POPE FRANCIS CENTER OF THE POOR

HISTORY

ORGANIZATIONAL CHART

LIST OF PATIENTS IN MALE AND FEMALE WARD

 NURSING HEALTH HISTORY
DEMOGRAPHIC PROFILE

Patient’s Name:
Sex:
Birthda te:
Age:
Time and Date of Admission:
Attending Physician:
Birthplace:
Permanent Address:
Nationality:
Religion:
Marital Status:
Educational Attainment:
Occupation:
Mother:
Occupation:
Father:
Occupation:
Health Care Financing:
Classification:
Source of Medical Care:
Hospital Number:
Chief Complaint:
Admitting Diagnosis:

IDENTIFYING DATA

SOURCE OF INFORMATION

HISTORY OF PRESENT ILLNESS

 Prior to Admission, what did the patient do?
 Are you referred here in EVR? Or kumadi kamo derecho?
 What is the child’s most urgent health concern?
 When did it start? What was it like?
 Has the problem changed at all? If so, when and in what way?
 Has medical attention been sought before now? If so, what investigations have been done so far? What
treatments have been tried?
 Were there any previous episodes?
 What are its relieving or aggravating factors?

PAST PERSONAL HISTORY

 Problems @ birth:
 Childhood illnesses:
  Immunizations to date:
 Adult illnesses (physical, emotional, mental)
 Surgeries:
 Accidents:
 Prolonged pain or pain patterns:
 Allergies:
 Physical, emotional, social or spiritual weakness:
 Physical, emotional, social or spiritual strength:

FAMILY HISTORY

 Age of parents (living? Date of death):

 Parents’ illness and longevity:
 Grandparents’ illness and longevity:
 Aunts’ and uncles’ ages, illness, and longevity:
 Children’s ages, illness or handicaps and longevity:
 Number of Children:
 Number of Siblings:
 GENEALOGY:
o Grandfather Sickness:
o Grandmother Sickness:
o Mother Sickness:
o Father Sickness:
o Sister Sickness:
o Brother Sickness:

Are there in your family who has a disease of:

o Diabetes, who:
o Hypertension, who:
o Asthma, who:
o Heart Problems, who:
o Cancer, who:
o Tuberculosis, who:
o Schistosomiasis, who:
o Allergies, who:
o Blood Disorders, who:
o Heart Disease, who:
o Liver Disease, who:
o Others, specify, who:

PSYCHOSOCIAL HISTORY
o Relationship with others:
o Alcohol Drinking:
o Smoking Sessions:
 o Coping Mechanisms on Stress:
o What are your hobbies at home?
o Do you do these often?
o In your work/school, do you participate in sports (if applicable)?
o What type of house do you live in?
o What is your religion?
o Do you read the bible?
o Impact of this illness on the family (especially if chronic or ongoing)?
o Erickson's Stage:

LIFESTYLE AND HEALTH PRACTICES:

o Description of a typical day (am to pm)
o Nutrition and weight management:
o 24-hour food recall
o Who purchases and prepares meals
o Activities on a typical day:
o Exercise habits and patterns:
o Use of medications and other substances:
o Self concept:
o Self responsibilities:
o Social activities for fun and relaxation:
o Type of work, level of job satisfaction, work stressors
o Finances:
o Stressors in life and coping strategies used:
o Residency, type of environment, neighborhood, environmental risks:

PSYCHIATRIC HISTORY
o Please tell us about your mental health history, if applicable (depression, anxiety, chemical dependency,
bipolar disorder, schizophrenia, suicide attempts)
o When was it Diagnosed?
o What are the Treatments Done?
o Medications Given?
o Please tell us if you have ever experienced any of the following and indicate dates and duration, e.g., last
6 months, 5 years ago:
 Depression
 Anxiety, excessive worries
 Suicidal ideation/behavior
 Homicidal ideation/behavior
 Abuse of any kind
 Difficulty concentrating
 Fights
 Compulsive Behavior (eating, sex, work, substances)
 Shopping sprees
 Phobia
 Mania
 Feelings of worthlessness
 Hallucinations
 Feelings of intense shame or guilt
 o Please tell us if you have experienced problems in any of the following areas. Please note the
approximate date and give a brief description.
 Gambling
 Sexual compulsion/Addiction
 Eating Disorders
 Relationships
 Internet Addiction
o Please describe any negative consequences you have experienced as a result of adverse mental health in
any of the following areas:
 Relationships
 Career
 Financial
 Health (include emotional health)
 Legal
 Personal
 Sexual
o Have you ever experienced any of the following?
 Shakes
 Blackouts
 Hallucinations
 Convulsions/Seizures
o Previous Employment:
o Date of Employment Previously:

SUBSTANCE USE/ABUSE
 Smoke

 Alcohol

 Drugs

 Psychiatric

 Suicidal

 Violent Behavior

DEVELOPMENTAL AND SOCIAL HISTORY

 Erickson Stage:

