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    Nursing Health History 1

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    huzai_barbi_jen704
    This nursing health history summarizes a 74-year-old female patient who presented with chest pain and difficulty breathing for two days. She has a family history of hypertension and asthma. On physical assessment, her vital signs were stable except for coarse crackles noted in her lung fields and a heart murmur. She also had decreased range of motion in her extremities and pallor of the nail beds.

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    Nursing Health History 1

    Uploaded by

    huzai_barbi_jen704
    3K views2 pages
    This nursing health history summarizes a 74-year-old female patient who presented with chest pain and difficulty breathing for two days. She has a family history of hypertension and asthma. On physical assessment, her vital signs were stable except for coarse crackles noted in her lung fields and a heart murmur. She also had decreased range of motion in her extremities and pallor of the nail beds.

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    This nursing health history summarizes a 74-year-old female patient who presented with chest pain and difficulty breathing for two days. She has a family history of hypertension and asthma. On physical assessment, her vital signs were stable except for coarse crackles noted in her lung fields and a heart murmur. She also had decreased range of motion in her extremities and pallor of the nail beds.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    3K views2 pages

    Nursing Health History 1

    Uploaded by

    huzai_barbi_jen704
    This nursing health history summarizes a 74-year-old female patient who presented with chest pain and difficulty breathing for two days. She has a family history of hypertension and asthma. On physical assessment, her vital signs were stable except for coarse crackles noted in her lung fields and a heart murmur. She also had decreased range of motion in her extremities and pallor of the nail beds.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    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.

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