A&M UNIVERSITY
College of Nursing
BASIC CONCEPTS PRACTICUM – NURS 3263

DATA COLLECTION TOOL

Student’s Name Date April 5, 2011
Biographical data
Client’s initials P.M. Unit/Room No. A735 Age 64 years old
Gender F Ethnicity Black Religion Baptist Marital Status Widowed
Occupation Unemployed Date of Admission March 31, 2011 Admitting Problem/Diagnosis Unstable Angina
Chief Complaint (Why did the patient come to the hospital – in patient’s own words)

“My chest was constantly hurting and I couldn’t figure out what was causing it and now my back is killing me.”

Past Health History
Asthma ________ Emphysema _______ Bronchitis ________ Pneumonia ________TB________ Angina ______ MI ______ Anemia ______ Hypertension _______ Rheumatic Fever _______ Pacemaker _______ Peripheral Vascular Disease _________ Blood Disorders _________ Stroke _________ Skin Disease ______ Bladder Infections _Kidney Disease ___________ Ulcers ________ DM _________ Dental Problems _________ Fractures _________Congenital Heart Defects Surgeries

Family Health History
Condition Family Members Condition Family Members
Heart Disease Mom died of heart attack Tuberculosis
Hypertension Asthma
Stroke Mental Illness
Diabetes Alcoholism
Cancer Aunt died of mylethoma Kidney Disease

Other Health Problems in Family: _________________________________________________________________

Medications Prior to Admission: (List)
Prescription: She only takes aspirin and pain medications, but she doesn’t know the exact medications.
Nonprescription: None Allergies and Reactions: Identify the drugs allergic to and describe the client’s response to them:
1.) Penicillin – Drug: causes