BROKENSHIRE COLLEGE SOCSKSARGEN, INC.

Ced Avenue, National Highway, Lagao, GSC

Fides et Setvitium
GUIDE FOR NURSING PROCESS
COMPLETE NURSING HEALTH HISTORY: WELL/SICK PEDIATRIC AND ADULT CLIENT

Name:Reyes, Huey Marithe Section/Group: BSN 3C – G4 Date: April 11,2024

Place of Experience: SEHI

A, ASSESSMENT

NURSING HEALTH HISTORY

(7 Components)

1. Identifying Data and Source of History

Psychosocial and Cultural History

Age: 53 years old Gender: Female

Marital Status: Married Number of Children: 7

Occupation: Housewife Highest Level of Education: Third year college

Religious affiliation: INC Place of residence: Uhaw, Fatima

Country of Origin: Philippines Primary Language: Bisaya

Military Service: N/A Foreign Travel/residence:

Date and Time of History: April 11, 2024

Source of the History: Patient

Reliability:

2. Reason for seeking health care / or the Chief Complaint(s) Why was the client admitted?
(the one or more symptoms or concerns causing the patient to seek care)
- The client admitted due to numbness and unable to move her face

3. History for seeking health care/ or of the Present Illness ( Why is this client still hospitalized?)
(describes how each symptoms develop: pulls in portions of the ROS called ''pertinent positives and negatives": may inelude medication
allergies, habits of smoking, and alcohol which are frequentlv pertinent to the present illness.)

Medications
(name, dose, route, frequency of use, home remedies, non-prescription drugs, vitamins and herbal supplements, oral contraceptives and
medicines borrowed from family members or friends.)
-The patient has a maintenance of losartan before, uses over the counter vitamins, no oral
contraceptives, and no medicine borrowed from family members or friends.

Allergies including specific reaction to each medication:

- The patient has no allergies in foods or medication

Tobacco Use
(report in pack-years a person who has smoke 1 1/2 pack of cigarettes a day for 12 years has an 18-pack year history. If someone has quit
note for how long.)

- The patient does not smoke.

Alcohol and I)mg Use

- The patient does not drink alcohol or has a history of drug use
4. PAST HEALTH HISTORY
Childhood Illnesses:
(communicable and chronic illnesses)

- Chicken fox
- Measles

Injuries/Accidents:
- The patient had a vehicle accident

Previous Hospitalizations:
- N/A

Adult Illnesses:
Medical: (include hospitalizations; and risky sexual
practices)

- Hypertension

Surgical:

- 2007 / Cesarian
- 2008 / Tubal Ligation
- Bilateral Oophorectomy
- Appendectomy
- Thyroidectomy
(dates, indications, and types of operations)

0B/Gyne:

(obstetrical history, menstrual history, methods of contraception)

- LMP: 2021

- G (7) P (7) A (0)

Psychiatric:

(illness, and time frame, diagnosis, hospitalizations, and treatments)

- N/A

Health Maintenance Practices Immunizations:

- N/A

Screening test:

Tuberculin test, pap smear, mammography, blood exams, results and when they were last performed)

- N/A

5. Family Health History

(documents presence or absence of specific illnesses in the family, such as hypertension, CAD, etc.)

- Hypertension on maternal and paternal side

Family Genogram with Family Illnesses

(outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents)

- The patient refused to share her family history

6. Personal and Social History

(describe the patient's personality and interest, sources of support, coping style, strengths, and fears. Include lifestyle habits that promote health or create
risk such as exercise and diet. measures and alternative health care practices.)
- The patient walks every morning as a form of exercise, eats three times a day with
snacks in between, and a diet consist of fruit, vegetables. And whole grains.
7. Review of Systems (ROS)
General :
(usual weight, recent weight change, weakness, fatigue and fever)

- The patient usual weight is 60 kg, during her hospitalization there is no recent weight
change does not experience weakness, fatigue, or fever.

Skin:
(rashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails and color/sizes of moles)

- The patient has no rashes, lumps, sore, itching but the skin is dry. There is no
abnormalities seen.

