I.

Nursing History
A. Past Health History

1.) Childhood illness – The client had usual childhood illnesses such as mumps,
measles, and chickenpox
2.) Immunization – The client has unrecalled immunizations
3.) Allergies – The client has no known allergy
4.) Accidents – The client mentioned that she fell from their stairs and had carpal
bone fracture 5 years from now; she was hospitalized for several weeks at that
time. Another was a motor accident and she had head trauma, it was 2 years from
now. Earlier was snake bite, she was not hospitalized for that
5.) Hospitalizations – Admitted at Jose Reyes 15-20 years from now from an
unknown illness. She said she was experiencing headache at that time and later
on, alopecia. She said she couldn’t remember the diagnosis.
6.) Medication used or currently taking aside from the drugs for ptb that she
completed, she wasn’t taking any medications in the past.
7.) Foreign Travel – No foreign travels yet

B. History of Present Illness

The present Illness started 2 months prior to admission as the patient
experienced undocumented moderate fever occurring anytime of the day. Consult
was done at a private physician and diagnosis was unrecalled. Patient was given
unrecalled medications to be taken for 7 days, which afforded temporary relief.
1 month prior to admission, patient noticed swelling of her lower
extremities. This was associated with other symptoms like fever, cough, headache,
nausea and vomiting, colds, loose stools and abdominal pain. No consultation was
done and no medication was taken.
2 weeks prior to admission, patient again experienced fever,
undocumented, moderate to high grade by touch. This condition is associated with
chills, difficulty of breathing and swelling of the lower extremities. Consult was done
at a private physician and laboratory tests were done, but results were unrecalled.
She was given unrecalled medications, to which she was adherent. These
medications afforded temporary relief.
Few hours prior to admission, still with the same signs and symptoms,
patient sought consult at a private physician and she was advised admission;
hence subsequently she was admitted in our institution.

C. Family History
The client’s mother and father are already dead, her mother died of giving
birth to her. She said she didn’t know what the cause was and she couldn’t
remember her age when she died and her father died at the age of 65 because of
fall that caused head trauma. Her mother’s side have the history of anemia while
her father’s side have the history of hypertension, rheumatic heart diseases and
pneumonia.
 Genogram
J.S. x
Fall and
P.A. x
head
Birth to
trauma
a child

M.S. x
Pneumon Client
ia

D. Maternal History
She has had menarche at age 15, subsequent menses at 28 – 30 days
interval with 4 -5 days consuming 4 – 5 napkins/day, each napkin moderately soaked,
with no associated dysmenorrheal and post coital bleeding. She is Gravida 9 Para 9 (9-
0-0-7). All births were normal spontaneous delivery, assisted with midwife at home, with
no feto-maternal complications. She had her menopause at 40 years old and this was
not associated with any symptoms.

II. Patterns of Functioning

A. Psychological Health
The client shares that whenever she has problems she just talks it out
and she is already eased, she also prefers to chat with her friends to relive heavy
feelings. She used to mingle with her children and grand children whenever she
has spare times. She has visual problems but and cannot read far texts anymore
she didn’t have consultation for that. She finds it difficult to hear low toned voices.
She is a happy – go – lucky person who tends to forget problems whenever she is
chatting with her children. They seldom encounter family problems.

ANALYSIS:
Psychosexual Development (Sigmund Freud)
Genital stage: Develops sexual maturity and learns to establish satisfactory
relationships with the opposite sex.
(Pillitteri, Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family, 5th Edition page 815)

Developmental Task (Erik Erikson)

Generativity vs. Stagnation: People extend their concern from just themselves and
their families to the community and to the world. They may become politically
active, work to solve environmental problems, or participate in far – reaching
community or world based decisions.
**When a person makes a contribution during this period, perhaps by raising a
family or working toward the betterment of society, a sense of generativity- a sense
of productivity and accomplishment- results.
(Pillitteri, Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family, 5th Edition page 817)

Cognitive Development (Jean Piaget)

Formal Operational Thought
Can solve hypothetical problems with scientific reasoning; understands causality
and can deal with the past, present, and future. Adult or mature thought. Good
activity for this period: “talk time: to sort through attitudes and opinions.
(Pillitteri, Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family, 5th Edition page 819)

INTERPRETATION:
Psychosexual Development (Sigmund Freud)
The client has developed close relationship with the opposite sex, it is not merely
establishing a good intimate relationship.

Developmental Task (Erik Erikson)

The client has developed generativity because she has established good
interpersonal relationship with her family as well as the community.

Cognitive Development (Jean Piaget)

The client had already developed Formal Operational thought; she uses logic in
solving problems and understanding causality

B. Socio – Cultural Pattern

The patient has high regards with respect to elders, she obliges her
grandchildren to respect elders, in her province they don’t have phrases like po
and opo but they still do some practices that give respect to elders like consulting
them before making a decision for the family. They celebrate some festivities in
their province and she is happy whenever that happens because she gets to see
her family together and her friends and relatives who live far away. She spends her
leisure time cleaning the house and caring for her grandchildren. They have a rice
farm but she couldn’t go there because her legs are cannot endure the walk, she
let her nieces and children to take of the rice fields.

