NURSING HEALTH HISTORY

BIOGRAPHIC DATA

Client’s name: CD Religious preference: Catholic

Address: Tanay, Rizal Health Care Financing: Family

Age: 16 years old Attending Physician: Dr. Ignacio

Sex: Female Marital Status: Single

Occupation: none

Usual Source of Health care: Health center

Date of Admission: July 31, 2010

Admitting Diagnosis: Eclampsia

CHIEF COMPLAINT

 Patients relative seek for doctor regarding seizure at her 7 month of being

pregnant.
HISTORY OF PRESENT ILLNESS

 One day prior to admission the patient’s relative state that the patient is active

before the seizure’s happen that night. At hospital settings the patient was 2

times transited and 3 times at emergency room her is BP: 160/120 mmHg.

PAST HISTORY

Health Status Year

Medical History Hepa B vaccine, measles 1994

vaccine, & TTD vaccine

Surgical History No Major Surgical History N/A

Medications Paracetamol 1999

Prescription Medication Paracetamol to decrease 1999

fever

Allergies No Known Allergies N/A

Injuries and Accidents Fall 1999

FAMILY HISTORY OF ILLNESS

AGE HEALTH STATUS

Spouse 21 N/A

Mother 60 High blood pressure

Father 70 Anemia

OB HISTORY

 G1P0 pre-term, cephalic eclampsia

LIFESTYLE

 Personal Habits: Client doesn't use tobacco.

 Diet: Client usually eats 3x a day; sometimes she’s the one who prepares and

cooks food for their family.

 ADLs: Client has no any difficulties experienced in doing basic activities of

eating, dressing, grooming and elimination, Sexual Activity patient x had

sexual intercourse to her husband 10 times a week

SOCIAL DATA

A. Alcohol use – N/A

B. Drug use – N/A
C. Tobacco use – patient smoke 1 pack of cigarette per day for 30 years.
D. Sexual practice – The patient is faithful to his wife and never had forbidden affair
E. Travel History – N/A
F. Work Environment – N/A
G. Home Environment –the patient’s environment was quiet, because they were
living at mountain.
H. Physical Environment – she lives in a bungalow type of house with a little space
for a yard and with clean surroundings.
I. Psychosocial Environment
J. Diet taken – food that has low in cholesterol and fatty acid, ate more vegetables
and less meat.
K. Exercise – He sometimes go on walking but most of the time he just stayed at
home.
L. Education – elementary level
M. Economic Status, Religion, Economic background – catholic, belongs to mangyan
people and difficult to earn money.
N. Roles and relationship – she’s a responsible daughter to her mother and a loving
wife to her husband.

PSYCOLOGIC DATA

 Major stressor: Financial budgeting

 Communication style: Client is able to verbalize her emotions ; non-verbal

communications-eye movements, gestures and use of touch

PATTERNS OF HEALTH CARE

 If client has any minor health problems, she use or go to their barangay clinic

 Client considers the care being provided by the said clinic.

REVIEW OF SYSTEMS

BODY PART TECHNIQUE FINDINGS NORMAL INTERPRETATION

SKIN Inspection Varies from Skin’s ability Normal Skin texture.

light deep to change
brown. shape and
Generally return to
uniform normal.
except in
areas
exposed to
sun; areas of
lighter
pigmentation
(palms, lips
nail beds) in
dark skin
people
Freckles,
some
birthmarks,
some flat, no
abrasions or
other lesions
Moisture in
skin folds and
the auxiliary
Uniform,
within normal
range

NAILS Inspection Convex nail bed is the Normal

curvature, skin beneath .
angle of nail the nail plate
plate about
160 degree
Highly
vascular and
pink in light-
skinned
clients; dark-
skinned
clients may
 have brown or
black
pigmentation
in longitudinal
streaks
Smooth
Intact
epidermis
Prompt return
of pink or
usual color
( generally
less than 4
seconds)

