NURSING HEALTH HISTORY

A. DEMOGRAPHIC PROFILE Name Address Age Birthplace Nationality Sex Occupation Religion Civil Status Date of Admission Time of Admission Attending Physician Chief Complaint Clinical Diagnosis : : : : : : : : : : : : : Patient A Navotas City 21 y/o Tondo, Manila Filipino Female House Wife Catholic Single November 26, 2011 10:15 PM Dr. Macasadia Lumbo Sacral Pain radiating to Abdomen Impending Labor

B. History of Present Illness Two (2) days prior to admission the patient experienced pain on her pelvic joints during the day. In the evening she started feeling a menstrual type cramping which got stronger when she went to bed. One (1) day prior to admission the patient had menstrual type cramping as soon as she woke up, and back pains that are unbearably sharp. The patient saw mucous plug on her underwear. Towards the evening the patient started to feel swelling of her genital area. She felt ripe and about to burst open. Few hours prior to admission the patient had menstrual type cramping, and when was about to go to the bathroom, a huge yellow, blood tinged spot of cervical mucus came out. At about 10:15 in the evening the patient was admitted to the hospital due to unbearable lumbo sacral pain radiating to abdomen. C. Past Medical History Immunization According to the patient she has a complete immunization of HBV, OPV, DPT Measles Vaccine and Tetanus Toxoid Vaccines; exact dates are no longer remembered. Childhood Illness As Child, Patient A has a history of measles, mumps, chicken pox, colds, cough, fever and sore eyes. Exact dates can no longer be remembered. Allergies Patient A has no history of allergy to any foods and drugs/substances. Hospitalization Patient A has no history of any serious hospitalization, accident or surgery.

FAMILY HISTORY Family Health History Illnesses Cardiac Dse HPN DM Cancer Asthma Others:

Paternal Side + + -

Maternal Side + + -

According to the patient they had a history of cardiac diseases on her Maternal Side. Hypertension was noted on both sides. Paternal side has history of asthma. OBSTETRIC HISTORY Patient A is a 21 year old, housewife who delivered her first baby one week ago at 40 weeks gestation by normal spontaneous vaginal delivery. Patient A is breast feeding and both baby and mother are well. The patient had her menarch when she was 13 years old, she had only one boyfriend which happened to be her husband now, the patient first engaged with sexually activities when she was 18 years old. The patient and her husband currently dont practice any family planning method and plans to still have a baby. SOCIO-ECONOMIC HISTORY Patient A lives in their rented house at Navotas City. Her husband is a tricycle driver and the source of the familys income which ranges from 2000-3500 every month. They can be measured up as to poor class family. The patient is a housewife and household chores is her recreational activity. The patient is a high school graduate with minimal knowledge with regards to stitching. The patient is non-drinker and non-smoker. The patient has good family relationship and social support.

ENVIRONMENTAL HISTORY Patient As rented house is situated near at the wet market of Sipac Navotas City. Their house is made of mix wood and stone. Their neighborhood is congested with house without spaces between each other. The streets are always muddy and wet due to the closeness to the wet market and often times the unpleasant odor of the fish shipments are scattered throughout the street, thus entering their houses. Insects, especially mosquitos are prominent due to the numerous stagnant water.

PHYSICAL ASSESSMENT I. II. III. A. Skin General Appearance Body build : Medium Frame Height & Weight: ht: 411; wt: 50kg. Posture : Relaxed and erect posture Hygiene & Grooming : Clean and neat Body breath & odor : Pleasant body odor Appearance : Healthy appearance Mental status : Oriented to person, time and place clean and intact memory Attitude: Cooperative. Friendly Mood & Affect : Appropriate to situation Quantity , Quality and organization of speech : Normal Pitch, moderate pace Vital signs Temperature : 37.1 C Pulse : 98bpm Respiration : 20bpm Blood pressure : 150/130 Integumentary

Assessing the skin

Normal findings

Abnormal findings

Inspect skin color Inspect and palpate skin lesion Palpate skin moisture Palpate for temperature Skin turgor

Fair Complexion No Skin lesion

Slightly Dry

warm to touch

Good skin turgor, skin when pinch returns to normal in less than 3 seconds

B. Nails

Assessing the skin

Normal findings

Abnormal findings

A. Inspect finger nails Plate shape

Texture Nail bed color Capillary refill test

Convex in shape; angle of nail plate about 160 degrees No clubbing of fingers Smooth Pinkish Good