TREATMENT PLAN (Refer to the Patient's Treatment)

 PHYSICAL EXAMINATION
(Check items that are present)

General

Vital Signs Vital signs taken and are as follows:

Time:
BP:
T:
PR:
RR:
O2 Saturation:
Skin, Hair and Nails Skin is brown, soft, and intact. No lesions and tenderness were noted.
Client has slight or no odor of perspiration. Hair is fixed, black, smooth,
and firm. No masses, deformities and tenderness upon palpation.
Fingernails are thin and pinkish in color. Capillary nail in both arms and
feet bed refills less than 3 seconds.
Head and Neck Head is symmetric, hard, smooth, and oval. Scalp is clean and dry. No
depression or masses on the head noted. Temporal artery is elastic and non-
tender. Neck is symmetric with head centered. Trachea is midline.
Currently, a neck mass was observed and noted.
EENT Eyeballs are symmetrically aligned in sockets without protruding or
sinking. Sclera is white. Upper and lower eyelids close easily and meet
completely when closed. Skin on both eyelids is without redness, swelling,
or lesions. Anicteric sclera. No drainage noted on nasolacrimal duct. Ears
are equal in size bilaterally. Auricle aligns with the corner of each eye.
Earlobes are free. Skin is smooth with no lesions, lumps or nodules. No
discharges present. Non tender. Canal walls are pink and smooth without
nodules. Nose and nasal passages are not inflamed. Nasal mucosa dark
pink, moist and free from exudate. Nasal hairs are coarser. No presence of
discharges, tenderness, and no active lesion. Sinuses are free from lesions
and pain. Mouth has no unusual or foul odor noted. No redness or free from
exudate. Lips are pink and moist. No cracks, active lesions, and dryness
noted.
C/L Above normal breathing pattern at 27cpm, but accessory muscles not used
in support for breathing. Sternum is positioned at midline and straight. No
masses, tenderness, tumors, lumps, lesions noted.
Heart Heart Rate is in normal range at 74 bpm. Normal pulse activity, not
bounding. No cyanosis noted.
Breast No observable masses, scars, lesions, and discoloration on the skin.
Abdomen Tenderness reported upon palpation. No mass nor lumps palpated.
Musculoskeletal Shoulders are symmetrically round; no redness, swelling, or deformity.
Muscles are fully developed. Clavicles and scapulae are even and
symmetric. Elbows are symmetric, without deformities, redness, or
swelling. Wrists are symmetric, without redness, or swelling. Knees
symmetric, hollows present on both sides of the patella, no swelling or
deformities. Lower leg in alignment with the upper leg. Toes point forward
and lie flat; Toes and feet are in alignment with the lower leg. Smooth,
rounded medial malleolar prominences with prominent heels and
metatarsophalangeal joints. Sole of the foot has calluses. Buttocks are
equally sized; iliac crests are symmetric in height.
Genitourinary No observable masses. Difficulty upon urination is noted.
REVIEW OF SYSTEMS
 MENTAL STATUS EXAMINATION
GENERAL APPEARANCE (Observed)
 Gait:
 Posture:
 Clothes:
 Grooming:

MOTOR BEHAVIOR (Observed)

 Mannerisms & Gestures:
 Psychomotor activity:
 Expression & Eye contact:
 Ability to follow commands/requests:
 Compulsions:

ATTITUDE AND BEHAVIOUR (Observed)

 Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused,
defensive:

LEVEL OF CONSCIOUSNESS (Observed)

 Vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating:

ORIENTATION (Inquired)
 “What is your full name?”
 “Where are we at (floor, building, city, county, and state)?”
 “What is the full date today (date, month, year, day of the week, and season of the year)?”
 “How would you describe the situation we are in?”

SPEECH AND LANGUAGE (Inquired)

 Quantity - Talkative, spontaneous, expansive, paucity, poverty:

 Rate - Fast, slow, normal, pressured:

 Volume - Loud, soft, monotone, weak, strong:

 Fluency and Rhythm - Slurred, clear, with appropriately placed inflections, hesitant, with good
articulation, aphasic:

MOOD (Inquired)
 “How are your spirits?”
 “How are you feeling?”
  “Have you been discouraged/depressed/low/blue lately?”
 “Have you been energized/elated/high/out of control lately?”
 “Have you been angry/irritable/edgy lately?”

