HOLY NAME UNIVERSITY

COLLEGE OF NURSING
City of Tagbilaran

HEALTH-STATE PROFILE/NURSING HISTORY

I. PERSONAL DATA:
Name: Age: Sex: C/S:
Address:
Educational Attainment:
Occupation:

II. PAST HISTORY

A. Development History

1. Developmental Task Theory (by Robert Haveghurts)

2. Psychological Development Theory (by Erick Erickson)

B. Illness in the Past:

1. Childhood

2. Adolescent

3. Adulthood

C. Travels (illness experienced during travel)

D. Accidents Trauma:

III. FAMILY HISTORY

If single:
Father’s Name: Age:
Occupation:
Siblings: Name Sex Biological Relation to the Patient

If married:
Name of Spouse: Age:
Occupation:
Children: Name Sex Biological Relation to the Patient

Heredo-familial Disease:
Diceased Family Member:

IV. VITAL INFORMATION

A. Present Hospitalization:
Date Admitted: Ward: Bed No.:

Chief Complaint:

Medical Diagnosis:

Surgery (if any):

B. Previous Hospitalization:

Date of Hospital Experience:

Causes of Hospitalization:

Medical Intervention:

Condition upon Discharge:

C. Vital Signs (present/upon interview):

Temperature: Pulse: Respiration:

Blood Pressure: Heart Rate: Pupils:

Height: Weight (before illness):

Weight (at present):

D. Informant:

Patient: Relationship:
Significant Others:
V. PERSEPTTIONS AND EXPECTATION OR PRESENT
ILLNESS/HOSPITALIZATION

1. Why did you come to the hospital?

2. What in your opinion caused you to get sick?

3. Has being sick made any difference in your way of life?

4. What do you expect to stay in the hospital?

5. How long do you expect to stay in the hospital?

6. With whom do you live?

7. Who is the most important person to you?

8. Are any of your family close friends able to visit you here in the hospital?

9. How has your hospitalization affected your family or friends?

10. What do you enjoy doing for recreation (or part-time) at home/and while you are
here in the hospital?

11. How do you expect to get along after you leave the hospital?

VI. HABITS OF DAILY LIVING

1. Food Habits
a. Meal Patterns:

Time Usual Food

Breakfast
Lunch
Dinner
Snacks

b. Food Dislikes:
c. Food Allergies:
2. Fluid Habits:
a. Fluid Preference:
b. Fluid Dislikes:
3. Sleep Habits: At Home: Hospital:
a. Usual Bedtime:
b. Usual Number of Hours of Sleep:
c. Get up at night? (if yes, why)
 d. Nap habits: Yes No
If yes, what time of the day?

4. General Hygiene:
a. Bathing Usual Time Frequency
At Home :
Hospital :
b. .Care of Teeth
Type: Normal :
Dentures :

5. Elimination:
a) Bowel Habits:
At Home :
Hospital :
b) Irregularities
Present Past
Yes No Yes No
Constipation
Fecal Impaction
Diarrhea
Fecal Incontinence

c) Bladder Habits: Usual Time Frequency

At Home :
At Hospital :

d) Irregularities:

Dysuria? :

Frequency? :

Nocturia? :

Anuria? :

Polyuria? :

Oliguria? :

Retention? :

Incontinence? :

Hematuria? :

Pyuria? :

Proteinuria? :

Glycosuria? :

VII. COMMUNICATION
1) Dialect Spoken:
2) Communication problem with hospital staff? Yes: No:
 If yes, elaborate:

3) Needs/Complaints Attended? Yes: No:

Specify:
Outcome

VII. LABORATORY
Normal Clinical Nursing
Name of Exam/Results
Value Significance Responsibility

IX. NURSE IMPRESSION

1. General Body Structure:

Body Built: Thin Long Bony Structure

Broad Short Body Structure

Physical Bearing:
Posture: Lorditic Kyphotic
Scoliotic Normal

Galt: Hemiplegic – leg is stiff and extended foot is lifted and

leg swung at pelvic level; arm drag not swing

Steppage – elevating hip and knee excessively high to

lift drag foot off ground

Dystropic – legs far apart shifting of weight from side

to side like waddling, abdomen, is often protracting and
lordosis is common

Tabetic – legs positioned far apart, lifted high, and

forcibly brought down with such step, stamping heel on
ground.
 Cerebellar – staggering gait with lurching from side to
side.

Parkensonian – shuffling gait with short steps; head iis

hunched forward

Dystonic – jerky dancing movements that appear non-

directional

Astasia – uncontrolled falling

Normal

2. Emotional Status

Happy Angry
Depressed Anxious
Agitated Scared
Isolent Drowsy

3. Emotional Status
Lethargic Delirious
Stuparous Confused
Tense Incoherent
Hysterical Apprehensive
Hallucinations Disoriented
Normal

4. Summary of Patient’s Present Condition Significant to Nursing Care: