a person’s
being, which results in a disharmony of
mind and spirit
Fear: response to perceived threat that is
consciously recognized as a danger
Grieving, risk for complicated: a t risk for
a disorder that occurs after the death of a
significant other, in which the experience of
distress accompanying bereavement fails to
follow normative expectations and manifest
in functional impairment
Health behavior, risk prone: impaired
ability to modify lifestyle/behaviors in a
manner consistent with a change in health
status
Relocation stress syndrome: physiological
and/or psychological disturbances that result
from transfer from one environment to
another
Relocation stress syndrome, risk for: at
risk for physiological and/or psychological
disturbances that result from transfer from
one environment to another
*Resilience, impaired individual:
decreased ability to sustain a pattern of
positive responses to an adverse situation or
crisis
*Resilience, readiness for enhanced: a
pattern of positive responses to an adverse
situation or crisis that can be strengthened to
optimize human potential
*Resilience, risk for compromised: at risk
for decreased ability to sustain a pattern of
positive responses to an adverse situation or
crisis
Human dignity, risk for compromised: at
risk for perceived loss of respect and honor
Self-concept readiness for enhanced: a
pattern of perceptions or ideas about the self
that is sufficient for well-being and can be
strengthened
Personal identity, disturbed: inability to
maintain an integrated and complete
perception of self
Self-esteem, chronic low: long-standing
negative self-evaluations/feelings about self
or self-capabilities
Post trauma syndrome: sustained
maladaptive response to a traumatic,
overwhelming event
Self-esteem, situational low: development
of a negative perception of self-worth in
response to a current situation
Post trauma syndrome, risk for: at risk for
sustained maladaptive response to a
traumatic, overwhelming event
Self-esteem, risk for situational low: at
risk for developing negative perception of
self-worth in response to a current situation
Power, readiness for enhanced: a pattern
of participating knowingly in change that is
sufficient for well-being and can be
strengthened
Sorrow, chronic: cyclical, recurring and
potentially progressive pattern of pervasive
sadness that is experienced (by parent, or
caregiver, or individual with chronic illness
or disability) in response to continual loss
throughout the trajectory of an illness or
disability
Powerlessness: perception that one’s own
actions will not significantly affect an
outcome, perceived lack of control over
current situation or immediate happening
Powerlessness, risk for: at risk for
perceived lack of control over a situation
and/or one’s ability to significantly affect an
outcome
Rape-trauma syndrome: sustained
maladaptive response to forced, violent
sexual act (penetration may not actually
occur) against victim’s will and consent
Stress, overload: excessive amounts and
types of demands that require action
Endo
Blood glucose, risk for unstable: risk for
variation of blood glucose/sugar levels from
the normal range
Elimination
Bowel incontinence: change in normal
bowel elimination habits characterized by
involuntary passage of stool
Constipation: decrease in normal frequency
of defecation, accomplished by difficult or
incomplete passage of stool and/or passage
of excessively hard, dry stool
Constipation, risk for: at risk for decrease
normal frequency of defecation
accompanied by difficult or incomplete
passage of stool and/or passage of
excessively hard, dry stool
Constipation, perceived: self-diagnosis of
constipation and abuse of laxatives, enemas,
and/or suppositories to ensure a daily bowel
movement
Diarrhoea: passage of loose, unformed
stools
*Motility, dysfunctional gastrointestinal:
increased, decreased, ineffective or lack of
peristaltic activity within the gastrointestinal
system
*Motility, risk for dysfunctional
gastrointestinal: risk for increased,
decreased, ineffective or lack of peristaltic
activity within the gastrointestinal system
Urinary elimination, readiness for
enhanced: a pattern of urinary functions
that is sufficient for meeting eliminatory
needs and can be strengthened
Urinary elimination, impaired:
disturbance in urine elimination
Urinary incontinence, functional: inability
of usually continent person to reach toilet in
time to avoid unintentional loss of urine
Urinary incontinence, overflow:
involuntary loss of urine associated with
over distention of the bladder
Urinary incontinence, reflex: involuntary
loss of urine at somewhat predictable
intervals when a specific bladder volume is
