NURSING HISTORY

Biographic Data
Clients Name: Ms. ARA
Address: Bgy. Dapdap Tigbauan Iloilo
Age: 25 years old
Sex: Female
Marital Status: Single
Occupation: Costumer Representative
Religion: Roman Catholic
Source of Information: Primary - Client
Relationship: Cousin
Attending Physician: Dra. Bullas
Admitting Impression/ Final Diagnosis:
Date and Time of Admission: February 5, 2020, 7 am

Chief Complaint
Obstetric History
Menarche: 13 years old
Duration of Menses: 5-7 days
Abnormalities and Discomfort: Dysmenorrhoea and Mood swing
Date of Onset LMP: April 7, 2019
Date of Previous Menstrual Period: August 23, 2020
Gravida and Parity: G1 and P1

Abortion: Client doesn’t have any intention.

Previous Pregnancies: Client is a first time mother.
Complications: Client doesn’t have any complications during her pregnancy.
Medications Prenatal check up: The client was given vitamins, those are mosvit elite and
calciumade.
Postpartum Complication: Client said that she didn’t experienced any postpartum
complications.
Contraceptive use: Client didn’y use any contraceptive instead she used natural method

Past Medical History

Childhood illness: The client had chicken pox when she was 10 years old.
Childhood immunization: Client received a full immunization
Allergies: The client don’t have any allergies
Accidents and injuries The client had few motorcycle accidents but doesn’t have any serious
injuries just a few scratches.
Hospitalization for serious illness: No history of hospitalization due to serious illness.
Medication: Client is currently taking her vitamins specifically centrum
Family History of Illness
 The Father of the client currently had arthritis and prostate. Her Mother is healthy except
for a few backpain due to carrying her granddaughter. Her grandmother died because of
stage 4 breast cancer and her Grandfather died because of pneumonia.
Lifestyle
 Personal habits: Client occasionally smoke and drink alcoholic beverages but stop
during her pregnancy and till now.
 Diet: The client describe herself as “healthy person”. She love to eat “laswa” or vegetable soup .
She don’t like drinking softdrinks and eating junkfoods.
 Sleep/ rest pattern: Because of her work the client sleep at day. She usually finish her
work around 7 am but she sleep around 9 am and wake up around 5pm. The client had
sleeping difficulties during her pregnancy but she resolved those by changing her position
and her pillows.
 The client had no difficulties in doing her activities.
 Before her pregnancy, the client love going to beach and doing some hikes. She
loves doing physical activities such as biking and running.

Personal Social History

 The client is a single mother but she has a good support system. Her family
supported her during her pregnancy even though it was unplanned. When her
partner left her, her family was there to support and help her stand on her own.
During her labor it was her cousin and her mother who was there the whole time.
 The client said that during her pregnancy her Aunt told her that during her
pregnancy she will eat foods that are white such as labanos and coconut in order
for her baby to have a white skin.
 The client finished her college with the degree of bachelor in science major in
tourism and management.