IV. Head A. Hair

Assessing the hair

Normal findings

Abnormal findings

Inspect the hair color Inspect the evenness of growth over the scalp Texture and oiliness

Black Evenly distributed Silky and fine Variable

Inspect the amount of body hair

B. Scalp

Assessing the Scalp

Normal findings

Abnormal findings

Inspect Presence of dandruff Note presence of infections and infestation Note presence of Masses, deformities, swelling and tenderness

No Presence of Dandruff No infection and infestation

No presence of masses, deformities, swelling and tenderness

C. Skull and Face

Assessing the Skull and Face Inspect and palpate the skull and for size, shape, and symmetry Inspect facial features and symmetry of facial movements

Normal findings

Abnormal findings

Normocephalic, rounded, smooth skull contour, absence of nodules or masses Symmetric facial features and movement

D. Eyes and Vision

Assessing the Eye and Vision Inspect eyebrow, eyelashes and Eyelids

Normal findings

Abnormal findings

Eyebrow hair is black, evenly distributed in both eyes; symmetrically

aligned; eyelashes curled slightly outward; lids close symmetrically Inspect the conjunctiva for color, texture, and presence of lesions Inspect the pupil for color, shape symmetry of size Assess each pupil for direct and consensual reaction to light Assess six ocular movements to determine eye movement and coordination Assess visual fields Slightly pale; sclera appears white

Brown in color; equal in size; normally 3-7 mm in diameter Constricted and response to light

Both eyes coordinated, move in unison, w/ parallel alignment

No decreased peripheral vision No impairment, can determined pictures and letter shown

Assess visual acuity

E. Ears and Hearing

Assessing the Ears and hearing

Normal findings

Abnormal findings

 Inspect the auricles for color, symmetry of size and position

Symmetrical, skin color is same with facial skin, firm, tender and recoils after it is recoiled, Auricle aligned w/ outer cantus of the eye No lesion or purulent discharge Able to hear normal voice and can hear whisper spoken 2 feet away

Inspect external ear canal Assess gross hearing acuity test

F. Nose and Sinuses

Assessing the Ears and hearing

Normal findings

Abnormal findings

Inspect the external nose for any deviation in shape, size or discharges Palpate the external nose to determine any areas of tenderness Using penlight inspect the nasal cavities Inspect facial sinuses to determine patency

Symmetric and straight, no discharges Not tender; no lesions

Mucosa pink, clear watery discharges, no lesion Sinuses are well outlined, contain air and light up equally; no tenderness in all sinuses

G. Mouth and Oropharynx

Assessing the mouth and Oropharynx

Normal findings

Abnormal findings

 Inspect the lips for symmetry, color, texture and ability to pursue the lips Inspect the surface of the tongue for position, color and texture Inspect the uvula for position and mobility Inspect the teeth and gums

Uniform pink color, soft moist, ability to pursue the lips Central position, Pink color

Positioned in midline of soft palate Upper part 14 teeth; lower part 14 teeth; pink moist gums

V. NECK

Assessing the Neck

Normal findings

Abnormal findings

A. Muscle Inspect the neck muscles for abnormal swellings or masses B. Lymph Nodes Palpate the entire neck for enlarged lymph nodes C. Trachea Palpate the trachea D. Thyroid gland Palpate the thyroid gland Lobes are Palpable, no enlargement Positioned in the midline Not palpable Muscles equal in size; soft palate

VI. CHEST AND BACK

Assessing the Chest and Back

Normal findings

Abnormal findings

A. Assess Posterior thorax

Skin intact; no tenderness

and lesion B. Lungs Assess breathing patterns o o o o Rate Rhythm Depth Quality /character

20 bpm (normal) Regular rhythm Normal Cooperative, easy to approach

C. Breast and axilla Left and right breast Shape Round Skin Has localized discoloration area; smooth and intact Round in size, pink in color, No tenderness, no mass discharge or lesions Round; brown in color; no tenderness; no mass discharge or lesion

Areola

Nipples

VII. UPPER EXTREMITIES

Assessing the Upper Extremities

Normal findings

Abnormal findings

A. Joint ROM Assess Shoulder Shoulders are symmetrically

round no redness, swelling or deformity or heat. Muscles are fully developed. Clavicles and scapulae are even and symmetric. The patient reports no tenderness. Assess Elbows Elbows are symmetric without deformities, redness or swelling. Wrists are symmetric without redness or swelling. They are nontender and free of nodules. Hands and fingers are symmetric, nontender and without nodules. No swelling or deformities. Rounded protuberance noted next to thumb over the thenar prominence. Smaller protuberance seen adjacent to the smaller finger.

