Nursing Health History
Biographic Data
Name: Patient R. A. D.
Address: Imus, Cavite
Age: 47 yrs old
Birth date: August 17, 1971
Birthplace: Sampaloc, Manila
Sex: Female
Race: Filipino
Marital Status: Married
Occupation: Housewife
Religion: Roman Catholic
Health care financing: None
Educational Level: College Graduate
Genogram
X X X X
X
X X X
LEGEND:
male
female
diabetes
- Deceased
Hypertension
client
Chief Complaint
Can you tell me the reason why you came to the hospital?
“When I was doing some household chores, I experienced a sudden headache. It was really painful. And it
is continuous for three days so I decided to consult a doctor.”
Onset- “I was doing household chores when it occurred, it was a sudden headache”
Provocation or palliation- “whenever I’m in a cold environment like when taking a shower or in an air-
conditioned room the pain was alleviated”
Quality of the pain- “it was like a hammer was beating my head; it is constant and throbbing”
Region and radiation- “it was particular in the middle back portion of my head and it does not radiates”
Severity- “In a scale of 1 -10, it is 8”
Time- “it is consecutive for three days and the pain was increasing and not tolerable”
History of Present Illness
The patient is having a hypertension. Prior to hospital checkup, the patient was experiencing headache
for three consecutive days. She thought it was only because of her eye glasses. It started on May 20, 2018
until May 23, 2018 when she decided to consult a doctor because the headache was not tolerable.
According to his doctor, avoid salty, fatty and foods that rich in sugar. Blood pressure monitoring for a
month then follow up checkup. Based on the laboratory results her triglycerides were high, the normal
range or reference range is 150 mg/dl but her result was 230 mg/dl. Her Fasting Blood Sugar (FBS) was
also high, the normal range was 74-106 mg/dl but her result was 107 mg/dl. Her Creatinine was low, the
normal range was 0.57-1.11 mg/dl but her result was 0.49 mg/dl.
Past Medical History
Childhood Diseases
- Asthma
Immunizations
- Measles, Dpt, other immunizations are cannot be remembered by the patient
Allergies
- None
Accidents and injuries
- 6 yrs old nabangga ng honer type jeep. Nagfracture yung right knee. May cast yung knee. Cannot
walk for almost a month
Hospitalizations
- Aside from giving birth, once due to severe viral infection January 22-24, 2017
Medications
- No maintenance at present
- Before Losortan 50 once a day for 3 months due to hypertension
Surgeries
- None
Transfusion
- None
Gynecologic and obstetric history
- Last menstrual period was from November 19-22, 2018
- 14 yrs old first period. normal
- No birth controls used
- 4 pregnancies, 4 children, all normal delivery
Psychosocial History
Gordon’s Functional Pattern
Health Perception/ health Management
-
-
Nutritional/ Metabolic
- 162.20 cm (5 ft, 4 in) tall; weighs 65 kg (143.3 lb)
- Usual eating pattern “3 meals a day”
- No appetite since severe headache
- Has eaten sweet potatoes today; last fluids at night
Elimination
- no problems in usual elimination
- frequency of urination and elimination were not lessen
- Form and consistency of stool was normal
Activity/ Exercise
- Seldom difficulty in breathing when lying down
- Does not exercise regularly
- Experiences joint pains frequently
- Gets tired easily especially on extreme activities
Cognitive/ Perceptual
- No sensory deficits
- Can determine time, place and person
- Responsive to questions
- Responds appropriately to verbal and physical stimuli
Roles/ Relationships
- Lives with 4 children ( 23, 20, 19, 18)
- Husband is an Overseas Filipino Worker in Saudi Arabia
- Has good relationships with friends and relatives
- Housewife
Self-perception/ Self-concept
Coping/ Stress
Value/ Belief
Medication/ History
Nursing Physical Assessment
TIMELINE
Pattern Before During Analysis Interpretation
During the
Confinement dark
and colorful foods
were not allowed
so that when tha
She can eat patient excreted
Nutrition whatever food she wastes they can
wants. monitor the color
of the stool. Her
foods were
limited according
to the diet that
was given to her.
