Nursing Health History

Date of assessment: on November

10, 2009

Name:Hilario, Susan M.
Sex:Female
Age:33 years old
Address: B9 L9, Imus Cavity
Date of birth: May 7, 1976
Place of birth: Tagbilaran City
Admission no.:96687-0003
Patient no.121116-2005
Religion: Catholic
Nationality:Filipino
Marital status: married
Chief Complaint: low segment transverse placenta
AMD: Dr. Fely T. Te
Nurse on duty: Ms. Michelle Kathleen Tan
Diagnosis: caesarean plus appendectomy

Present Health History

The patient started to recognize that she is pregnant when she noticed that she
experienced three 1 week of no menstruation. She used pregnancy monitoring exam
and determines a positive sign. She experience nausea and vomiting but not that usual
unlike her first pregnancy. She experience early signs of pregnancy such as breast
tenderness, urinary frequency and fatigability. The patient did meet her regular check
at Metropolitan Hospital center. 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 February 15, 2009. The expected
date of confinement is November 22, 2009 but was admitted in Metropolitan Hospital
center on November 10, 2009, normal for age of gestation which is 38 3/7 weeks. The
duration of procedure took 3 hours and the baby was delivered at 1825H by caesarean
section because of transverse placental presentation. In addition to the procedure, she
also undergo to an appendectomy. The nurse on duty that took care of her is Ms.
Michelle Kathleen Tan and the doctor is Dr. Fely. T. Te. She was instructed to have
flat on bed and has an IVF of D5LR 1L at her right lower arm regulated at 31
gtts/min.
Past Health History

Ms. Susan started her first menstrual period when she was 13
years old. She has a regular flow of menstruation. She uses 2 to 3
pads a day. She experience dysmenorrhoea when she was in high
school but gone when she has married. Ms. Susan was hospitalized
three times in Metropolitan Hospital center. It started on 2006 when
she undergoes a caesarean section because of the small cervix. The
second hospitalization is the cervix cannot handle it. The baby died
inside when it was 1 ½ months. And the last hospitalization was the
present baby delivery. She plan to continue breastfeeding which she
prefer during her 1st baby. She told us that she has no allergies in
terms of food or things that surround her but she has an allergy for
penicillin as noted. Her childhood immunization is complete.

Family Health History

The both sides of the family have a history of diabetes. Ms. Susan
doesn’t have diabetes.

Social History
The patient is living with her family. The members of the family are open to
share when there is a problem within the family or personal problems. She doesn’t
have any problem on communicating her brother and sister although they are really
far from each other. She believes that when someone is facing the door, she will
experience difficulty in labor.

Lifestyle
The patient continuous her work although her expected date
of confinement is near. She often exposed to radiation because of
her work as a professional accountant. Nothing changes her
lifestyle, she does whatever she wants. She doesn’t have any vices
such as drinking and smoking. She prefers to eat vegetables and
fish rather than meat. Ms. Susan doesn’t experience any sleep
disturbance and complete her sleep.

Psychological data
The patient is open on giving information. She participates on
the assessment done.

Patterns of Health Care

The family seeks only for medical check up when there is complicated
situations such as unmanaged pain and illness. They only buy medicine when they
have simple coughs and cold. During her pregnancy she completes her check up
because she knows it is important to her. She does not drink any medicine during her
pregnancy unless prescribed by doctors.