Patient’s Nursing History
Name of patient:
Hospital: Ward:
Demographic Data:
Address:
Birthday: age: sex: civil status:
Religion: Nationality:
Educational Attainment: Occupation:
Initial Data:
Mode of admission: emergency room
Vital signs on admission: BP: PR: RR: T=
General appearnce:
Dentures/ prothesis used:
Sensory motor deficits:
Psycho-social data:
Patient’s understanding of illness and hospitalization:
Patient’s expectation of present illness:
Family and Significant others:
Effects of hospitalization in the family:
Recreational activities/ hobbies/ special interest:
Specific Basic Needs or Problems:
Any pain or discomfort:
Measures/ intervention to relieve pain or discomfort: t
Assistance needed:
Sleeping patterns or problems:
Type of bath preferred and usual time:
Safety difficulty:
Is there any difficulty in walking? If yes, how did you manage?
Any special doctor’s order related to activity:
Ay difficulty in seeing or hearing:
Do you wear eyeglasses, contact lens, hearing aid?
Fluids and nutrition:
Fluid preferences:
Food preferences:
Appetite:
Condition of teeth:
Elimination:
Bowel frequency:
Bowel problems:
Bladder frequency:
Others:
Any breathing problems:
How do you manage:
Home medication:
Smoking:
Alcohol:
Nursing Impression:
Family History of Illness
- Diabetes Mellitus
- Pulmonary Tuberculosis
- Cancer
- Renal Disease
- Cardiac disorders
Past Medical History:
Example:
- 1968- PGH- appendectomy; s/p appendectomy
- 1982-PGH- stab wound RUQ of abdomen; s/p explore lap
History of Present Illness:
Example:
- 1mo PTA- patient have productive cough with whitish to yellowish phlegm accompanied by low garde fever. There is occasional Difficulty of breathing; didn’t seek medical assistance; took self-medication of Salbutamol tablet
- 1 wk PTA- Cough with whitish to yellowish phlegm is still visible; didn’t seek medical assistance; took self- medication of Amoxicillin tablet
- 1 day PTA- persistence of the above signs and symptoms w/ noted enhance severity of difficulty of breathing; still no consultation was done
- few hrs PTA- persistence of the above signs and symptoms with sever difficulty of breathing that lead in prompting consultation