Asses Wrist

Assess Hands and Fingers

B. Muscle Assess muscle Muscles are equal in size on both sides of the body, no contractions on muscles and tendon, No tremors present on hands and arms. Muscle have

smooth coordinated movements

VIII. ABDOMEN

Assessing the Abdomen Inspect , Auscultate, Palpate and Percuss the abdomen

Normal findings Unblemished skin and uniform in color; Abdomen is flabby normal and soft; no evidenced of enlargement of liver and spleen

Abnormal findings

IX. LOWER EXTREMITIES

Assessing the Lower Extremities

Normal findings

Abnormal findings

A. Gross motor and Balance Test Walking Gait Has upright posture and steady gait with opposing arm swing; walks unaided maintaining balance Able to walk several steps on toes/heel

Toe/heel Walking

B. Joint ROM Hip Buttocks are equally sized; iliac crests are symmetric in height. Hips are stable, nontender and without crepitus. Knees are symmetric, hallows present on both side of the patella, no swelling or deformities. Lower leg are alignment with upper leg.

Knee

Ankle

 No pain, heat, swelling or nodules are noted. Skin is smooth and free from corns and calluses. Longitudinal arch; most of weight bearing is on foot midline.

GORONS FUNCTIONAL RULE: Pattern of Health Perception and Health Management BEFORE PRESENT Sa tuwing makakaramdam kami ng anumang SAME AS BEFORE sakit, pumupunta kami palagi sa health center ng Baranggay para magpatingin, sinusunod namin ang bawat suhestyon at instruction ng mga Doctor doon. Nutritional-Metabolic Pattern BEFORE PRESENT kahit ano naman kumakain ako,hindi ako mapili Medyo limitado pero madalas ako uminom, sa pagkain,pero mahilig ako sa gulay,hindi ako wala akong gana kasi ayaw ko dito sa ospital kumakain ng baboy at kumakain din ako sa oras, 3 beses ako kumain sa isang araw, minsan 4 p nga Pattern of Elimination BEFORE PRESENT minsan 3 beses ako dumumi sa isang lingo halos araw-araw ako kung dumumi, minsan lng minsan 4, nakakaihi ako ng 3-4 na beses sa isang ako umiihi sa isang araw, minsan 2 beses lang araw pero minsan pinipigil ko Pattern of Activity & Exercise BEFORE PRESENT maharot ako sa school, madalas ako naglalaro hindi na kasi nandito ako sa ospital, kailangan ng nkkpagod, kada umaga nag eexcercise kme pg magpahinga flag ceremony Cognitive Perceptual Pattern BEFORE PRESENT active ako sa class namin, magaling ako sa mejo mahina kasi nga mahina dn ang katawan memorization, at matalino daw ako,sabi nila. ko, feeling ko madami n akong hindi alam.pero hindi problema yun, hhbol nlng ako Sleep-Rest Pattern BEFORE PRESENT regular akong nkakatulog sa gabi pero hindi sa wala ata akong ginawa kundi matulog at tanghali. 8 oras ang tulog ko madalas minsan 6 magpahinga. Nkk-bagot dito lang.. Self Perception BEFORE PRESENT malakas ako, pala-laro nga ako madalas, hindi OK na naman ako, mejo nanghihina kasi lagi ako masyadong tinatablan ng sakit.kasi nga ako nakahiga, pero na-realize ko hindi din pala malakas ako. ganun kalakas ang pangangatawan ko Role-Relationship Pattern BEFORE PRESENT Masaya ako sa pagiging anak. Walang pag uwi ko, back to normal ulit, pero siguro masyadong ginagawa kasi may mga magulang babawasan ko n ang paglalaro sa labas. ako na nag tataguyod sakin. Mainsan tumutulong

ako sa mga gawaing bahay pero mas madalas naglalaro lang ako. Sexuality Pattern BEFORE PRESENT maaya ako sa paiging isang babae, syempre SAME AS BEFORE lalaki ang gusto ko, at hindi ko pa iniisip ang pag aasawa. hehe.

Coping Pattern BEFORE PRESENT madalas sinasarili ko lang ang mga problema SAME AS BEFORE pero pag hindi n kaya, sinasabi ko na kay mama lalo n pag tungkol sa school. Values-Belief Pattern BEFORE PRESENT katoliko kami nila mama, madalas kami nag SAME AS BEFORE sisimba, hindi ko nkakalimutang magdasal pag gabi at pagka-gising.