Nursing Health History

I. Biographic Data This is a case of Ms. X a 36 year old, female, married, Roman Catholic. Currently residing in San Fernando, Pampanga. This is the client first admission in Jose b. Lingad Memorial General Hospital last February 14, 2011. She is diagnosed with Cerebrovascular accident infarc prob. MCA HPN stage II. II. Chief Complaiint weakness on left sided extremity III. History of Present illness A day prior to consultation. Client experienced dizziness and headache for that reason patients cousin called their neighbour who is care giver and know how to take Blood pressure. According to the client cousin the BP of the patient that time is 160/110mmHg. The client provide rest and no management done. An hour prior to admission. Client condition is still persisted. Now with increasing severity of symptoms. Client experience left sided extremity weakness. This prompted client to seek consultation for further evaluation & management. IV. Past History Immunization unrecalled. Childhood illness recalled fever and cough. The client has no allergic reaction to any foods or medication. No previous admission on hospital. V. Lifestyle Client is a non smoker, she dinks alcohol occasionally. She drinks coffee every morning. Client is fond of eating foods rich in fats & salts such as patis, bagoong. Client has no difficulty of sleeping. She usually sleeps 6-8 hours. She usually eats her favorite foods. Client moves his bowels regularly & has no problem with urination. She has no problems with dressing & grooming himself. Lately she has been having difficulty in doing her household chores and she was not energetic as she used to be. Client does not have an exercise routine. VI. Social Data Client is a Roman Catholic. She is a High school graduate. She has good relationships w/ her husband, daugther and relatives.

Physical Assessment

Body Parts
A. General Appearance

Findings
The patients body built is medium frame. Patient is appropriately dressed and well groomed. Patients height and weight is proportionate to his body built. Her vital signs are as follows. BP: 140/90mmHg; Temp.: 36.3C; PR: 72bpm; RR:17cpm. Patient posture and gait were not assessed because the patient only stay at bed.

Interpreta tion
Not normal

Analysis
All findings are normal except, Clients is hypertensive, caused by or result from disease affecting other regulatory blood pressure process like, increasing viscosity of the blood.

B. Nails

Capillary refill is <3 seconds.

Not normal

Indicated problem in peripheral circulation.

C. Upper Extremities

Client muscle strength obtained a score of 3/5. Client has fair strength. No deformities and swelling noted with left sided weakness, she can move it but limited only. The peripheral pulses can be assessed and with no abnormalities.
Client muscle strength on lower extremities obtained 3/5. Client has fair strength. Both legs of client are symmetrical. The right leg can stretch, flex, extend and bend without difficulty except for the left leg. No sign of deformities, lesion, laceration and bleeding upon inspection

Not normal

Muscle strength obtained score of 3/5 indicates client has fair strength, full range of motion against gravity only.

D. Lower Extremities

Not normal

Muscle strength obtained score of 3/5 indicates client has fair strength, full range of motion against gravity only.