University of San Carlos

College of Nursing
Cebu City

HEALTH HISTORY

I. PATIENT DEMOGRAPHIC PROFILE

Name: Labis, Abigail Age/Gender: 9mos./Female Status: Single

Home Address: Upper La Guerta Lahug, Cebu City
Religion: Roman Catholic Nationality: Filipino Occupation: Patient is a child

II. HEALTH HISTORY PROFILE

A. Past Medical History
1. Pediatric and Adult Illness

Date Illness Medication Remarks

SO can’t Common Colds None Patient applied / underwent water

recall therapy & was then relieved of the
colds after a few days.

2. Immunization

Immunization Doses Dates Remarks

BCG 1 SO didn’t Dosages of these vaccines were
OPV 3 recall the completed.
DPT 3 exact dates of
Hep B 3 vaccination.

3. Hospitalization

Date/Year Hospital Diagnosis Duration

This is the
patient’s first
hospitalization

4. Injuries and Accidents

The patient did not have any injuries and accidents, as verbalized by the mother.

5. Transfusions
Patient did not undergo any transfusions, as verbalized by the mother.

6. Allergies (specify)
Patient doesn’t have any allergies, as verbalized by the mother.

B. Family History
C. Social and Personal History

1. Occupation
Patient does not have an occupation since she’s still 9 months.

2. Number of Children
No children; patient is the only child in the family so far.

3. Military Experience, foreign travel

Patient was not exposed to military experience or any foreign travel.

4. Habits (tobacco, alcohol, non-prescriptive drugs, others)

Patient was not exposed to these habits mentioned.

5. Diet
Patient was breastfed but whenever the mother is working, the patient is bottlefed
as an alternative for feeding.

6. Type of Family
Patient lives in an extended type of family; her father’s mother is residing in the
family’s house.

7. Cultural & Religious Beliefs

Patient is joined with the parents whenever they would attend masses.

8. Brief Description of Average Day

7:00 AM – Patient wakes up
8:00 AM – Patient is breastfed or bottlefed, patient is carried by the SO
9:00 AM – Patient sleeps in the crib/”duyan” 3:00 PM – Patient plays w/ SO
10:00 AM – Patient is carried/plays with the SO 6:00 PM – Patient is bottlefed
12:00 AM – Patient is bottlefed 8:00 PM – Patient sleeps in crib
1:00 PM – Patient sleeps in crib/”duyan”

D. Review of Systems

General Weight loss Fatigue Anorexia Night Sweats

Chills Fever Weakness
The mother verbalized that patient had her first fever as a side effect
of the first dose of OPV.
Skin Itch Rash Lesions Bruising Bleeding
Color Changes

Eyes Pain Discharge Itch Vision Loss Diplopia

Excessive tearing Glasses/contact lens Date of last exam

Ears Earaches Discharges Tinnitus Hearing Loss

Nose Obstruction Discharges Epistaxis

Throat & Mouth Sore throats Bleeding gums Toothache Dentures

Neck & Head Swelling Dysphagia Hoarseness

Chest Cough Sputum: Amt. & Character Hemoptysis

Wheeze Pain on respiration Dyspnea
The mother verbalized that patient had experienced cough and
dyspnea about 1 month old. Sputum was white and less sticky.
These happened also after labor. Few episodes of wheezing also
happened. The conditions were then relieved after being suctioned
via bulb syringe.
Cardiovascular Precordial pain Palpitation Dyspnea on exertion
Paroxysmal nocturnal Dyspnea Orthopnea
Edema Heart murmur Thrombophlebitis Claudication

GI Heartburn Nausea Vomiting Bloating Diarrhea

Food Intolerance Excessive gas or indication
Constipation Change in bowel movement Jaundice
Melena Hemorrhoids Hernia
The relative verbalized that the infant had few episodes of nausea
and vomiting when she was still about 1-2 months old. The emesis
was brownish in color and would happen shortly after being
breastfed or bottlefed.
Genitourinary Pain Rectal Bleeding Dysuria Frequent nocturia
Retention Polyuria Discharge Dribbling
Hematuria Flank Pain Infections
Male: Penile discharge Lesion Hx of VD Infertility
Testibular pain Mass impotence Libido
Female: Menarche at Age: LMP: Flow Days
Menopause Abnormal Bleeding

Extremities Joint pains Varicose veins Claudication

Back Pain Edema Stiffness Deformities

Neurology Numbness Tingling Tremor Fainting

Headaches Muscle weakness Ataxia
Unconsciousness Paralysis/Paresis Memory loss
Dizziness Seizure

Psych Anxiety Depression Sexual Problems Insomnia

Nightmares

Others
III. CURRENT HEALTH PROFILE

A. Presenting complaints & medical diagnosis to include interventions done prior to

hospitalization
2 days prior to admission, patient was sent by her parents for a check-up at Cebu
City Medical Center due to high-grade fever and persistent cough. After 2 consecutive
days of check-up, the physician ordered admission of the child in the hospital for further
management.

