Nursing Health History

A. Biographic Data

Name of Patient: Casimero, Felicidad Occupation:

Housewife
Age: 74 years old Civil Status: Married
Address: Malitbog Maasin,City Religion: Roman
Catholic
Gender: Female

B.Chief Complaint or Reason of Hospitalization

>Chest pain

C. History of Present Illness

>Two days PTA, the patient feels dizziness and difficulty of breathing.

D. History of Past Illness

> No verbalization on food allergies

E. Family History of Illness

The patient has the family history of hypertension and asthma. No
familiar history reported about rheumatoid arthritis, DM, and heart problems.

F. Functional Health Pattern

1. Health Perception and Health Management
a. The patient/SO seeks for hospitalization/consultation if management for
general health will be necessary.
b. Good health will be acquired through intake of nutritious foods.
1. Nutritional and Metabolic Pattern
a. The patient has impaired appetite prior to admission.
1. Elimination Pattern
a. The pt doesn’t have any problem in voiding and defecating.
1. Activity –Exercise Pattern
a. She exercises every morning like walking.
1. Sleep-Rest Pattern
a. Slept 8-10 hours per night.
1. Role-Relationship Pattern
a. She have a good relationship to her family and neighbor
1. Coping-Stress Tolerance Pattern
a. Relaxation techniques
b. Going to church
1. Value-Belief Pattern
a. Roman Catholic is her religious affiliation
b. Believe the God is the one that helps everyone’s problem.

1. Sexuality- Reproductive Pattern

a. Sex is not practiced. Before I haven’t used any family planning.

10. Self perception and self concept pattern

a. Simple man la q dai. Tiguwang na ko.

11.Value- Belief Pattern

a. The pt consult in manghihilot and tambalan. She used also herbal.

 Physical Assessment
VITAL SIGNS:
BP – 130/70 mmHg
Temp – 36.5 C
PR – 77 bpm
RR – 19 cpm

GENERAL SURVEY:
The patient is responsive, coherent, and conscious.

HEAD:
Configuration is symmetrical; slightly moist scalp; hair color is white
with some black hair.

EYES:
Symmetrical in size and shape; pupils are PERRLA; sclera is white;
eyeball is brown in color; pinkish conjunctiva.

NOSE:
Nasal septum is midline; mucous membrane is pinkish; no nasal
discharges, not inflamed sinuses

MOUTH:
Incomplete set of teeth; mucous membrane is pinkish; tongue is
midline; dry lips.

EARS:
Symmetrical pinnae; no discharges; symmetrical gross hearing

CHEST AND AXILLAE:

Symmetrical in shape; (-) masses and (-) lesions

BREAST AND LUNGS:

Symmetrical breast shape; (-) discharges; (-) lesions and masses; (+)
coarse crackles noted at lung fields.

HEART:
Heart rate of 77bpm; (+) heart murmur

ABDOMEN:
(-) lesions and masses; soft to touch; bowel sound is not hyperactive

BACK AND EXTREMITIES:

Symmetrical peripheral pulses; (+) bed sore at right buttock; spine is
midline; decreased ROM both lower and upper extremities; nail beds are slightly
pallor; capillary refill is 3-4 minutes.