III.

ASSESSMENT

NURSING HEALTH HISTORY A

Patient: Patient P
Date: November 27, 2013 Room: ICU`
Age: 5y/o Sex: Female C/S: Child Religion: Roman Catholic
Examiner: BSN IV-B Group 9
Informant: Patient Ps Mother

I. CHIEF COMPLAINT:
Difficulty of Breathing

II. HISTORY OF PRESENT ILLNESS

Patient P is known to be asthmatic, her last attack was on
November 11, 2013. 1 week prior to admission, patient suffers from cough but no
consultation was made and uses over the counter drug like salbutamol.
One hour prior to admission, patient experienced dyspnea,
cough, and fast breathing.

III. PAST MEDICAL HISTORY (include dates, complications if any)

A. Pediatric and Adult Illness:

Mumps(x) Pertussis(x) HPN(x)

Measles(x) Rheumatic(x) Heart Disease(x)
Chicken Pox(x) Pneumonia(x) Hepatitis(x)
Rubella(x) Tuberculosis(x) Other:
IMMUNIZATIONS/TEST:

BCG() Hep B()

DPT() Measles()
OPV() For Flu()

B. HOSPITALIZATIONS
Her 1st hospitalization happened when she was 3 years old which she was
diagnosed of Urinary Tract Infection for 3 days. She was fully treated on this
disease.
 C. INJURIES
She didnt have any injuries.

D. TRANSFUSION
She didnt have any tranfusions.

E. MEDICATIONS
Everytime the patient experiences cold, they let the patient take
salbutamol and when patient is being attack by asthma, her mother uses ventulin as a nebulizer.

F. ALLERGIES
She didnt have any allergies.
IV. FAMILY HISTORY

AGE DISEASES PRESENT IN

LIST HEALTH STATUS
L D THE FAMILY
L Grandfather Healthy none
L Grandmother Healthy none
L Father Healthy none
L Mother Healthy none
L= living TB= tuberculosis HPN= Hypertension OB= obesity
D= deceased DM= diabetes mellitus CA= cancer J= jaundice
HD= heart disease MI= mental illness KD= kidney disease O= others

V. SOCIAL AND PERSONAL HISTORY

Birthplace: San Miguel Tarlac City Birthday: 09/05/2008

Education: Preparatory Ethnic Background: Kapampangan
Clients position in the family: child
Residence: Mapalacsiao San Miguel Tarlac

HOME ENVIRONMENT:
According to the mother, they live in a simple house which is a bunggalo type. They are
living near the Azucarera Factory which releases bulky of dark smoke every hour.

OCCUPATION:
none

FINANCIAL SUPPORT:

The father of the patient works as a factory worker in the IWS while her mother is
also working as a factory worker at DELUXE factory.
 HABITS (Tobacco/ Alcohol use, others):
none

DIET (Meal Distribution, others):

The patients preferred to eat junk foods and meat, according to her mother she
doesnt want to eat fruits and vegetables. She seldom drink water.

PHYSICAL ACTIVITY/ EXERCISE, if any:

The patient loves to play in their home. She is not fund of getting outside thats
why her cousins are just joining her at their home.

VI. REVIEW OF SYSTEM

A. GENERAL DESCRIPTION OF THE CLIENT

VITAL SIGNS:
RR: 45 breaths/min T: 38
PR: 184 bpm

General Description

Weight loss (x) Fatigue(x) Anorexia(x) Night Sweats(x)

Weakness()
Skin

Itch(x) Bruising(x) Rash(x)

Bleeding(x)
Lesions(x) Color Change:Palor
Eyes:

Pain() Itch(x) Vision loss(x) Diplopia(x) Blurring(x)

Excessive tearing(x) Glasses/Contact lenses(x)
Ears:

Earaches(x) Discharge(x) Tinnitus(x) Hearing loss(x)

Nose:

Obstruction:NGT Epistaxis(x) Discharge(x)

Throat and Mouth:

Sore throats:N/A Bleeding Gums N/A Toothaches N/A

Decay N/A
Neck:

Swelling(x) Dysphagia(x) Hoarseness:N/A

 Chest:

Cough/Sputum:()
Hemoptysis (x) Wheeze ()
Pain on Respiration()

Dyspnea()
Breast:

Lump(x) Pain (x) Bleeding(x) Discharge(x)

CVS:

Chest Pain Palpation N/A Edema(x)

Orthopnia (x) Others(x)
GIT:

Food intolerance N/A Heartburn (x) Nausea(x) Jaundice(x)

