NURSING HEALTH HISTORY

I. Personal Data of Patient

Name: Homer Paguia

Age: 60 y/o

Address: San Ildefonso , Bulacan

Occupation: None

Gender: Male

Civil Status: Married

Religion: Roman Catholic

Educational Attainment: High School Graduate

Date of Admission: March 3, 2020

Time of Admission: 7:45 PM

Diagnosis: Acute appendicitis

Chief Complaint: right lower quadrant abdominal pain

Date of Interview: March 5, 2020

Admitting Physician: Dr. Gastardo

Informant: Homer Paguia

II. Reactions and expectations to illness, hospitalizations, diagnostic study and personnel

A. History of Present Illness

He was brought to Emergency room in Bulacan Medical Center Last March 3, 2020accompanied
by his wife with chief complaint of right lower quadrant abdominal pain at around 5:30 pm.

He was admitted at Surgery ward by Dr. Gastardo with an order of NPO, IVF of PNSSIL at
32gtts/min and with laboratory orders of CBC, UA, blood typing, Na, trop I and CXR Upright. For stat
.appendectomy. With medications of Cefoxitin 1g TIV every 8 hours and omeprazole 40 mg TIV OD/

On March 5, 2020upon handling the patient he has pinkish conjunctiva, capillary refill of 1-2
seconds, with complaints of tolerable pain right lower quadrant abdomen and still for STAT
appendectomy. With an IVF of D5LRIL @ 700 cc level with regulation of 32gtts/min infusing well @ right
metacarpal vein .
B. Past Health History

He is fully immunized. He does not have any known allergies to foods nor medications. He
sometimes experienced having fever, cough and colds. He also experienced having chicken pox when he
was in grade school. He is not involved in any major accidents. According to him this is his first
hospitalization.

He doesn’t take any vitamins.

C. Family Health History

On his Paternal side, he stated that his father has hypertension and old age was the usual cause
of death in his paternal side.

On his Maternal side, Old age was the usual cause of death in his maternal side.

III. ACTIVITIES OF DAILY LIVING

A. Circulation

His blood pressure was 120/80 mmHg. His body temperature is 36.9 ⸰C/ axilla. Pulse rate is 86
beats per minute, normal in rhythm. For capillary refill test it took 1-2 seconds. He has an oxygen
saturation of 99%.

B. Respiration

His respiratory rate is 19 breaths per minute. It slow, regular respiration and not in respiratory
distress. The client did not report any difficulty in breathing. No use of accessory muscles and no
abnormal breath sounds heard upon auscultation.

C. Foods and Fluids

Before hospitalization, He eats 3 times a day in moderate amount. His breakfast is usually
consisted of 2 cups of rice and egg. Lunch consisted of 2 cups rice of rice and meat. Dinner is consisted
of 2-3 cup of rice, meat, fish or vegetables. His wife usually cooked his food fried. He sometimes drinks
soft drinks. He eats salty foods seldom. He drinks 8-10 glasses of water per day and he drinks alcohol
twice a week.

During hospitalization, He is on NPO diet

D. Elimination

Prior to hospitalization, he stated that he urinates 4-5 times a day. Approximately 30 cc per
micturition. He describes his urine as yellowish in color. He does not have any difficulties in urination. He
defecates twice a day, usually in morning. He described her stool as formed, cylindrical in shape and is
brown in color. He does not experience any difficulty in defecating.

During hospitalization, he stated that he urinates every day he said that there are no changes in
his stool and bowel movement. No difficulty in urination and defecation.
E. Personal Hygiene

Prior to hospitalization, He takes a bath once a day. He uses soap and shampoo. He uses Rexona
for his deodorant. He brushes his teeth twice a day, in morning and before going to sleep. He changes
his clothes once a day.

During hospitalization, he doesn’t take a bath. He brushes his teeth once a day. He changes his
clothes once a day and sometimes depending on his mood.

