Nursing History

Past Medical History

According to the SO patient X’s last hospitalization prior to this one was last December
2017 because of his asthma attacks, he was given a prescription of Salbutamol (Ventuli Tab) for
his take home medications. The patient’s asthma is triggered by sudden change of environment.
During the interview the SO was asked of any vaccines the patient had in the past, the SO said
that the patient had no vaccines given to him. The patient had no reported injuries in the past.
The patient has no known allergies.

Present Medical History

7 days prior to hospitalization the patient experienced fever, dizziness and cough. The pt.
was admitted at Bello Integrated Hospital in Jones, Isabela on and he undergone laboratory tests
like Chest APL and Urinalysis and he was ordered to take antibiotics then was admitted on
October 6. The SO said “nahihirapan na kasi siyang huminga noon, tapos medyo hindi na siya
nagre- respond sa amin. Yung tipong tulog na tulog na siya” so they decided to transfer him to
Southern Isabela General Hospital on October 10, 2018. He was admitted at 4:00 pm and was
diagnosed with Acute Respiratory Failure secondary to Hospital Acquired Pneumonia.

Family History

They have a Family history of Diabetes, Asthma, Hypertension and Cancer in his
maternal side as stated by the SO. No one in their family had a Respiratory failure he was the
first one to have Acute Respiratory Failure.

Social History

The patient lives with his children and son-in-law. Patient X’s family is very supportive
and he is really close to his children. Their family lived in Daligan Jones, but when his wife left
them they decided to move in Centro Jones. Their house is near the road or highway and it is
approximately 5 meters away from their neighbors. Their house is 100 meter away from their
restaurant and the billiard house of his brother where he helps everyday. The patient sleeps at 8
pm and wakes up at around 4:30 in the morning. According to the SO the pt. doesn’t have
problems sleeping at night. The patient’s vices are smoking, he consumes half pack of cigarette a
day and he drinks alcohol and can consume half a bottle of alcohol then he will continue the
other half the next day. The patient drinks alcohol 3 times in one week. According to SO the
patient started smoking and drinking alcohol when he was teenager and stopped smoking at the
age of 65. The patient doesn’t drink sodas according to the SO, he’d rather drink water. He
consumes 1 liter of water daily. The patient was a farmer and a fisherman, they own a farm
where he plants corns and rice and a fish pond, but he stopped farming when he was 64 years
old.