COMPREHENSIVE NURSING HEALTH HISTORY (ADULT)

Name of Student: Shena Cadiz Area of Assignment:

Name of Clinical Instructor: Michelle Arnaiz Inclusive Dates:
Date and Time Conducted: October 16 2016

I. PERSONAL HISTORY
A. Personal Data
Name of Patient: Sheila Mae D. Albuera
Address: Poblacion, Danao, Bohol
Age: 19 Sex: Female Birthdate: March
13 2001
Civil Status: Single Number of children: None
Occupation: Student
Address: Poblacion, Danao, Bohol
Name of Spouse: Occupation of Spouse:
Highest Educational Attainment: College Religious Affiliation: Roman Catholic
Client’s position in the family: 2nd Child Living Situation: Lives with Family
Date of Admission: December 19 2018 Living with others (specify):
Time of Admission: 12:00 PM Ht: 153cm Wt: 40kg
Source of Healthcare:
Attending Physician (specialization): Dr. Valdez, Pediatrician
Co-managing Physicians (specializations):
Diagnosis: Dehydration and Acute Ulcer

B. Chief Complaints

In for complaints of stinging pain in the umbilical region, discomforting headache with a pain
scale of 7 with 10 being the highest and remittent fever with the highest recorded
temperature of 38.1 night PTA accompanied by fatigue, and an episode of vomiting. Patient
verbalized “Wa nakoy umoy, di nako kalihok, di nako kabuhat sa mga buhatunon.”

C. History of Present Illness

Night PTA patient experienced chills and increase in temperature while on duty at pet clinic.
Patient went home and experienced remittent fever with a temperature of 38.1 and mild pain
on the abdominal region.

Morning PTA patient continued to experience the mentioned symptoms, this time,
accompanied by horrible headache and 30 minutes after, an episode of vomiting with 3
hours of interval which consisted mostly of water with small portions of porridge amounting
to about 1 glass. Patient verbalized “Hapdos ako tiyan sa may abdomen nya murag gi
pokpok ako ulo nya suka ko kaduha.” These symptoms then prompted the patient to take his
medications which is a 250 milligram paracetamol and took a rest which provided temporary
relief with water therapy which lead her headache with a pain scale of 7 narrowed down to 4
with no further mangement done.

No other medications taken aside from paracetamol. Patient is admitted due to exhaustion,
loss of energy in the body and fatigue.
D. Past Medical History

Patient was diagnosed by Dengue and was admitted at Ramiro Hospital last 2013 for 3 days
given with medications and CBC’s. Patient was also diagnosed with Pneumonia last 2015
and was not admitted but given proper medication by the attending physician. Patient is non-
diabetic, non-hypertensive and non-asthmatic with no maintenance medication. Patient has
no allergies, accidents and past injuries with complete immunization and has not had
experienced blood transfusion. Patient has no psychiatric or mental history along with the
family.

Patient’s menarche was last February 2012 and has regular monthly menstruation but
irregular count of days. Patient’s menstruation last approximately for 5 days accompanied
with dysmenorrhea every cycle. Patient’s last menstruation was October 5.

C. Family History

Patient’s parents are both alive with no known illnesses, maintenance medications and have
a nuclear type of family. Patient’s grandparents from the maternal side are both dead,
caused by stroke and murder while both are alive on the paternal side. Heredofamillial
diseases include asthma from the maternal side and pneumonia from the paternal side with
no history of cancer from both sides.

D. Environmental History

Patient lives in their owned house with her parents, located in an urban area. The toilet type
is flush type and private owned and drainage facility is covered. Patient’s method of waste
disposal is by trash bin collected by a garbage truck and also by burning. Patient did not
include presence of environmental hazards.

II. REVIEW OF FUNCTIONAL HEALTH PATTERNS (Gordon’s)

A. Health Perception and Health Maintenance Management Pattern:

Patient described her general health as “good”, and exercises daily and eats healthy foods.
Patient has never smoked tobacco or use illicit drugs. Alcohol intake is occasionally 3 a year
and can approximately intake 1 liter of beer.

Patient knows how to do breast examination but doesn’t perform it.

Patient adds some beliefs and health practices like “hilot”, whenever a family member is ill
before going to the hospital to get checked. Patient eagerly follows the prescribed
management and treatments of doctors.