F. Rest and Sleep

Prior to hospitalization, He sleeps approximately 9 hours starting from 10:00pm and wakes up at
around 7 am. He does not have any difficulty in sleeping. He is not fond of taking a nap in the afternoon.

During hospitalization, according to him there is no changes in his sleeping pattern.

G. Exercise

Prior to hospitalization, Jogging is his form of exercise.

During hospitalization, he does not have any form of exercise.

IV. COMPETENCIES

A. Physical

Prior to hospitalization, he can do all of his daily activities.

During hospitalization, he can do everything on his own. Currently he is confined at Surgery

Male Ward.

B. Emotional

According to him he has a good relationship with his family, relatives as well as in their
community. He usually drinks alcohol to solve his problems with his friends.

C. Mental

He is an High School graduate. He can maintain eye to eye contact when I asked him on how he
feels and when he answer questions. He was able to answer all of my questions without difficulty. He
has presence of mind. With regards to his decision making, he decides on his own as well as regarding to
his family.

D. Spiritual

He is a Roman Catholic. He attended mass once a month. He is not member of any organization
in their church.
E. Social

He is an extrovert type of person. he has a lot of friends in their community. He does not belong
to any organization in their community. He said that he always drinks alcoholic beverages with his
friends.

F. Environmental

According to him he lives in his house. Their home is made of concrete materials their house is 2
story building. They are near a water drainage. Health center is 20 minutes’ walk away from their house.
Their source of water is tap water. There is a garbage collector and they collect garbage once a week.

During hospitalization, he was in BMC Surgery Male ward.The room is well ventilated and the
comfort room is inside the ward about 20 steps. They put their garbage on a plastic near the bed.

PHYSICAL ASSESSMENT

I. General Appearance

He is physically independent and can perform daily activities without assistant. He has trimmed
and tidy fingernails and toenails. he’s wearing a black shirt and blue shorts. He has an IVF of D5LR IL @
700cc level with regulation of 32 gtts/min infusing well @ right metacarpal vein

II. Vital Signs

BP: 120/80 mmHg

Temp: 36.9 °C/ axilla

PR: 86bpm

RR: 19 bpm

O2 Sat: 99 %

III. Physical Assessment (focused assessment)

A. Head

His hair is short and black. It appears to be clean upon assessment. No foul odor was smelled.
The head has no lesions, lacerations and swelling. Upon palpation the head is hard and smooth without
any lesions and wounds.

B. Face

His face is oval in appearance. The color of the face is the same with the color of the body upon
inspection.
C. Eyes

Conjunctiva is pinkish in appearance. Both pupils are equal and reactive to light.

D. Ears

His ears are equal in size in a distance of approximately 7 feet. The external ear is clean. The
external ear doesn’t have any discharges. For sense of hearing he can hear as evidence by answering my
questions well.

E. Nose

No discharges, no nasal flaring and no tenderness upon palpation. He can smell his
surroundings.

F. Mouth

His lips are slightly dark in appearance and dry. No ulcers, lesions or nodules, gingiva is pinkish.
No halitosis noted.

For the sense of taste, he cannot taste anything because of his NPO diet.

G. Neck

His neck is symmetric with head centered with no presence of mass. No lesions, ulcers and
lacerations. He can move his neck freely.

H. Abdomen

His abdomen has no ulcers, lesions or nodules. He has no incision or any wounds, scar on his
abdomen.

He has complaints of pain his right lower quadrant of abdomen with painscale of 5/10.

I. Genitalia

Not Assessed

J. Upper Extremities

He has an IVF of D5LR IL @ 700cc level with regulation of 32 gtts/min infusing well @ right
metacarpal vein. He can do ROM. No pain or discomfort. Capillary refill took 1-2 seconds. No lesions,
swelling and ulcerations noted.

K. Lower Extremities

Toenails are short and well trimmed, he can do Range of motion he can walk and
stand. . No lesions, swelling and ulcerations noted.