Sample of Nursing Health History

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Nursing Health History
Nursing health history is the first part and one of the mostsignificant aspects in case studies. It is a systematic collection ofsubjective and objective data, ordering and a step-by-step processinculcating detailed information in determining client’s history, healthstatus, functional status and coping pattern. These vital informationsprovide a conceptual baseline data utilized in developing nursingdiagnosis, subsequent plans for individualized care and for the nursingprocess application as a whole.
In keeping the private life of my patient and in maintaining confidentiality, let me hide for with the pseudonym of Patient B.
Patient B was born on December 19, 1992. She didn’t know herparents but she has relatives
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A thorough record of relevant dates is important in determining relevance of past illnesses or events to the patient 's current condition.
Past and current medical history includes details on medicines taken by the patient, as well asallergies, illness, hospitalizations, procedures, pregnancies, environmental factors such as exposure to toxins or carcinogens, and health maintenance habits such as self breast examination or immunizations.
An example of a line of questioning might be:
• How are your ears?
• Are you having any trouble hearing?
• Have you ever had any trouble with your ears or with your hearing?
If the patient indicates a history of auditory difficulties, this would prompt further questions about medicines, surgeries, procedures, or associated problems related to their current or past condition.
In addtion to identifying data, chief complaint, and review of systems, a comprehensive health history also includes factors such as the patient 's family and social life, family medical history, mental or emotional illnesses or stressors, detrimental or beneficial
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