B. Nutritional & Metabolic Pattern

Patient’s daily average food intake includes 1 cup rice, egg and hot dog for breakfast, 1 ½
cup of rice with meat and veggie for lunch and 1 ½ cup of rice with fish and vegetable for
dinner along with snacks like “bananacue” for a day. Patient’s daily water intake is 6-8
glasses of water, does not drink coffee and seldom drinks soft drinks

Patient has stated changes in weight and appetite during and after hospitalization. Decrease
in weight is evident with 3 kg weight loss in a span of a week. Patient has no food and diet
restrictions and favors more on sweet type of foods.

Patient explained recurrent skin problems last 2014 due to the bacteria in water and some
foods but does not recall the diagnosis of the doctor. Patient explained that it is itchy and
fluid filled that spreads throughout the body except for the face. Patient was given ointment
and medications by the doctor.

Patient has braces and teeth restoration with the 2 lower molars. Patient has complete set of
teeth and has no dental problems currently.

C. Elimination Pattern

Patient defecates 1 a day and at least 2 times a week. Patient urinates 5-8 times a day with
a pale-yellowish color and has no difficulty in both bowel and urinary elimination. During
hospitalization, patient’s urinary elimination decrease to 4-5 times a day due to dehydration.
Patient has no excess perspiration and odor problems.

D. Activity-Exercise Pattern

Patient describes her typical daily routine as waking up, prepares breakfast, change clothes
and do usual activates in school then go home.

Patient’s leisure activities include playing futsal and volleyball. Patient does not get easily
tired, no difficulty in breathing and can perform her leisure activities independently.

Patient has experience a decrease in energy level due to lack of appetite and lessened
intake of fluids. Patient stated that during hospitalization there was little to none restriction of
movements because most of the time she is in bed. After hospitalization, patient regained
her energy in 2 months with no significant changes in her activities.

E. Sleep-Rest Pattern

Patient’s usual bedtime is at 9 PM and wakes up at 5 AM. Patient sometimes wakes up at

dawn but stated that she has no trouble falling asleep or any sleep illnesses. Patient’s daily
night routine includes a half bath, scanning of notes and scroll through social media apps.
Patient doesn’t feel tired waking up because of right amount of sleep.

Patient often reads novels, eat and sleep for relaxation. Upon hospitalization, patient stated
that she rests longer due to exhaustion and lack of energy of her body.

F. Cognitive-Perceptual Pattern

Patient stated that she is able to see cleary. Patient has no glasses.
Patient has can hear me correctly and has no hearing aids. Patient is satisfied with her
vision with no corrective lenses. Patient stated that she has no memory problems.

Patient stated that an easier way for her to learn things is by sleeping early and waking up at
dawn to refresh her mind.

Patient does not experience any discomforts currently.

G. Self-Perception and Self-Concept Pattern

Patient stated that she feels good about herself and describes herself as independent and
one who follows the rules clearly. During hospitalization there are no significant changes in
her perception of herself and her body image.

Patient also stated the things the make her stressed is when she is bombarded with school
works and lots of things to do. Crying, eating and sleeping are her ways in coping up with
stress.

H. Role Relationship Pattern

Patient is strongly attached is has an open interaction and communication with the family.
Both of her parents are the source of income while the father makes the most decisions in
the family. Patient is 2nd oldest among her siblings whose responsibilities is to guide the
younger ones. Patient also stated that she belongs to a social group with many close friends
and has good relationship within her neighborhood.

I. Sexuality-reproductive Pattern

Patient is not sexually active and has no experience of sexual intercourse. Patient has not
used contraceptives.

Patient has not been pregnant before

J. Coping-Stress Pattern

Patient’s feels tensed lots of times due to school related activities and considered it as her
stressors. Upon hospitalization, patient considered it as one factor of her stress due to the
difficulty in coping up with the missed activities. Patient stated that communication with her
friends and family is one way of coping up with different stressors. Patient also stated that by
eating, sleeping and resting, she can cope up in dealing with stressors and is very effective
and successful.

Patient stated that there is no significant change in her life for the past 2 years.
K. Value-Belief Pattern

Patient values consistency and people that are committed to their promises and doings.
Patient is a devoted roman catholic that goes to church every Sundays and prays the rosary.
Patient stated that her illness made her belief stronger.

Others

Patient stated that she thinks that her stomachache is ulcer and that pain in her stomach is
recurrent. Patient added that she sometimes skips meals and she likes spicy foods.