reached
Urinary incontinence, stress: sudden
leakage of urine with activities that increase
intra-abdominal pressure
Urinary incontinence, urge: involuntary
passage of urine occurring soon after strong
sense of urgency to void
Infant feeding pattern, ineffective:
Growth and development, delayed:
impaired ability to suck or coordinate the
deviations from age-group norms
suck-swallow response resulting in
inadequate oral nutrition for metabolic needs Health and promotion/Education:
Urinary incontinence, risk for urge: at
Health maintenance, ineffective: inability
risk for involuntary loss of urine associated
to identify, manage, or seek out help to
Nutrition: imbalanced, less than body
with a sudden, strong sensation or urinary
requirements: intake of nutrients
maintain health
urgency
insufficient to meet metabolic needs
Health management, self, ineffective:
Urinary retention: incomplete emptying of Nutrition: imbalanced, more than body
pattern of regulating and integrating into
the bladder
requirements: intake of nutrients that
daily living a therapeutic regime for
exceeds metabolic needs
treatment of illness and its sequelae that is
unsatisfactory for meeting specific health
Food/fluid
Breastfeeding, effective: mother-infant
Nutrition: imbalanced, risk for more than goals
body requirements: at risk for intake of
dyad/family exhibits adequate proficiency
nutrients that exceeds metabolic needs
Health-seeking behaviors (specify): active
and satisfaction with the breastfeeding
seeking (by individual in stable health) of
process
Nutrition, readiness for enhanced: a
ways to alter personal health habits and/or
pattern of nutrient intake that is sufficient
environment to move toward higher level of
Breastfeeding, ineffective: dissatisfaction
for meeting metabolic needs and can be
health
or difficulty a mother, infant or child
strengthened
experiences with the breastfeeding process
Immunization status, readiness for
Breastfeeding, interrupted: break in the
enhanced: a pattern to conforming to local,
Oral mucous membrane, impaired:
disruptions of lips and soft tissues of the oral national, and/or international standards of
continuity of the breastfeeding process as a
cavity
result of inability or inadvisability to put
immunization to prevent infectious disease/s
baby to breast for feeding
that is sufficient to protect a person, family
Swallowing, impaired: abnormal
or community and can be strengthened
Electrolyte imbalance, risk for: at risk for functioning of the swallowing mechanism
associated with deficits in oral, pharyngeal
change in serum electrolyte levels that may
Knowledge deficient (specify): absence or
or oesophageal structure or function
compromise health
deficiency of cognitive information related
to a specific topic
Failure to thrive, adult: progressive
Gastro
functional deterioration of a physical and
*Jaundice, neonatal: the yellow orange tint Knowledge (specify), readiness for
cognitive nature. The individuals ability to
of the neonate’s skin and mucous membrane enhanced: the presence or acquisition of
live with multisystem diseases, cope with
that occurs after 24hours of life as a result of cognitive information related to a specific
ensuring problems and manage his/her care
topic is sufficient for meeting health-related
unconjugated bilirubin in the circulation
is remarkably diminished
goals and can be strengthened
Liver function, impaired, risk for: at risk
Fluid volume, readiness for enhanced: a
for a decrease in liver function that may
Therapeutic regime management: family
pattern of equilibrium between fluid volume compromise health
ineffective: pattern of regulating and
and chemical composition of body fluids
integrating into family processes a program
that is sufficient for meeting physical needs Nausea: an subjective unpleasant, wave-like for treatment of illness and its sequelae that
and can be strengthened
is unsatisfactory for meeting specific health
sensation in the back of the throat,
goals
epigastium or throughout the abdomen that
Fluid volume, deficient: decreased
may or may not lead to vomiting
intravascular, interstitial and/or intracellular
Hygiene
fluid (refers to dehydration, water loss alone Growth and development
*Neglect, self: a constellation of culturally
without change in sodium level)
framed behaviors involving one or more
Dentition, impaired: disruption in tooth
self-care activities in which there is a failure
development/eruption patterns or structural
Fluid volume, deficient, risk for: at risk for integrity of individual teeth
to maintain a socially acceptable standard of
experiencing vascular, cellular, or
health and well-being
intracellular dehydration
