Você está na página 1de 4

Date of assessment: august 27, 2009

Nursing Health History

Name: Mary Grace Sucito
Age: 25 years old
Address: 313 Ramirez St. BDO Manila
Date of birth: January 19
Place of birth: Hongkong
Religion: Buddhist
Nationality: Chinese
Marital status: C, 1984
Chief Complaint: Severe Lumbo sacral pain
AMD: Dra. C Espinosa
Midwife on duty: Ms. J Tan
Diagnosis: Normal Spontaneous Vaginal Delivery

Next kin of data:

Name: Socoro Sucita

Age: 20 years old
Relationship: younger sister

Present Health History

The patient started to recognize that she is pregnant when she noticed that she
experienced three consecutive months of no menstruation. Her first and last visit for check up is
on June 22, 2008 at San Nicolas lying in health center. The patient did not meet her regular
check up. She told us that because of lack in financial sustain, she failed to have her x-ray and
laboratory procedure. She does experience any nausea and vomiting. On the whole month of her
pregnancy, she denies having any fever, and any communicable disease and there is also no
presence of bleeding. Her last menstrual period was noted on December 28, 2008. The expected
date of confinement is October 5, 2009 but was admitted in San Nicolas Lying in on august 27,
2009 that can cause a premature delivery. The duration of labor took 2 hours and the baby was
delivered at 7:45 am by Normal Spontaneous Vaginal delivery. The midwife on duty that took
care of her is Ms. J. Tan and the doctor is Dra. C. Espinosa. She was instructed to have flat on
bed and has an IVF of D5W 1L at her right lower arm regulated at 11 gtts/min. The baby was
brought to an hospital because it was a premature baby. The health center cannot provide any
incubator for the baby.
Past Health History

Ms. Sucito was born via normal spontaneous vaginal delivery. She was
hospitalized two times in San Lazaro Hospital. It started when she was 3
years old due to her meningitis. According to the mother, the patient
experience sudden fall or bump her head unconsciously. The second
hospitalization is when her temperature continues to increase and leads to
convulsion. She experience also sudden mild stroke in her right part of her
body. She experience asthma and said to be inherited to her father. There
are no medications taken when her asthma attacks. She just stop her choirs
and continue when she can breath normally again. There are no allergies
noted in terms of food or things that surround her. Her childhood
immunization is complete.

Family Health History

The Family has a history of hypertension and asthma. Ms. Sucito inherited
her asthma on her father. Both sides of the family have a history of
hypertension that the patient may acquire. As of now, she doesn’t
experience any signs of hypertension.

Social History
The patient is living with her family. It is her first time to have her own family but her
future husband left her alone after knowing that her husband is reliable on it. She is afraid of
giving birth but her family is always there especially her younger sister to support her. The
members of the family are open to share when there is a problem within the family or personal
problems. They are very close to each other.

The patient is responsible for their household choirs. She often wash
clothes for others and fetched water to be used. The money that she gets
from it is given to her mother to budget for the family. Even when knowing
that she is pregnant, she continues her heavy job. She doesn’t know the
risks that may happen to her baby. She prefer to eat vegetables and fish
rather than meat.

Psychological data
The patient is afraid when she is giving birth. Upon the assessment
there is still fear as her movement tells us that she is uncomfortable
touching her. She tries to protect herself from hurting again. The fear was
lessen when we continue chatting her.

Patterns of Health Care

The family seeks only for medical check up when there is a free consultation on the
center. During her pregnancy she doesn’t complete her check up although it is important to
them. She does not drink any medicine during her pregnancy although her asthma attacks.

Review of the Systems

General system:
“nanghihina ako tsaka masakit ang mga braso ko. Kumikirot din yung tahi ko ” as verbalized by
the client.

Integumentary system:
“wala naman akong allergies kahit saan” as verbalized by the client.
“nung malapit na akong manganak, ayun naglabasan yung rashes ko sa singit singit lang” as
verbalized by the client.

Respiratory system:
“hindi naman, pero kanina nahihirapan akong huminga habang nanganganak” as verbalized by
the client.

Cardiovascular system:
“hindi naman naninikip ang dibdib ko ” as verbalized by the client.

Musculoskeletal system:
“Masakit ang mga braso ko” as verbalized by the client.

Urinary system:
”mahapdi nung umuhi ako” as verbalized by the client.

Nervous system:
“makakalimutin nga ako minsan” as verbalized by the client.
“hindi naman ako masyadong nahihirapang gumalaw, madalas akong makabasag ng pinggan
kasi nanginginig ang kamay ko” as verbalized by the client.

Digestive system:
“hindi pa nga ako nakakadumi” as verbalized by the client.
genitourinary system:
“kumikirot ang tahi ko sa puerta” as verbalized by the client.

Endocrine system:
“nung December 28, 2008 ang huli kong nagkaroon ng regla” as verbalized by the client.