History taking for nursing students

a guide in a form of outlines for history taking from pediatric patients. it is written in a way that eases the process of information collecting from patinets as its organized and easily filled out.

1. History Taking


i. Biographical data

Name: _________ Medical diagnosis: _________

Age: _________ Occupation: _________

Gender: _________ Admission date: _________
Via: __________

Address: _________ Race: _________

Religion: _________ Birth date/ place: _________

Blood type:_________ Source of data: _________

Parent's education: Mother_______ / Father________

Date of interview: ___________

2. ii. Chief complaint/ Reason for seeking care (cc)
(One or two major symptom + their last occurrence before admission)



______________________________________________

______________________________________________

iii. Present illness (PI)
as bbreviatedA. obtain all details related to the chief complaintTo (
)P.Q.R.S.T.U.A

P
Palliative/what can decrease the symptom: ________________________




Provocative/ what can increase the symptom: _____________________

___________________________________________________________

3. Q
Quality/ how can you describe the symptom: ______________________


R
Region/ where has the symptom occurred on your body:______________



Radiation/ does it radiate to other parts of the body. If yes, where: _____


S
Severity/ on a pain scale of 1-10, how much is your pain: _____________


T
Timing
Onset/ when & how did the pain or symptom start: _________________

__________________________________________________________

Duration/ for how long does it last: ________________________ ______

4. Frequency/ how many times a day does it happen: __________________

U
(Quoted statement from the patient or parents)

Understanding/ what did you thought the symptom is indicating for:

"____________________________________________________

_____________________________________________________"

A
Associated factors/ was the symptom associated with other symptoms:



___________________________________________________________



Write present illness as a paragraph

5. ___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

6. iv. Past illness (ph)
A- Birth history
If patient is under 2 years, collect it:
/ mother health during pregnancy, any illness (HTN, DM, Pregnancy-
hemorrhage), or any infections: _________________________________

X-ray: ______________ nutrition: _____________
Gestation time : _________ months


Were problems faced during past pregnancy, yes/no. What were

They? ________________________________________________


______________________________________________________

/ when did your contractions first start: ________________Labor

How often were your contractions coming: _________________

Were they getting stronger_________were they regular________

.vaginal or cesarean: Was it Delivery

:Child condition at birth

Crying: yes/ no
Basic problems ( with respiration..ect):______________________

7. Birth injury: Yes/no. What was it ________________
Birth weight: __________kg
Skin color: cyanosis ( ) jaundice ( ) fever ( ) rash ( )

B- Previous illnesses, injuries, or operations

Previous illnesses: _____________________________________

Injuries: __________________________when________________

Surgical operations/ pervious hospitalization:
Cause_________________________________________________

Date__________________________________________________

Treatment_____________________________________________


C- Allergies

Does the patient have allergies from food, medication, any other
agents like pets, or house hold products, what is the reaction?



_____________________________________________________

________________________________________________
D- Current medications

___________________________________________________________

8. ___________________________________________________________


Immunizations E-

The name of the disease/vaccination: ___________________________


The number of injections: ______________________________________
___________________________________________________________

The ages when administered: ___________________________________


The dosage (was the dosage of the vaccinations lessened or did they give
it to the patient fully):_________________________________________
__________________________________________________________
Vaccination not given_____________ cause _______________
Habits F-
Hours of sleep and arising:___________________________________

9. Regularity of stools and urination/ how many times a day:
___________________________________________________________

G- Growth and development
Growth
•Approximate/current weight at 6 months, 1 year, 2 years, and 5 years of
age:
________________________________________________________
•Approximate/current length at ages 1 and 4 years:
_________________________________________________________
 Head/chest circumference:
_______________________________________________________
•Dentition, including age of onset, number of teeth, and symptoms
during teething:


___________________________________________________________


Developmental milestones include:
Gross motor:
• Age of holding up head steadily: _______________________________
 Can patient sit/ walk:______________________________________
Age of sitting alone_____________________ walking____________

Fine motor:

10.  Can patient Hold a spoon/draw/pick up something:_______________
Smiling: ________

Language:
• Age of saying first words with meaning: _________________________
 Can patient talk/understand what others say:_____________________
Sociality:
• Interactions with other children, peers, and adults:__________________
Other questions:
• Present grade in school: ______________________________________
• Scholastic performance:______________________________________
• If the child has a best friend:__________________________________

H- Family medical history (used primarily to discover any hereditary
or familial diseases in the parents and child.)
chronic illnesses in the tree family of patient parents, their immediate aunts and
uncles, and their grandparents ( heart problems, hypertension, cancer, obesity,
cancer, DM…etc)
Age of mother______ Father ________
Illness (HTN, DM..etc): mother_________ ____father _______________
Siblings: How many_______ age of each______________________
_________________________________illness__________________
Grandparents: Age of grandmother _______ grandfather_______
If anyone deceased name cause/ date:
___________________________________________________________

___________________________________________________________

11. I- Family structure:
• Family composition: _____________________________________


• Home and Community Environment: _______________________


• Monthly income: _______________________________

• Occupation and Education of Family Members:________________

______________________________________________________


______________________________________________________

G- Feeding history/ diet/ nutrition assessment (significant in
child less than 2 years):

• Type of feeding: breast fed Yes/No. If yes,
duration_____________
Bottle fed Yes/No. if yes, at which age_______,
composition of formula______________________,
amount_____________ ml, frequency/day____________

• Supplements (iron, vitamins..etc): ___________________

________________________________________________

• Current diet:______________________________________
K- Psychosocial History:
Fears: adaption/regression:

12. Vital sings

Normal
range
according to
age
result Vital sings

Temperature

pulse

Respiratory
rate

Blood
pressure

O2 saturation


Lab test
Normal
range
Result Chemistry Normal
range
Result CBC
Na+ WBC
K+ RBC
CL- HCT
CA+ HGB
Bun LYMPH
CRT MONO
GLU Neutro
Platelet


URIANLYSIS: STOOL CLUTURES:
CSF:

13. Medication

Nursing
implication
Frequency Dose Route Action
Indication
Medication
Classification