Development delayed, risk for: at risk for
Self care, readiness for enhanced: a
delay of 25% or more in one or more of the
Fluid volume, excess: increased isotonic
areas of social or self regulatory behavior, or pattern of performing activities for oneself
fluid retention
that helps to meet health-related goals and
in cognitive, language, gross or fine motor
can be strengthened
skills
Fluid volume, imbalanced, risk for: at risk
for decrease, increase, or rapid shift form
Growth disproportionate, risk for: at risk Self-care deficit, feeding: impaired ability
one to the other of intravascular, interstitial
to perform or complete feeding activities
for growth above the 97th percentile or
and/or intracellular fluid (refers to body
below 3rd percentile for age, crossing two
fluid loss, gain or both)
percentile channels
Self-care deficit, bathing: impaired to
perform or complete bathing/hygiene
activities for self
Self-care deficit, dressing: impaired ability
to perform or complete dressing and
grooming activities for self
Self-care deficit, toileting: inability to
perform or complete toileting activities for
self
Life principles
*Activity planning, ineffective: inability to
prepare for a set of actions fixed in time and
under certain conditions
Decisional conflict: uncertainty about
course of action to be taken when choice
among competing actins involves risk, loss
or challenge to values and beliefs
Decision making, readiness for enhanced:
a pattern choosing courses of action that is
sufficient for meeting short and long-term
health-related goals and can be strengthened
Moral distress: response to the inability to
carry out one’s chosen ethical/moral
decision/action
Noncompliance (specify): behavior of
person and/or caregiver that fails to coincide
with a health-promoting or therapeutic plan
agreed on by the person (and/or family
and/or community) and health care
professional; in the presence of an agreedon, health promoting, or therapeutic plan,
person’s or caregiver’s behavior is fully or
partially nonadherant and may lead to
clinically ineffective or partially ineffective
outcomes
Hope, readiness for enhanced: a pattern of
expectations and desires that is sufficient for
mobilizing energy on one’s own behalf and
can be strengthened
Hopelessness: subjective state in which
individual sees limited or unavailable
alternatives or personal choices and is
unable to mobilize energy for problem
solving on his or her own behalf
Religiosity, impaired: impaired ability to
exercise reliance on beliefs and/or
participate in rituals of a particular faith
tradition
Religiosity, readiness for enhanced: ability
to increase reliance on religious beliefs
and/or participate in rituals of a particular
faith tradition
Confusion, acute, risk for: at risk for
reversible disturbances of consciousness,
attention, cognition, and perception that
develop over a short period of time
Religiosity, risk for impaired: at risk for an
impaired ability to exercise reliance on
beliefs and/or participate in rituals of a
particular faith tradition
Confusion, chronic: irreversible, longstanding, and/or progressive deterioration of
intellect and personality characterized by
deceased ability to interpret environmental
stimuli and decreased capacity for
intellectual thought processes, and
manifested by disturbances of memory,
orientation, and behavior
Spiritual distress: impaired ability to
experience and integrate meaning and
purpose in life through the individual’s
connectedness with self, others, art, music,
literature, nature or a power greater than
oneself
Spiritual distress, risk of: at risk for an
impaired ability to experience and integrate
meaning and purpose in life through the
individual’s connectedness with self, others,
art, music, literature, nature or a power
greater than oneself
Spiritual well being, readiness for
enhanced: ability to experience and
integrate meaning and purpose in life
through connectedness with self, others, art,
music, literature, nature, or a power greater
than oneself that can be strengthened
Neuro
Autonomic dysrelexia: life threatening,
uninhibited sympathetic response of the
nervous system to a noxious stimulus after
spinal cord injury at T7 or above
Environmental interpretation syndrome,
impaired: consistent lack of orientation to
time/place/person/circumstances over more
than 3-6 months necessitating a protective
environment
Infant behavior, disorganized:
disintegrated physiological and
neurobehavioral responses to the
environment
Infant behavior, disorganized, risk for:
risk for alteration in integrating and
modulation of the physiological and
neurobehavioral systems of functioning (i.e.