Head, Eyes, Ears, Nose Throat (HEENT)

(headache, head injury, vision, glasses or contact lenses, last eye exam, glaucoma, cataract, hearing, vertigo, hearing aids, frequent colds, nosebleeds, bleeding
of gums. dentures, last dental exam, sore throat; hoarseness)

- The patient complains headache after her medication but no head injury, the vision is
not stated but uses reading glasses, no glaucoma, cataract, has a good hearing acuity,
no hearing aids, does not get frequent colds, no nosebleeds, no bleeding of gum, does
not use dentures, no sore throat nor hoarseness.
Neck:
C'swollen glands", goiter, lumps, pain, stifthess in the neck)

- No swollen glands, lumps, pain, or stiffness in the neck.

Breast:
(lump, pain, discomfort, nipple discharge, BSE)
- No discomfort and nipple discharge.

Respiratory:
(cough, sputum, hemoptysis, dyspnea, last chest x-ray)
- The patient has no cough during the assessment.
Cardiovascular
(high blood pressure, chest pain, palpitation, dyspnea, edema, past ECG or other heart test results)
- The patient has a malignant hypertension, does have chest pain, palpitation, dyspnea,
or edema present upon assessment.
Gastrointestinal
(difficultv swallowing, heartbum, appetite, nausea, vomiting, indigestion, bowel movements, abdominal pain, food intolerance, belching, or passing ofgas,
jaundice.)
- The patient does not have abnormalities in this area when assessed.
Peripheral Vascular
(intermittent claudication, leg cramps, varicose veins, color changes in finger tips and toes during cold weathers, swelling with redness ot tenderness)
- The patient does not have abnormalities in this area when assessed.
Urinary
(changes in the pattern of urination, flank pain, kidney stones, suprapubic pain, incontinence)
- The patient does not have/experienced abnormalities in this area when assessed.
Male Reproductive
(hernias, discharge from or sores on the penis, scrotal swelling, history of STD and treatment, sexual habits, birth control methods-condom)

Posterior Thorax and Lungs

- Refused the assessment.
- No adventitious sound heard

Breast and Axilla

- Refused the assessment.

Anterior Thorax and Lungs

- Refused the assessment
- No adventitious sound heard

Cardiovascular System
- On auscultation, there was a normal first and second heart sound (S1 and S2) in all 4
valvular areas with no additional sounds or murmurs detected.
 Abdomen
- Refused the assessment

Lower Extremities
- Maintains posture of flexion
- Feet and legs were symmetric in size, shape, and movement. Extremities are warm
to touch and mobile.
- The nail in toes is dirty and unkept, the skin is dry.

Nervous System
Mental Status
- The patient is oriented to time, place, person, and situation. The body movement is
voluntary, deliberate, coordinated, smooth, and even. No signs of anxiety seen.

Cranial Nerves
- Cranial nerve 7: The patient is unable to move her right side of face due to bell’s
palsy the rest of cranial nerve is normal.

Motor System
- N/A
Sensory System
- N/A
Reflexes
- N/A
Additional Examination
Rectal Exam for Men
- N/A
Genital and Rectal Exam in Women
- N/A
Female Reproductive
(age at menarch: regularitv, frequency, and duration of periods: amount of bleeding: LMP, dysmenorrhea: PMS, age at menopause and symptoms: if born
before 1971 exposure to DES: number of pregnancies and type of deliveries, number of abortions, birth control methods, sexual preference)

- Menarche: 12 years old

- The patient had a regular menstrual period and would last for 5 days with normal
flow. The patient used 5 pads per day during menstruation.
- LMP: 2021
- No reports of dysmenorrhea, G(7) P(7) A(0), six are normal deliveries and one is
cesarian.
Musculoskeletal
(muscle or joint pain, stiffness, arthritis, gout, backache)
- On the right hand, the patient reported having stiffness on her ring finger but no pain
palpated.
Psychobiologic
(nervousness, tension, mood and memorv change, suicide attempts)
- N/A
Neurological
(fainting, blackouts, seizures, paralysis, numbness, tingling, tremors)
- No abnormalities reported during the assessment.

