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Nursing History Sample

Mr. N.C Laguna is a 60-year-old Filipino man who was admitted to the hospital with a chief complaint of chest pain and difficulty breathing. He had been previously hospitalized for an intolerable chest pain and diagnosed with pleural effusion. His past medical history includes diabetes mellitus and hypertension. A review of systems was otherwise unremarkable. He is married with children and retired from the military. His social history is significant for occasional alcohol use and no smoking or drug use.

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John Kenneth Dalumpines
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34K views3 pages

Nursing History Sample

Mr. N.C Laguna is a 60-year-old Filipino man who was admitted to the hospital with a chief complaint of chest pain and difficulty breathing. He had been previously hospitalized for an intolerable chest pain and diagnosed with pleural effusion. His past medical history includes diabetes mellitus and hypertension. A review of systems was otherwise unremarkable. He is married with children and retired from the military. His social history is significant for occasional alcohol use and no smoking or drug use.

Uploaded by

John Kenneth Dalumpines
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

I.

Name: Address: Age: Gender: Race: Marital Status: Occupation:

PATIENTS BIOGRAPHICAL INFORMATION Mr. N.C Laguna City 60 Male Filipino Married Military (retired) Roman Catholic Pleural Effusion II. CHIEF COMPLAINT

Religious Affiliation: Admitting diagnosis:

Health Care Financing: Siblings Income

Chest pain, Difficulty of Breathing III. NURSING HISTORY

I. History of Present Illness One month prior to clients admission, the client felt chest pain which he could still tolerate. Clients significant others stated that the client has been hospitalized at a hospital in laguna due to an intolerable pain in the chest area. Then he was reffered to Veterans Memorial Medical Center and based on lab results it was ruled out that the patient has pleural effusion among with some complications like tuberculosis, abdominal pain cyst in the liver and malignant ischemia.

II. Past Health History Medical History- Diabetes Mellitus, Hypertension Surgical History-none Accidents-none Medications- multivitamins Prescribed Medications- insulin, Calcibloc Childhood Illnesses and ImmunizationsImmunization Allergies- no known food and drug allergies III. Family Health History Mother- HPN, DIABETES MELLITUS, (deceased) Father- HPN, DIABETES MELLITUS, (deceased) Wife- No known disease, Occupation- Nurse Son- No known disease, Occupation- none IV. Social Health History Alcohol use- occasionally Smoking use-never Drugs use-none Travelling History- parts of mindanao (surigao del norte and del sur, Agusan del norte and del sur, Basilan, Cagayqan de Oro). Hobbies and Leisure Act- Reading books and newspapers, jogging. Work Environment- fresh air, nice working area, good people to interact with. Physical Environment- nice neighbourhood, clean, fresh air. Home Environment- clean, well ventilated house. Economical Status and ethnic and cultural beliefs- Middle class family, Roman Catholic. Chickenpox, Complete

Roles and Relationships- Husband, father

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