autonomic, motor, state, organization, selfregulatory, and attentional-interactional
systems)
Infant behavior, organized, readiness for
enhanced: a pattern of modulation of the
physiological and behavioral systems of
functioning (i.e. autonomic, motor, state,
organization, self-regulatory, and
attentional-interactional systems) in an
infant that is satisfactory but that can be
improved
Autonomic dysreflexia, risk for: at risk for
life threatening, uninhibited response of the
sympathetic nervous system; post-spinal
shock; in an individual with spinal cord
injury or lesion at T6 or above (has been
demonstrated in clients with injuries at T7 or Intracranial adaptive capacity, decreased:
intracranial fluid dynamic mechanisms that
T8)
normally compensate for increases in
intracranial volumes are compromised,
Communication, impaired verbal:
resulting in repeated disproportionate
decreased, delayed or absent ability to
increases in intracranial pressure (ICP) in
receive, process, transmit, and use a system
response to a variety of noxious and nonof symbols
noxious stimuli
Communication, readiness for enhanced:
pattern of exchanging information and ideas Memory, impaired: inability to remember
or recall bits of information or behavioral
with others that is sufficient for meeting
skills
one’s needs and life’s goals and can be
strengthened
Neurovascular dysfunction, peripheral
Confusion, acute: abrupt onset of reversible risk for: at risk of disruption in circulation,
sensation or motion of an extremity
disturbances of consciousness, attention,
cognition and perception that develop over a
short period of time
Sensory perception, disturbed (auditory,
gustatory, kinesthetic, olfactory, tactile,
visual): change in the amount or patterning
of incoming stimuli accompanied by a
diminished, exaggerated, distorted, or
impaired response to such stimuli (auditoryhearing) (gustatory- taste) (kinestheticmuscle sense) (olfactory- smell) (tactiletouch) (visual- see)
Gas exchange, impaired: excess or deficit
in oxygenation and/or carbon dioxide
elimination at the alveolar-capillary
membrane
Unilateral neglect: impaired sensory and
motor response, mental representation and
spatial attention of the body, and the
corresponding environment characterized by
inattention to one side and over attention to
the opposite side. Left side neglect is more
severe than persistent right side neglect
Ventilatory weaning response,
dysfunctional (DVWR): inability to adjust
to lowered levels of mechanical ventilator
support that interrupts and prolongs the
weaning process
Pain/discomfort
*Comfort, impaired: perceived lack of
ease, relief and transcendence in physical,
psychospiritual, environmental and social
dimensions
Comfort, readiness for enhanced: a
pattern of ease, relief and transcendence in
physical, psychospiritual environmental
and/or social dimensions that can be
strengthened
Pain, acute: unpleasant sensory and
emotional experience arising from actual or
potential tissue damage or described in
terms of such damage; sudden or slow onset
of any intensity from mild to severe with
anticipated or predictable end and a duration
of less than 6 months
Pain, chronic: unpleasant sensory and
emotional experience arising from actual or
potential tissue damage or described in
terms of such damage; sudden or slow onset
of any intensity from mild to severe,
constant or recurring without an anticipated
or predictable end and a duration of more
than 6 months
Respiration
Airway clearance, ineffective: inability to
clear secretions or obstructions from the
respiratory tract to maintain a clear airway
Aspiration, risk for: at risk for entry of
gastrointestinal secretions, oropharyngeal
secretions, solids or fluids into the
tracheobronchial passages
Breathing pattern, ineffective: inspiration
and/or expiration that does not provide
adequate ventilation
Spontaneous ventilation, impaired:
decreased energy reserve result in an
individual’s ability to maintain breathing
adequate to support life
Safety
Body temperature, imbalanced, risk for:
at risk for failure to maintain body
temperature within normal range
Contamination: exposure to environmental
contaminates in doses sufficient to cause
adverse health effects
Contamination, risk for: accentuated risk
of exposure to environmental contaminants
in doses sufficient to cause adverse health
effects
Falls, risk for: increased susceptibility to
falling that may cause physical harm
Home maintenance ineffective: inability to
independently maintain a safe and growthpromoting immediate environment
Hyperthermia: body temperature elevated
above normal range
Latex allergy response, risk for: risk of
hypersensitive reaction to natural latex
rubber products
Perioperative positioning injury, risk for:
at risk for inadvertent anatomical and
physical changes as a result of posture or
equipment used during an invasive/surgical
procedure
Poisoning, risk for: accentuated risk for
accidental exposure to, or ingestion of, drugs
or dangerous products in doses sufficient to
cause poisoning
Protection, ineffective: deceased in the
ability to guard self from internal or external
threats such as illness or injury
Self mutilation: deliberate self-injurious
behavior causing damage with the intent of
causing on-fatal injury to attain relief of
tension
Self mutilation, risk for: at risk of
deliberate self-injurious behavior causing
damage with the intent of causing on-fatal
injury to attain relief of tension
Skin integrity, impaired: altered epidermis
