Nursing Health history

The text book we use is Jarvis Physical Examination & Health Assessment by Saunders
I Demographics (include patient initials MM, age 38,sex F,race Hispanic, marital status single,occupation unemployed, education BA criminal justice)

II chief complaint – Abdominal pain
III History of present illness-started 4days ago achy pain crampimg, nausea/vomitting, no diarrhea, lying on side relieves a little pain
IV Medical History
a. past med history- htn, smokes occasionlly,
b..fam history- 2 brothers 2 sisters parents deceased
c. social history- improvise
d. ob/gyn history – 2 children
e. sexual history – improvise
V Review of Systems
Subjective- improvise but it has to coincide with chief complaint
Objective- improvise but it has to coincide with chief complaint
VI Nursing DX- need actual and a at risk for
VII Plan
a. goals
b. interventions
c. evaluation
VIII Summary

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