NURSING HISTORY

Nursing Student: Demetrio Ferrer III

Year Level:
BSN- 4A
Date:
September 5,2013
Clinical Instructor: Ms. Rose dawn Maranon Rn
I.

VITAL INFORMATION:

Clients Name:
Bejo, Ron Mikael
Age:
26 yrs. Old
Sex:
Male
Civil Status:
Single
Religion:
Romam Catholic
Nationality:
Filipino
Birthdate:
March 3, 1987
Birthplace:
Barotac Nuevo, Iloilo City
Current address:
Barotac Nuevo, Iloilo City
Educational attainment:
College Graduate
Occupation:
Waiter
Chief complaint/s:
Pain on lower right arm
Date and time of admission to ER:
August 19, 2013 at 3:00 am
Attending Physician:
Dr. Legada
Medical Diagnosis:
Galeazzi Fracture
Number and Dates of previous hospital admission: none
Ward/Unit, bed and room number:
Orthopedic ward
Food and drug Allergy:
None
Source of information:
Patient, Patients chart
II.

HISTORY OF PRESENT ILLNESS:

2 hours prior to hospitalization, the patient was hit by a tricycle that

caused him to rush in the hospital. According to him, he was drunk while
driving his motor cycle. He sustained a broken bone of his lower right arm
because he used this as a support from fall. The impact causes the
dislocation of his radius. He then rushed himself to West Visayas State
University Medical Hospital. He was then examined by medical staff for
further evaluation.
Upon admission, patient was conscious, coherent and oriented with
time and date. He arrived in the hospital alone. He was instantly checked
by the physicians and her vital signs were all normal but he complained of
pain on his right lower arm. He was then given tramadol 100mg for pain
relief.
After series of assessment, he was transferred orthopedic ward.

III.

PAST MEDICAL HISTORY

Prior to problem he has no problem with his health, he has no
known childhood disease nor any accidents or hospitalization, and he
never had any hospitalizations before and never had any surgical
operations aside from circumcision.

IV.

CURRENT HEALTH STATUS

Patient has no known allergies with food or drugs, he had no sign
and symptoms of any diseases aside from typical flu and fever.
He used exercises once in a blue moon. He sleeps at least 7-8hours
a day, he usually sleeps around 12-1am and wakes up around 8am.
He usually eats meats and chicken. He seldom eat vegetable
because according to him, fish is a lot expensive than meats and
chicken. His normal pattern of defecating is every 2days but he usually
urinates often. He drinks at least 8 glasses of water a day. He drinks
alcohol and smokes cigarettes.
He never had taken any medications for a certain illness
except for the medications needed for his pain that he felt. He is
currently taking tramadol 100mg.

V.

FAMILY HISTORY
According to the patient, he has a very loving and close family ties,
he stays with his
family but he is currently lodging here in the city for his job.
His parents are still alive. He has no siblings. He is currently in
relationship. He is very much positive in his lifes outlook.

VI.

Stressors
Hes been having a hard time moving his affected arm, he
verbalizes Badtrip ko ah. Di kagiho akon kamot. Anu abi kay hubog
ang motor ko mo. Kasaw-ah magkaon nga left hand ang ginagamit
ko. Bisan magbukas sang zipper ko kabudlay.
According to patient, he has no problems regarding financial for
many helped him with this matter since his girlfriend is currently
working in Saudi Arabia who finances him for his entire
hospitalization She can cope well for many of her friends and family
supports her and even her husband is always there beside her.