and/or dermis
Skin integrity, impaired, risk for: at risk
for skin being adversely altered
Sudden infant death syndrome, risk for:
presence of risk factors for sudden death of
an infant under 1 year of age
Hypothermia: body temperate below
normal range
Suffocation, risk for: accentuated risk of
accidental suffocation (inadequate air
available for inhalation)
Infection, risk for: at increased risk for
being invaded by pathogenic organisms
Suicide, risk for: at risk for self-inflicted,
life-threatening injury
Injury, risk for: at risk of injury as a result
of the interaction of environmental
conditions interacting with the individual’s
adaptive and defensive resources
Surgical recovery, delayed: extension of
number of postoperative days required to
initiate and perform activities that maintain
life, health, and well-being
*Maternal/fetal dyad, risk disturbed: at
risk for disruption of symbiotic
maternal/fetal dyad as a result of comorbid
or pregnancy related complications
Thermoregulation, ineffective:
temperature fluctuation between
hypothermia and hyperthermia
Latex allergy response: a hypersensitive
reaction to natural latex rubber products
Tissue integrity, impaired: damage to
mucous membrane, corneal, integumentary
or subcutaneous tissue
Trauma, risk for: accentuated risk of
accidental tissue injury (eg: wound, burn,
fracture)
*Trauma, risk for vascular: at risk for
damage to a vein and its surrounding tissues
related to the presence of a catheter and/or
infused solutions
Violence, self-directed risk for: at risk for
behaviors in which an individual
demonstrates that he or she can be
physically, emotionally, and/or sexually
harmful to self
Violence, other-directed, risk for: at risk
for behaviors in which an individual
demonstrates that he or she can be
physically, emotionally, and/or sexually
harmful to others
Wandering: meandering, aimless or
repetitive locomotion that exposes the
individual to harm; frequency incongruent
with boundaries, limits or obstacles
Sexuality (component of ego integrity and
Social interaction)
*Childbearing process, readiness for
enhanced: a pattern of preparing for,
maintaining and strengthening a healthy
pregnancy an childbirth process and care of
newborn
Sexual dysfunction: the state in which an
individual experiences a change in sexual
function during sexual response phases of
desire, excitation, and/or orgasm, which is
viewed as unsatisfying, unrewarding,
inadequate
Sexuality patterns, ineffective: expressions
of concern regarding own sexuality
Social Interaction
Attachment, parent/infant/child, risk for
impaired: disruption of the interactive
process between parent/significant other and
infant/child that fosters the development of a
protective and nurturing reciprocal
relationship
Care giver role strain: difficulty in
performing family caregiver role
Care giver role strain, risk for: caregiver
is vulnerable for felt difficulty in performing
family caregiver role
Family processes, dysfunctional:
psychosocial, spiritual and physiological
functions of the family unit are chronically
disorganized, which leads to conflict, denial
of problems, resistance to change,
ineffective problem solving and a series of
self-perpetuating crises
Family processes, interrupted: change in
family relationships and/or functioning
Family processes, readiness for enhanced:
a pattern of family functioning that is
sufficient to support the well-being of family
members and can be strengthened
Loneliness, risk for: at risk of experiencing
discomfort associated with a desire or need
for more contact with others
Parenting, impaired: inability of primary
caretaker to create, maintain or regain an
environment that promotes optimum growth
and development of the child
Parenting, readiness for enhanced: pattern
of providing environment for children or
other dependent person/s that is sufficient to
nurture growth and development and can be
strengthened
Parenting, risk for impaired: risk for
inability of primary caretaker to create,
maintain, or regain an environment that
promotes optimum growth and development
of the child
*Relationships, readiness for enhanced: a
pattern of mutual partnership that is
sufficient to provide each other’s needs and
can be strengthened
Role conflict, parental: parent experience
of role confusion and role in response to
crisis
Role performance, ineffective: patterns of
behavior and self-expression that do not
match the environmental context, norms and
expectations
Social interaction, impaired: insufficient
or excessive quantity or ineffective quality
of social exchange
Social isolation: aloneness experienced by
the individual and perceived as imposed by
others and as a negative or threatened state
Readiness to enhance = willingness to
strengthen or improve
1
Health History Paper
Student Name
Division of Health and Public Services, Compton College
NURS 146: Health Assessment
Instructors preferred name
Current date, 2021
2
Health History Paper
Subjective Data Summary
Summary in your own words of the patient’s positive and negative subjective reports, including comments
about the patient’s overall mental status. Remove the red and start typing in the box for the body of your paper
[Click here & type the body of your paper]
Biographical
Data
Gender:
Female
Patient History
Research Findings
These are examples only
These are examples only
Patient reports that she tries to walks at least
2x/week, for about 25-30 min. She states
since she has become older the exercise is
becoming harder to do.
