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University of the East

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC.
#64 Aurora Blvd., Brgy. Doña Imelda, Sta. Mesa, Quezon City

COLLEGE OF NURSING

NCM 107
NURSING PROCESS

COMPONENTS OF NURSING HEALTH HISTORY

1. INTRODUCTION
1.1. BACKGROUND
• Purpose: Determine the background of the case
• Discuss about case (is it Antenatal? Intranatal? Postnatal? Newborn 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, 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

This format is specifically prepared for NCM 107 and NCM 109 students only.
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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

This format is specifically prepared for NCM 107 and NCM 109 students only.
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• 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 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.

This format is specifically prepared for NCM 107 and NCM 109 students only.
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• 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.

This format is specifically prepared for NCM 107 and NCM 109 students only.
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• 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,

This format is specifically prepared for NCM 107 and NCM 109 students only.
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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.

This format is specifically prepared for NCM 107 and NCM 109 students only.
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Sample Format
GORDON’S Before During Nursing Diagnosis
HEALTH Hospitalization Hospitalization
PATTERN Subjective > Subjective >

Objective > Objective>

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.

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

• Purpose: Determine the normal anatomy and physiology of the body system
involved.

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.

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,
mechanism of action, side effects, adverse affects, contraindications of the
medication in relation to the case of the patient and the nursing responsibilities.

Generic Name, Dosage, Mechanism Side Adverse Contraindications Nursing

Frequency, Route. (based of Action Effects Effects Responsibilites
on the Doctor’s order)
Brand Name
Drug Classification

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.

This format is specifically prepared for NCM 107 and NCM 109 students only.
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10. NURSING CARE PLAN

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

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

Assessment Nursing Scientific Planning Implementation Evaluation
Diagnosis Rationale
S> P+E+S Explain S.M.A.R.T 1. Independent Should be
format why/how the Interventions in future
O> etiology caused 2. Dependent tense and
Sample: the Interventions related to
*Only problem/incident 3. Collaborative the plan
include NANDA dx
what will related to
support the (related
diagnosis factors) as
(specifically manifested
your by (1 or 2
etiology) signs and
symptoms)

*Make sure
that the
etiology is
the real cause
of the
problem
*Avoid using
medical
diagnosis as
the etiology.
*Choose
only 1 or 2
unique
manifestation
that are
reflected in
the
assessment.

ALL data from the Assessment until Evaluation should be congruent. If one area of the
Nursing process is incorrect, EVERYTHING IS CONSIDERED INCORRECT.

This format is specifically prepared for NCM 107 and NCM 109 students only.
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JOURNAL READING REFLECTION FORMAT

CLINICAL AREA/ DATE of ROTATION

Title of the Journal and Author with reference
What is the Journal all What did I learn from it? Application of learnings in
about? the clinical area.

*to be submitted at the end of the 3 weeks rotation.

LEARNING REFLECTION FORMAT

WEEK # OF ROTATION
DATE ACTIVITY RATIONALE RESPONSES/OBSERVATIONS

*this will be a weekly requirement to be passed on the last day of duty

Prepared by: Level II Team/SY2019-2020/rlp

This format is specifically prepared for NCM 107 and NCM 109 students only.