Vomiting(x) Pain N/A Bloating N/A
Constipation() Melena(x)
GU:

Dysuria(x) Nocturia(x) Retention(x) Polyuria (x)

Dribbling(x)
Hematuria(x) Flank pain(x)
Others:
Extremities:

Joint pains(x) Varicose veins (x) Claudication(x)

Edema (x) Stiffness(x) Deformities(x)
Neuro:

Headache N/A Dizziness N/A Memory loss N/A

Fainting N/A
Numbness N/A Tingling N/A Paralysis(x) Paresis
N/A
Seizures N/A Others N/A
Mental Health Status:

Anxiety N/A Depression N/A Insomnia(x) Sexual problems(x)

FearN/A

NURSING HEALTH HISTORY B

A. Health Perception-Health Management Pattern

According to the mother, they are very worried about the present condition of their child.
B. Nutritional-Metabolic Pattern
The mother stated that her average food intake of the patient everyday was little rice with meat
and more junk foods.
D. Elimination Pattern

Mothers patient stated that her usual bowel movement schedule irregularly. Mostly she voids 3
times per day.

E. Activity-Exercise Pattern
She usually played with her cousins.

F. Sleep-Rest Pattern
Our patient sleeps after she played and goes at bed at 5 pm and usually awakes at 6 am.

G. Cognitive-Perceptual Pattern
The patient is unable to asses.

H. Self- perception-Self- concept Pattern

Patients mother perceives the health status of her daughter at present as problem in life.

I. Role-Relationship Pattern
Patient P who is 5 year old was the one being cared in the family and cannot do tasks because
of her young age.

J. Coping-Stress Tolerance Pattern

The family considered poverty and illnesses as they major stress. But because of the
emotional support that the family had been provided, they are able to handle their situation

K. Value-Belief Pattern
Their family religion Roman Catholic. They go to church seldom.

SUMMARY
PHYSICAL ASSESSMENT

GENERAL SURVEY
BODY POSITION/ALIGNMENT:
Supine: Fowlers _____ Semi-Fowlers______ Others: _______
Alignment: Appropriate __ Inappropriate

MENTAL ACUITY:
 Oriented Coherent Appropriately responsive Others: _______
Disoriented Incoherent Inappropriately responsive

SENSORY/MOTOR RESTRICTIONS:
Amputation(x) Deformity(x) Paresis(x) Paralysis (x)
Fracture (x)
Gait(x) Hearing disorder (x) Speech (x)
Others:______

EMOTIONAL STATUS:
Euphoric Depressed Apprehensive
Angry/Hostile Others: ANXIOUS_____________

MEDICALLY IMPOSED RESTRICTIONS: NONE

CBR w/out BRP ___ BR w/ BRP ___ OOB- Chair___
Restricted Ambulation___

OTHER HEALTH RELATED PATTERNS:

Fatigue Restlessness Weakness Insomnia
Coughing Dyspnea Dizziness Pain
Others:

ENVIRONMENT:
Room Temperature Adequate Inadequate
Lighting Adequate Inadequate

SAFETY:
Violations of medical asepsis: NONE
Violations of safety measures: NONE

ACTIVITIES OF DAILY LIVING:

Can/Cannot perform
Feeding Brushing Teeth Bathing Transferring
Dressing Combing Others: _______

VITAL SIGNS:

HR /min
BP Supine R/L arm 100/70 mmHg Temperature: 38
Capillary Refill: >2-3 seconds
.
Physical Examination Findings

HEAD/SKULL:
 Round, symmetrical and upright.
Hair is black, fine to coarse without presence of manifestations and evenly
distributed

EYES/VISION:

Unable to asses

EARS/HEARING:

Ears are symmetrical with upper attachment at eye corner level, firm, smooth, equal
in size and similar appearance
Skin smooth and without nodules. Non-tender auricle..
Pinna was able to return immediately to its normal state after was folded.

NOSE

Nose located midline of the face.

(-) inflammation of the sinus, (-): tenderness, bleeding, masses.
Both nares are patent with NGT.

MOUTH &THROAT:

Lips are dry

HEART & CARDIOVASCULAR SYSTEM:

Heart sounds

ABDOMEN:

Veins: not visible.

NEUROLOGICAL & MUSCULO SKELETAL:

GENITALIA:
Unable to assess

EXTREMITIES:

Nail beds are pink in color. Nails are round, hard immobile.
 Uniform in color of both the upper and lower extremities, and temperature is
slightly elevated. Good capillary refill.
Lower and upper limbs: normal