B. Application of the Nursing Process

1. Assessment Findings (Head to Toe)
Laboratory/Diagnostic Results

Date Lab Exam Patient Normal Interpretation /

Results Findings Significance

9/22/09 CBC
- Hgb 100 g/L F: 120-160 An increase in
- Hct 0.30 F: 0.37-0.47 lymphocyte levels
- Lymphocytes 0.41 0.20-0.35 indicate viral infection.
- Monocytes 0.01 0.02-0.06

2. NCP
3. Drug Study
4. Discharge Plan
PHYSICAL EXAMINATION

A.) General
Patient is seen lying on bed, asleep and dyspneic, w/ IVF of PLR 1000cc @ 36
cc/hr infusing well @ right arm. Initial vital signs were Temp: 36.4°C, RR: 60 cpm, PR:
117 bpm. Patient appeared clean and well groomed.
B.) Skin
Patient’s skin is pinkish white in color, equally colored in all parts, slightly warm
to touch, fair skin turgor, smooth in texture. No lesions, erythema, discolorations and
bleeding noted.
C.) Head
Head appears normocephalic with no lesions or sores noted. Forehead is large and
prominent. Chin is receding. Hair is abundant, well-distributed on scalp, thin and fine in
texture. Anterior fontanelle palpable as a soft spot.
D.)Eyes
Eyes appear symmetrical and clear with no redness or discharges noted. Cornea is
round and proportionate in size on both eyes. Has brown iris and black pupils; PERRLA
direct and consensual on both eyes. Eye movement distinctive: follows across midline,
blinks when penlight is shone on the eyes. Eyebrows equally distributed; slightly curved
eyelids. Tears present upon crying..
E.) Ears
Ears are in symmetrical position; color is the same as that of the whole skin; no
lesions, discharges and deformities noted on both ears, nontender upon palpation. Pinna
on both ears recoils after folding. Hearing distinctive as infant looks at me after sound is
made/talking softly.
F.) Nose
Nose appears symmetrical, located midline; no deformity, flaring, bleeding, and
discharges noted; nontender.
G.) Mouth
Lips are pinkish in color, no sores and lesions noted. No teeth, pink gums with no
bleeding present. Lips moist upon palpation. Tongue in central position with no sores and
bleeding, pink in color. Intact and symmetrical hard and soft palate. Tongue moves
freely; mouth opens evenly when cries.
H.) Neck
Neck appears short, chubby with creased skin folds; no masses, lesions, redness
noted. Head rotates freely using the neck, indicating good muscle tone. Trachea
prominent and in central placement in the midline of neck. Nontender upon palpation;
nonpalpable lymph nodes.
I.) Chest, Heart and Lungs
Chest appears rounded with anterior-posterior and transverse diameters
approximately equal. Patient showed slight heaviness on respiratory effort upon lying on
bed; breathing pattern is irregular with periods of apnea in between respirations;
retraction no present. Chest slightly indraws. Fremitus most palpable on upper thorax
anteriorly and posteriorly when crying. Resonance on selected lung fields (anterior and
posterior) heard on percussion. Crackles heard on selected lung fields (anterior and
posterior) upon auscultation. Regular apical pulse with S1 and S2 heart sounds heard.
Chest nontender upon palpation. Patient had slightly productive cough, sputum appears
sticky, whitish in color.
J.) Abdomen
Abdomen appears slightly protuberant even upon lying on bed, rises and falls as it
is used for respirations; no lesions, sores, redness or bleeding and discharges on
umbilicus are noted; umbilicus midline, inverted. Soft, medium-pitched bowel sound
heard every 15 secondsin all four quadrants on auscultation. Tympanic in all four
quadrants upon percussion, dullness over organs. Nontender on palpation; liver, spleen
and kidneys nonpalpable.
K.) Extremities (upper and lower)
Upper and lower extremities equal in size and bilaterally symmetrical; prominent
subcutaneous fats; warm to touch especially on palms and soles. Legs appeared short and
slightly bowed. No lesions, redness, bleeding, edema, deformities and discolorations
noted on upper and lower extremities bilaterally. Both extremities move symmetrically;
good muscle tone and ROM (complete with some resistance) manifested by flexion and
extension of arms and legs, hands and feet. Fingers and toes soft and smooth, nontender;
nails on fingers and toes intact and smooth, 160° curvature angle, no deformities or
cracks noted; appeared short, capillary refill time on both fingernails and toenails of
about 2 seconds; pink in color with no discolorations noted.