_DF-002

MSU-Iligan Institute of Technology August 2016

College of Nursing PN-1/Ward

NURSING HEALTH ASSESSMENT I

Student Name: Catane, Miguel Kelly D. Date/s of Care: _______________ Score: _________
Area of Assignment: Medicine Ward Clinical Instructor: Prof. Abdullah Junior S. Mangarun, DScN, MAN, MN, RN

DEMOGRAPHIC DATA

Name: Arturo L. Mendoza Age: 52 Sex: Male Status: Married

Address: Purok 9, Pala-o, Iligan City, Lanao del Norte Religion: Roman Catholic Occupation: Faculty of MSU-IIT COE

HEALTH HISTORY
A. Chief Complaint/s:

Patient has complaints of lethargy, banding headache, pruritus on both legs, lower extremity edema, nausea, and
emesis.

B. Impression/Admitting Diagnosis:

Fluid and electrolyte imbalance.

C. History of Present Illness: (Location, onset, character, intensity, duration, aggravation and alleviation, associated
symptoms, previous treatment and result, social and vocational responsibilities)

Patient stated that he had 4 episodes of nausea and vomiting at home which consisted mainly of food he ingested at
dinner time last night. These episodes of nausea and vomiting were preceded by a banding headache which was not
relieved by a dose of Paracetamol 500 mg tablet he took last night. His wife stated that the patient has been having
swelling of both legs in the last four weeks which was temporarily relieved by leg elevation at night. Patient has been
taking his medication prescription for hypertension. The pruritus on his legs was going on for four weeks now. Patient
stated that he gets easily short of breath when walking 20 feet distance.

D. History of Past Illness/es: (Previous hospitalization, injuries, procedures, infectious disease, immunization/ health
maintenance, major illness, allergies, medication, habits, birth and development history, nutrition – for pedia)

Patient was hospitalized due to a motor vehicular accident but no trauma or injury sustained. Patient also undergone
Appendectomy on the year 2015. Patient stated that he has a left-sided hearing loss at birth and experienced
diseases; chickenpox, Measles, Head lice, and mumps during childhood. Patient received BCG and Hepatitis B
vaccine for immunization. Has illnesses; Hypertension, Insomnia, Hearing loss, Pneumonia, and headaches during his
adulthood. Patient is allergic to Penicillin and Azithromycin which causes generalized itching and difficulty of breathing.
Current medications taken at Home Amlodipine 10 mg tablet PO daily and Metformin 500 mg PO tablet daily.

E. Health Habits
Kind Frequency Amount Period
1. Tobacco N/A N/A N/A N/A
2. Alcohol N/A N/A N/A N/A
3. OTC drugs Amlodipine PO Daily 10mg
Metformin
PO Daily 500mg

F. Family History with Genogram

History of Heredo-familial diseases: Genogram (up to 3rd generation)
____ Cancer Legend:
_X__ DM - Male
_X__ Asthma - Female

Patient’s Name / Room No. | 1

_X__ Hypertension - Deceased M
_X__ Cardiac Disease - Deceased F
____ Mental Disorder - EGO
____ Others: Tuberculosis

G. Patient’s Perception
Present Illness:

Hospital Environment:

H. Summary of Interaction

Patient’s Name / Room No. | 2