HEAD   Inspection Rounded Evenly Normal

(skull, scalp, (normal distributed,
hair) cephalic and thick, silky,
symmetrical, resilient, no
with frontal, infection or
parietal, and infestation( ha
occipital ir and scalp)
prominences); no
smooth skull abnormality
contour. noted
Smooth,
uniform
consistency;
absence of
nodules and
masses.
No depression
, dry hair, no
infection or
infestations

FACE Inspection Symmetric or Symmetric Normal

slightly facial feature
symmetric
facial
features;
symmetric
naso labial
folds
 EYES Inspection Hair evenly Hair evenly Normal
(eyebrows, distributed; distributed;
eyelashes, skin intact; skin intact;
eyelids, eyebrows eyebrows
conjunctiva, symmetrically symmetrically
sclera, aligned; equal aligned. No
cornea, iris, movement edema, no
pupils) Equally redness
distributed,
curled slightly
outward
Skin intact; no
discharge; no
discoloration;
lids close
symmetrically
Approximately
15-20
involuntary
blinks per
minute;
bilateral
blinking
When lids are
open, no
visible sclera
above
corneas, and
upper and
lower borders
of cornea are
slightly
covered
Transparent;
capillaries
sometimes
evident; sclera
appears white
(yellowish in
dark-skinned
clients)
Shiny, smooth
and pink red
White
Transparent,
 smooth, shiny,
details of iris
are visible

VISUAL Inspection, Able to read No edema, Normal

ACUITY snellen chart newsprint not sunken
120/200 vision eye, no
on snellen redness, no
chart pain when
assessing.

EARS Inspection Color same as No edema, Normal

(otoscope) facial skin; no redness,
symmetrical; no secretion,
auricle aligned no presence
with outer of impacted
cantus of the serum
eye, about 10
degrees from
vertical
Mobile, firm
and not
tender; pinna
recoils after it
is folded.

HEARING Weber’s test Normal voice No edema, Normal

ACUITY TEST and Rinne’s tones audible no redness,
test Able to hear hearing is
the ticking in clear and
both ears balance
Sound is
heard in both
ears or is
localized at
the center of
the head
(Weber
negative)
Air conducted
hearing is
greater than
bone
conducted
 NOSE Inspection Symmetric No edema, Normal
and straight; no pus
no discharge secretion,
or flaring; moist, pink in
uniform in color
color
Mucosa is
pink; clear;
watery
discharge; no
lesions
Nasal septum
intact and in
midline
Air moves
freely as the
client breathes
through the
snares
No tenderness
and
displacement
No tenderness

MOUTH (lips, Inspection Dry lips, no 32 adult No lesion inspected no

buccal with tongue lesion, soft, teeth, edema, no puss, no
mucosa, depressor 27 number of smooth, redness, no wound,
teeth, gums, teeth, with white, shiny Presence of carries or
tongue) presence of tooth enamel fillings are not normal.
carries or This takes place due to
fillings improper dental
,Smooth, hygiene.
white, shiny
tooth enamel
Pink gums,
moist, firm
texture to
gums; no
retraction of
gums
Smooth
tongue base
with prominent
veins
Central
 position
Pink color;
moist, slight
rough; thin
whitish coating
Smooth lateral
margins; no
lesions; raised
papillae
It moves
freely; no
tenderness, 
Smooth with
no palpable
nodules

NECK AND Inspection No tenderness no redness, normal

LYMPH and palpation Central no
NODES placement in tenderness
the midline of
the neck;
spaces are
equal in both
sides
Not visible on
inspection

Uniform pink color, soft, moist, smooth texture, symmetry of contour

PHYSICAL ASSESSMENT

General Appearance Actual Findings Norms Interpretation

>Body built, proportionate Proportionate NORMAL

height and weight height and weight.
in relation to the
Client’s age.