Cardiovascular disease has killed more women
than men every year since 1984 and is the #1
cause of death for women age 35 and older
because 70% of American women don’t exercise
regularly. The article emphasized that as little
as 30 minutes a day of moderate aerobic
activity, such as walking, could significantly
reduce a person’s risk of heart disease (Center
for Disease Control and Prevention, 2019).
Medical History;
Cardiomyopathy, HTN, Hyperlipidemia
Race:
African
American
Occupation:
Plumber
Patient has a family history of Diabetes,
HTN, CA. Her maternal grandfather died
from Diabetes related complications. Patient
reports that because of the medical history of
both her and her family, she is conscientious
about her diet, does not smoke or drink
alcohol beverages.
According to the CDC, “In the US, the
prevalence of high blood pressure in African
Americans is among the highest in the
world.” Diet related diseases for black women
is associated to the following factors;
37% obesity, 11.2% Diabetes and 36.6% are
hypertensive (Jarvis, 2020).
Patient does not have time to pack her lunch
daily. She admits that fast food is her staple
diet.
NANDA Nursing Diagnosis
Actual
Risk
3
Conclusion
Finalize the body with a conclusion of your patient’s overall health status. Where are they on the health
continuum. Provide any information on any teaching you did for your patient
4
References
Center for Disease Control and Prevention (2019, November 18). Heart disease. Retrieved
December 9, 2019, from https://www.cdc.gov/heartdisease/
Jarvis, C. (2020). Physical examination and health assessment (8th ed.). St. Louis, MO:
Elsevier Inc.
5
Name of Interviewer (Nurse): ________________________
Date: _____________
COMPTON COLLEGE
N146 HEALTH HISTORY INTERVIEW WORKSHEET
Biographical Data: (Do not fill in grey areas)
Name (Initials):
Address:
Marital Status:
Occupation:
Gender: M/F
Date of Birth:
Age:
Race:
Telephone:
Contact Person:
Source of Data:
Reason for Seeking Care:
Present Health History:
Current medical conditions
Chronic medical conditions
Medications
Food allergies
Current medical treatments
Past Health History:
Chronic illnesses (circle all that apply)
Measles
Mumps
Ear infections
Throat infections
Previous Medical
conditions
Rubella
Other:
Chicken pox
Pertussis
Previous
hospitalizations/surgeries
Accidents/Injuries
Immunizations: (Circle)
Date of last exams –
Physical, dental, vision
Women
Tetanus
Poliomyelitis
Diphtheria
Hepatitis B
Date last pap smear:
Pertussis
Influenza
LMP:
Mumps
Varicella
Date last
mammogram:
Family History:
(Indicate age and current health. If deceased, indicate age and cause of death.)
Mother and father:
Rubella
Other:
6
Maternal grandparents:
Paternal grandparents:
Parents’ siblings:
Client’s siblings:
Spouse and children:
Personal and Psychosocial History:
Family/Social Relationships (significant others, individuals in home, role within family, etc)
Diet/Nutrition (include appetite, typical food intake, etc):
Functional Ability (indicate ability to independently perform following self-care activities
Mental Health (anxiety, depression, irritability, stressful events, personal coping strategies):
Person Habits:
Tobacco use: ____________________
Alcohol intake: _____________________
Illicit drug use: _______________________________________________
Health Promotion
Exercise (type/frequency):
Self-examination (type/frequency):
Oral hygiene practice (frequency of brushing/flossing):
Environment (including living and work environment)
REVIEW OF SYSTEMS: (Must include both positive and negative findings)
Circle all symptoms that apply, and comment below. Use PQRSTU symptom evaluation.
Remember this is not a physical exam but information which the client reports to nurse (subjective
information.)