Hematologic/immunologic
(easy bruising, or bleeding, past transfusions and reactions, autoimmune disorders)
- The patient did not experienced easy bruising and has not past transfusion.
Endocrine
(thvroid trouble, heat intolerance, excessive sweating, diabetes, excessive thirst or hunger, polyuria, change in glove or shoe size)
- No excessive sweating, the patient has tolerance in heat and cold, no history of
diabetes, no reports of excessive hunger or thirst.
PHYSICAL ASSESSMENT
Using IPPA record findings following the attributes, body functions and system:

General Survey
(physical appearance, age, hygiene, grooming, posture, mobility, use of ambulatory devices, weight, height and vital signs)
- The client’s overall hygiene and grooming are clean and neat. No foul body odor, no
signs of weakness during the conversation but was cooperative and not hostile as a
defense mechanism. The client’s mood and responses are appropriate to the situation.
The speech and quantity were normal paced and soft-spoken. The relevance and
organization of thoughts is logical and have sense of reality.
 - Blood pressure: 130/100 mmHg Heart rate: 88 bpm Respiration rate: 18 CPM
Temperature: 36.5 degrees celsius O2 Saturation: 96%

Skin

- Upon inspection, the client’s skin is intact, and the color is brown, with exposed skin
darker than the unexposed area. There are no lesions, rashes, or edema present.
When palpated, the skin is warm to the touch, and the texture is dry. When pinched,
the skin springs back to its previous state.

Head Eyes, Ears Nose, Throat (HEENT)

- On inspection, the head is round, symmetric, erect, and in midline. Upon palpation,
there is no discomfort, lesions but has a presence of lump but no pain when palpated.
The head is normocephalic, traumatic, and has a skull depression occipital area. The
head is appropriate in the body proportion of the patient. Wrinkles and fine lines are
seen on both side eyes of the patient. The temporal artery pulsation +2

- Upon inspection, the patient’s upper and lower lids close easily and meet completely
when closed except on the right side due to bell’s palsy. The skin around the eyes is
free from redness, swelling, and lesions. The eyeballs are symmetrically aligned in
sockets without protruding or sinking. The bulbar conjunctiva is clear, moist, and
smooth. The sclera is white. The eyelash of the patient is evenly distributed. The
lower palpebral conjunctiva is clear and free of swelling or lesions. The patient is
using a reading glass when reading. No cataract is seen. PERRLA. The six cardinal
movement is normal.

- The auricle is aligned with the corner of each eye and is within a 10-degree
angle of vertical. Earlobes can be free-standing, affixed, or soldered. While in
palpation there are no lesions, tumors, or nodules on the skin.

- By inspection, the outside of the nose is symmetrical and midline, with no

scars, and inflammation is allowing the patient to breathe through each nostril.
On palpation, no tenderness or sinuses were noted. Normal patency, is firm and
intact. Normal smell acuity.

- Lips are smooth and moist without lesions or swelling.

- No presence of teeth.

- Tongue is whitish and moist.

- Gums are pink and moist

- A gag reflex is present.

- The patient is not using dentures

- The uvula is midline

- There is presence of uvula is midline.

- No difficulty in swallowing

- Ability to purse lips

Neck
- Full ROM of neck movement.
- Has a presence of scar
 - No presence of neck vein distention.
- Coordinated, smooth movement with no discomfort
- There is no swelling or enlargement.
- No tenderness upon palpation.
- Trachea is midline upon palpation.

Back

- No abnormalities were heard when auscultated. The s1 and s2 are head, with
no adventitious sound. Muscles are equal in size.

OTHER SOURCES
Laboratory Data
Laboratory Test Indication to the Normal Value Client's Value Interpretation
Patient

Diagnostic Test
Non-Invasive
Invasive

On-Going Appraisal
Si nificant chan es ne ative or ositive on a dail basis)

Date Time Pro ess Notes

Nurses' Notes
Reference:

Bickley, Lynn S. Bate 's Guide to Physical Examination Timby,

Barbara K. Introductory Medical-Surgical Nursing