> Posture, gait, & Not relaxed, has an Not normal, the
sitting, erect in posture. erect in patient must relax
And coordinated posture,
body movement coordinated
when the patient is movement
conscious.
>Overall hygiene and Haven’t take a bath, The patient must
grooming Doesn’t brush her provide a healthy Not normal, no
teeth for the whole hygiene for her self practice of proper
day, Hair is not and her baby hygiene
fixed.

>Body and breath Bad smell in breath

odor odor, and body The liver can’t
odor. palpate because of
Abdominal – being 7 month
pregnant. It can be
Inspect for skin palpated in thin
integrity person and it can
(Pigmentation, be felt in costal
lesions, striae, margins.
scars, veins, and If liver is palpated, it
umbilicus). must be smooth,
regular in contour,
 Contour (flat, Skin integrity – firm and non-
rounded, uniform in color, tender.
scapold) presence of linea
 Respiratory nigra (7 months
movement. pregnant), and
striae.

Rounded ( 7
months pregnant)

Normal

Skin Uniformity in color,

Uniform in color normal.
brown skin color. except to the areas
expose to the sun
3. Age Dresses and cannot The ideal self is the Doesn’t acts
Appropriateness communicate individual’s accordingly with her
appropriately for perception of how age
her age one should behave
based on certain
 personal standards,
aspirations goals
and values

4. verbal Behavior The client shows A wide variety of This only shows
enthusiasm and feelings can be that the patient is
interest upon conveyed when kind and
communication and people talk. approachable.
answers the Moreover, the Respect is shown
question messages need to by her during the
appropriately. relate to the interview. Every
person’s interests question that was
and concerns. answered conveys
a normal behavior.

5. Non-verbal No mannerism, with Non-verbal Every facial and

behavior involuntary communication body gestures that
movements, either reinforces or have observed to
showed smiles contradicts what is the client was
which indicate said verbally. congruent to what
happiness, kept she is saying.
eye-contact.
Measurements
1. Temperature 36.8°C 36°C-37° C No indication of
fever, findings is
within normal
range.

2. Pulse rate 92bpm 60-100 bpm Normal within

normal range.

3. Respiratory Rate 32 cpm 12-20 cpm Not normal, with

sign of difficulty of
breathing.

4. Blood pressure 100/80 mmHg Non pregnant Normal within

120/80 mmHg normal range.
Pregnant
114/65 mmHg

Abdomen    
Inspect for skin Unblemished skin, No indication of
integrity uniform color  No indication of infection. Check the
 Stoma: red infection stoma color, secretion
and moist for any sign of
 Swelling infection, redness,
 puss forming, and
edema around the
stoma every 1 hour. If
irritation occurs do not
rub instead flush
PNNS. Pus is sign of
accumulation of
pathogen that causing
redness and if not
treated well it will infect
the entire stoma.
Skin Contour no palpable mass, Hot to touch and Because of the incision
flat round, Convex redness is observed site the skin becomes
red and flashy. Edema
is normal after 1 week.
Palpate for liver During palpitation No enlargement of n/a
or spleen the abdomen was liver and spleen.
enlargement enlarged due to
distention of the
colon. Pain was
elicited when
applying pressure
to left lower
quadrant.
Inspect for skin Symmetric Distended abdomen Obstruction was
contour when contour elicited and seen after
standing at the MRI test and when
bottom of the colonoscopy is done.
bed An obstruction on the
abdomen permits the
abdomen to enlarge
and the waste product
cannot be excreted.

Abdominal Symmetric Disturbed Gastro Constipation is

movements intestinal movement observed because of
during due to obstruction. the obstruction inside
respiration and the sigmoid colon and
peristalsis also the blockage of
malignant tumor arises
in the site were the
feces flow.

Auscultate the Audible bowel Hard and dull during Absence of flatus
abdomen sounds auscultate. because of obstruction.
Accumulation of hard
feces due to long
period of stay of feces
inside the sigmoid
colon.
Percuss the Percussion notes Hard and dull during Hardening abdomen
abdomen resonate percussing. when percussing
(except LLQ) because the abdomen
is distended.