ANALYSIS:
Moral Development (Kohlberg)
Post Conventional (Level III): Universal ethical principle orientation. Follows
internalized standards of conduct.
(Pillitteri, Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family, 5th Edition page 821)

INTERPRETATION:
The client had already developed Post Conventional Moral development. She
doesn’t just follow simple rules or abides law imposed by the government but also
applies ethical principles just like the requirement consulting the elders before
making a decision.
 C. Spiritual Patterns
The client goes to church every day and prays the rosary every day; they
celebrate Christmas, New Year, fiesta and birthdays together. She’s a member of
Women’s for Christ. She believes that God has the power of healing her and
making their family closer as possible.

ANALYSIS:
Spiritual Development (Fowler)
Stage 5: Paradoxical, Consolidative / Conjunctive Faith, awareness of truth from
variety of viewpoints
Stage 6: Universalizing, becomes an incarnation of the principles of love and
justice. Person loves with God’s love (unconditional love)

INTERPRETATION:
The client considers God as a Supreme being and the source of all blessings and
prefers to consider her belief as the truth.

III. Activities of Daily Living

Activities of Before During Interpretation and Analysis

Daily Living Hospitalization Hospitalization
Nutrition The client prefers Diet as tolerated but ANALYSIS: An individual’s health
eating vegetables and with strict aspiration status greatly affects eating habits and
fish, sweet potato precaution. nutritional status. Habits about eating
shoots, upo, string are influenced by many factors such as
beans, papaya, developmental considerations, personal
nilagang baka, preferences, lifestyle, medications and
nilagang manok at therapy. People develop likes and
baboy. dislikes based on associations with a
typical food. Certain lifestyles are linked
to food-related behaviors. People who
spend many hours at home may take
time to prepare more meals, Individual
differences also influence lifestyle
patterns. (REF: Fundamentals of
Nursing 7th ed. By Kozier et. al., p.1176)

INTERPRETATION: The client prefers

eating foods that can be helpful in her
geriatric years, healthy food preferences
is a manifestation of a good health, The
client was placed on NPO because this
is one of the measures should be done
to resolve her pancreatitis.
Elimination The client defecates The client has the ANALYSIS: Normal defecation is often
everyday and varies same pattern of facilitated in both well and ill clients by
from brown soft formed elimination. providing privacy, teaching clients to
stools to slightly hard attend to the defecation urges promptly,
and sometimes watery. assisting clients to normal sitting
 But she doesn’t have positions whenever possible,
problem with her encouraging appropriate food and fluid
defecation. Excretes intake and scheduling regular exercise.
straw – colored urine at (REF: Fundamentals of Nursing 7th ed.
least 4 times a day. By Kozier et. al., p.1253)
She shared that she
attends promptly when INTERPRETATION:
she has the urge to The client has normal elimination
defecate and to pattern before hospitalization and during
urinate. the elimination.
Exercise The client considers The client ambulates ANALYSIS: Physical activity is an
walking around the around the area when important factor in an adult’s ability to
yard every morning as she’s bored. She said maintain health and independence.
a form of exercise. she do it with Regular exercise promotes appetite,
assistance or while improves mental health, and decreases
holding the edges of stress. (REF: Fundamentals of Nursing,
the beds and the walls Saunders p. 337)
because her legs
cannot totally support INTERPRETATION:
her. Even though the client has reduced
strength and endurance at her lower
extremities she still makes it to the point
that her activities were totally absent.
Hygiene The client shared that The client takes a bath ANALYSIS: Personal hygiene is the
she takes a bath once during confinement self-care by which people attend to
a day but she quipped once a day and does such functions like bathing, toileting,
that she doesn’t brush oral care. general body hygiene and grooming.
her teeth more Hygiene is a highly personal matter
frequently because she determined by individual values and
doesn’t have teeth practices. It involves care of the skin,
anymore. hair, nails, oral and nasal, eyes, ears
and perineal – genital areas. (REF:
Fundamentals of Nursing by Barbara
Kozier et., al page 106)

INTERPRETATION:
The client can attend to her hygienic
needs alone before hospitalization, and
she needs assistance during the
hospitalization.
Substance NONE NONE -
Abuse
Sleep and Rest The client said that she The client sleeps at ANALYSIS: Just as activity is important
sleeps for 4 hours; she about 6 hours every to the adult, so too is rest. According to
said she’s okay with day, she sleeps at 10 the National Sleep foundation (2001),
that. She said that she pm and wakes up at adults need 8 hours of uninterrupted,
sleeps at 19 pm and am. She also takes a quality sleep each night for optimum
wakes up at 3 am nap at the afternoon. health, safety, and productivity. (REF:
because she pray the Fundamentals of Nursing, Saunders p.
rosary. She said that 337)
she take naps every
afternoon INTERPRETATION:
The client has normal sleeping pattern
during hospitalization. It seems that her
sleep was undisturbed during the
hospitalization.