General
Symptoms:
Pain
Fatigue
Problems sleeping
Weight changes
Weakness
Fever
Comments:
Integumentary Changes in
System:
skin/color/texture
Sores that do not
heal
Excessive bruising Itching
Skin lesions
Change in mole
Sun exposure
Recent hair loss
7
Comments:
Head:
Headaches
Comments:
Eyes:
Head Injury
Dizziness
Fainting spells
Change in
vision
Sensitivity to
light
Correct lenses
Y/N
Comments:
Discharge
Halos around
lights
Eyeglasses Y/N
Excessive
Eye pain
tearing
Difficulty
reading
Contact Lenses Y/N
Ears:
Ear pain
Changes in
hearing
Comments:
Drainage
Recurrent
infections
Tinnitus
Sensitivity to
noises
Excessive wax
Hearing devices
Y/N
Nose,
Nasopharynx,
Sinuses
Nasal discharge
Frequent
nosebleeds
Postnasal drip
Sneezing
Nasal obstruction
Change in smell
Snoring
Sinus pain
Comments:
Sore throat
Sore in mouth
Bleeding gums
Change in taste
Dental prosthesis
Change in voice
Swelling/mass
Neck pain
Stiffness
SOB
Cough up blood
Wheezing
Night sweats
Cough
Mouth/Oropharynx
Trouble swallowing/chewing
Comments:
Neck
Lymph nodes
Comments:
Breasts
Respiratory
System
Frequent colds
Pain w
breathing
Comments:
8
Cardiovascular
System
Chest pain
Palpitations
Dyspnea
Edema
Cold extremities Discoloration
Leg pain w activity
Paresthesia
Comments:
Dyspnea w sleep
Varicose veins
GI System
Pain
Jaundice
Flatus
Comments:
Heartburn
Nausea/Vomiting
Change appetite Diarrhea
Change in bowel habits
Vomiting blood
Constipation
Urinary System
Hesitancy
Pain w
urination
Comments:
Frequency
Flank pain
Change in stream
Blood urine
Nocturia /Anuria
Increase/Decrease
urine volume
Muscle pain
Weakness
Joint Swelling
Joint pain
Stiffness
Limited ROM
Limited mobility
Back pain
Seizures
Fainting
Tremor
Reproductive
Musculoskeletal
Comments:
Neurologic System Pain
Spasms
Comments:
Change in sensation, cognition, memory, coordination
VAMC
SLUMS Examination
Questions about this assessment tool? E-mail aging@slu.edu
Name___________________________________________________________
Age______________________
Is the patient alert?____________________ Level of education________________________________________
__/1
1 1. What day of the week is it?
__/1
1 2. What is the year?
__/1
1 3. What state are we in?
4. Please remember these five objects. I will ask you what they are later.
Apple
Pen
Tie
House
Car
__/3
1
2
5. You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20.
How much did you spend?
How much do you have left?
__/3
6. Please name as many animals as you can in one minute.
0 0-4 animals
1 5-9 animals
2 10-14 animals
__/5
7. What were the five objects I asked you to remember? 1 point for each one correct.
__/2
8. I am going to give you a series of numbers and I would like you to give them to me
backwards. For example, if I say 42, you would say 24.
0 87
1 648
1 8537
__/4
3 15+ animals
9. This is a clock face. Please put in the hour markers and the time at
ten minutes to eleven o’clock.
2
Hour markers okay
2
Time correct
1 10. Please place an X in the triangle.
__/2
__/8
1
Which of the above figures is largest?
11. I am going to tell you a story. Please listen carefully because afterwards, I’m going to ask
you some questions about it.
Jill was a very successful stockbroker. She made a lot of money on the stock market. She then
met Jack, a devastatingly handsome man. She married him and had three children. They lived
in Chicago. She then stopped work and stayed at home to bring up her children. When they were
teenagers, she went back to work. She and Jack lived happily ever after.
2 What was the female’s name?
2 What work did she do?
When
did
she
go
back
to
work?
2
2 What state did she live in?
TOTAL SCORE
SCORING
High School Education
Less than High School Education
27-30
Normal
25-30
21-26
Mild Neurocognitive Disorder
20-24
1-20
Dementia
1-19
CLINICIAN’S SIGNATURE
DATE
TIME
SH Tariq, N Tumosa, JT Chibnall, HM Perry III, and JE Morley. The Saint Louis University Mental Status
(SLUMS) Examination for detecting mild cognitive impairment and dementia is more sensitive than the MiniMental Status Examination (MMSE) – A pilot study. Am J Geriatr Psych 14:900-10, 2006.