AFFECTIVE STATE (Observed)

 Appropriateness to situation, consistency with mood, congruency with thought content:
 Fluctuations - Labile, even:
 Range - Broad, restricted:
 Intensity - Blunted, flat, normal intensity:
 Quality - Sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious,
animated, irritable:

THOUGHT PROCESS (Observed/ Inquired)

 Linear, goal-directed, circumstantial, tangential, loose associations, incoherent, evasive, racing,
blocking, perseveration, neologisms:

THOUGHT CONTENT (Observed/ Inquired)

 “What do you think about when you are sad/angry?”
 “What’s been on your mind lately?”
 “Do you find yourself ruminating about things?”
 “Are there thoughts or images that you have a really difficult time getting out of your head?”
 “Are you worried/scared/frightened about something or other?”
 “Do you have personal beliefs that are not shared by others?” (Delusions are fixed, false, unshared
beliefs.)
 “Do you ever feel detached/removed/changed/different from others around you?”
 “Do things seem unnatural/unreal to you?”
 “What do you think about the reports in papers such as The National Enquirer?”
 “Do you think someone or some group intend to harm you in some way?”
 [In response to something the patient says] “What do you think they meant by that?”
 “Does it ever seem like people are stealing your thoughts, or perhaps inserting thoughts into your head?
Does it ever seem like your own thoughts are broadcast out loud?”
 “Do you ever see (visual), hear (auditory), smell (olfactory), taste (gustatory), and feel (tactile) things
that are not really there, such as voices or visions?” (Hallucinations are false perceptions)
 “Do you sometimes misinterpret real things that are around you, such as muffled noises or shadows?”
(Illusions are misinterpreted perceptions)

SUICIDALITY AND HOMICIDALITY (Inquired)

SUICIDALITY
 “Do you ever feel that life isn’t worth living? Or that you would just as soon be dead?”
 “Have you ever thought of doing away with yourself? If so, how?”
 “What would happen after you were dead?”
 HOMICIDALITY
 “Do you think about hurting others or getting even with people who have wronged you?”
  “Have you had desires to hurt others? If so, how?”

INSIGHT AND JUDGMENT (Observed/ Inquired)

 “What brings you here today?”
 “What seems to be the problem?”
 “What do you think is causing your problems?”
 “How do you understand your problems?”
 “How would you describe your role in this situation?”
 “Do you think that these thoughts, moods, perceptions, are abnormal?”
 “How do you plan to get help for this problem?”
 “What will you do when ____ occurs?”
 “How will you manage if ____ happens?”
 “If you found a stamped, addressed envelope on the street, what would you do with it?”
 “If you were in a movie theater and smelled smoke, what would you do?”

ATTENTION (Observed/ Inquired)

DIGIT SPAN (FORWARD AND REVERSE
 “I will recite a series of numbers to you, and then I will ask you to repeat them to me, first forwards and
then backwards.” [Begin with 3 numbers – not consecutive numbers, and advance to 7-8 numbered
sequence.]
 SPELLING BACKWARDS
 “Spell the word ‘world.’ Now spell the word ‘world’ backwards.”
 CALCULATIONS
 (Serial 7’s) “Starting with 100, subtract 7 from 100, and then keep subtracting 7 from that number as far
as you can go.”
 (Serial 3’s) “Starting with 20, subtract 3 from 20, and then keep subtracting 3 from that number as far as
you can go.” [Monitor for speed, accuracy, effort required, and monitor patient reactions to the request]
 “Add these numbers: (15 + 12 + 7)”
 “Multiply these numbers: (25 x 6)”
 “If something costs 78 cents and you give the cashier one dollar, how much change should you get
back?”

MEMORY (Observed/ Inquired)

RECENT MEMORY
 “What is my name?”
 “What medications did you take today?”
 “What time was your appointment with me for today?”

REMOTE MEMORY
 “Where were you when President Kennedy was shot?” (For patients over 40)
 “What is your Social Security number?”
 “What were the dates of your graduation from high school, college, graduate school?”
 “When and where did you get married?”
IMMEDIATE MEMORY AND NEW LEARNING
 “I am going to ask you to remember three words (color, object, animal – e.g., blue, table, and horse) and
I will ask you to repeat them to me in 5 minutes. Please repeat them now after me: blue, table, and
horse.” – 5 minutes elapse – “What were those three words I asked you to remember?” [Monitor
accuracy of response, awareness of whether responses are correct, tendency to confabulate or substitute
other words, ability to correct themselves with category clue and multiple choice].

INTELLECTUAL FUNCTIONING (Observed/ Inquired)

INFORMATION AND VOCABULARY
 “Name the last 5 presidents.”
 “Name 5 of the largest cities in the country.”
 “Name the current president, vice president, governor, and mayor.”

VOCABULARY
 Grade school level, high school level, fluent, consistent with education:

ABSTRACTION
 Similarities – “How are the following items similar?”
 “An apple and an orange” (round ~concrete, fruit ~abstract)
 “A chair and a table” (made of wood ~concrete, furniture ~abstract)
 “A watch and a ruler” (measurement instruments ~abstract)
 Proverbs – “How would you describe the meaning of the following sayings?”
 “People living in glass houses should not throw stones.”
 “A bird in the hand is worth two in the bush.”
 “You shouldn’t cry over spilt milk.”
 “Two heads are better than one."

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SENSORIUM AND COGNITION

PERCEPTION

DEFENSE MECHANISM