Metropolitan Hospital College of Nursing

3A Rotation
August 24-27,2009

Requirements:
(1)Nursing History
•Present Health History
Past Health History
Family Health History
Social History
Characteristics, Patterns of daily living
Functional Health Assessment
Health Maintenance Activities
(3)Physical Assessment
(3)Nursing Care Plan

Submitted by: Kathlean O. Quimson II-G

August 27,2009
Submitted to: Ms.Facundo

Nursing Health History

*The Nursing History was taken last August 25, 2009 at the 3A Ward, Room #315 of
the Metropolitan Medical Center at approximately 1800H . The History was taken
through the client itself, Mrs. Andrea R. Sison.

• Client Data:
Bed/Room #: #315 of 3A Ward
Client Name: Andrea Romero Sison
Address: 12th St. 68 port avenue, Manila
Age: 34 years old
Birthday: May 14,1975 Birthplace: Manila
Religion: Catholic Occupation: Radiologist(Ultrasound)
Citizenship: Filipino
Admission No.: 93344
Admission Date: August 24,2009; 10:15pm
Attending MD: Dr. Fely Te
CC/Admitting Diagnosis: For Rpt CS (baby girl)
LMP: December 1, 2008
AOG: 37 6/7 weeks
EDC: Sept 6, 2009

• Source and Reliability of Information

All the information gathered was through the client herself, Mrs.
Andrea Romero Sison and through her husband, Mr. Michael Sison.
Client was in good mental condition, with good recall and answer all
the question cooperatively.

A. Present Health History

The client’s condition is very well that she is actively conscious and
can’t stand up herself yet but she can move her upper extremities.

B. Past Health History

The client has no-remarkable disease before. Whenever she has
fever, cough, or colds, she just buys over-the-counter medication Like
Biogesic and Neozep. The client have allergy in pain reliever tablets
and denies any other injuries/ accident prior to the present condition.
She has no cognitive, physical or psychological disability.
The client claimed that she has her complete immunization. The
client also claimed any surgical procedure performed on her like
primary CS to her 2nd child and also denies having communicable
diseases like TB before.

C. Family Health History

The client claimed that her family has a history of Lung diseases,
Hypertension and Diabetes. In her present immediate family, she told
us that she has 3 children with her husband, the eldest is Alysa 8yrs
old, 2nd is Abigael 6 yrs old and the last is Ayana who she had deliver
last August 24,2009 im Metropolitan Medical Center. All her children
and husband, she claims are all healthy and well without any medical
illness or diseases.

D. Social History
1. Alcohol Use
The client is drinks occasionally,

2. Drug Use
The client buys OTC drugs whenever she has fever, cough, or colds, like
Biogesic and Neozep. She claimed that she is not using any illegal drugs.

3. Tobacco Use
The client claimed that she is not a chain smoker.
 4. Work Environment
The client is a Radiologist(ultrasound) here in Metropolitan Medical
Center still working here 2 years now.

5. Education
The client have finished and graduated from college in Manila from the
course Radiologic Techinician.

6. Hobbies and Leisure Activities

Before illness, the client usually watches TV and exercise during her free
time.
During present condition, the client watches TV during free time or
sleeps when she has nothing else to do.

7. Stress
When the client is stressed out, she just goes to church to pray and
relieve the stress or problem that she encountered.

8. Economic Status
The client and her husband both do the financial status of the family,
she works as a Radiologist here in Metropolitan Medical Center at the
same her husband own a family business.

9. Religion
The client is a practicing Roman Catholic.

10.Ethnic Background
The client was born and raised in Manila. He can speak Tagalog and
English.

E. Characteristics, Patterns of Daily Living

1. Meal
Before illness, he eats 3-4 times a day and prefers “good tasting” food.
During the present condition, the client is not allowed to eat the food
she likes, because she has been CS.

F. Functional Health Assessment

At the present, the client’s body is weak due to her CS delivery but she
can still
move small. She needs any assistance in walking and changing her
clothes she does need
assistance. Her husband takes care of her hygiene and care needs.

G. Health Maintenance
1. Sleep
The client doesn’t have any sleep disturbances and sleep well per night.
She sleeps at night at approximately at 9pm and wakes up 4:30am. She
gets a complete 7-8 hours of sleep a day.

2. Diet
She eats whatever that doctor order for now. She misses eating the food
that she likes.

3. Exercise
 At the present, the client stays in her room to watch TV or just sleep.

4. Health Check-Up
The client and her family had a regular check-up in Manila Doctors,
when she started working in Metropolitan Medical Center her family had
a regular check-up here in MMC.

Physical Assessment
*The Physical Assessment was done last August 25, 2009 at 1800H Room
#315 at the 3A Ward of Metropolitan Medical Center.

A. General Appearance
1. Body Built
The client is 34 yrs old Large framed woman.
2. Posture
Posture is not seen due to client’s inability to stand up and sit up.
3. Gait
The client needs assistance while doing something due to inability to move
because of pain.
4. Dress, Grooming Hygiene
The client wears a hospital gown. But she still looks well-groomed and neat.
5. Odor/Body and Breath
The client does not have any bad body odor.
6. Others:
In totality, the client is abnormal in appearance with gross and obvious
deformity.
B. Vital Signs
Normal Actual Remarks
Findings
Temperature 36.5-37.5 C 36.7 Normal
Blood Pressure 90/60- 120/70 mmHg Normal
140/90mmHg
Pulse Rate 60-100 bpm 68 bpm Normal
Cardiac Rate 60-100 bpm 72 bpm Normal
Respiratory Rate 12-20 bpm 17 bpm Normal
C. Mental Status
1. Level of Consciousness
The client is conscious but not well oriented to time, place and person.
2. Emotional Status
The client is pleasant and cooperative. She follows orders well and does
not complain.
3. Language and Communication
The client can speak and communicate well.

D. Physical Assessment
Body Parts Technique Used Normal Actual Analysis
Findings Findings
Head Inspection Norm cephalic Norm cephalic
smooth skull, smooth skull,
contour, contour, Normal
proportion to proportion to
the size of the the size of the
neck and neck and
body. body. No
infestations of
lice dandruff.
Palpation
Absence of Absence of
nodules or nodules or Normal
masses. masses. No
lesions,
masses and
nodules.
Scalp Inspection No lice and No lice and
nits. nits. Normal
No dandruff. No dandruff.
Hair Inspection Evenly The hair is
Distributed evenly
hair, color distributed, Normal
varies mostly color varies
in black, mostly in
smooth in black, smooth
texture & in texture &
shiny. shiny.
Face Inspection Symmetric Facial
facial movement Normal
movement, and nasolabial
symmetric is symmetric.
nasolabial
folds.
Eyes Inspection 20/20 visions, Client has
round cornea 20/20 visions,
in black color round cornea
& white in black color Normal
sclera. Reacts & white
to light & sclera. Reacts
accommodatio to light &
n. accommodatio
n.
Eyebrows Inspection Hair evenly With even hair
distributed distributed
w/skin intact, symmetrically Normal
symmetrically aligned
aligned w/equal
w/equal movement.
movement
Eyelids Inspection Skin intact, no Skin color
discharge, no same with
discoloration. facial skin
Lids able to tone, skin Normal
close intact, w/no
symmetrically. discharge and
no
discoloration,
symmetrical
movement of
lids.
Ears Inspection Same color as Ears with
facial skin, same color as
symmetrical facial skin
auricle with tone, Normal
outer cantus symmetrical
of eyes about auricle with
40 degrees 10 degrees
from vertical. outer cantus
from vertical.
Palpation Mobile, firm
and not Mobile, firm. Normal
tender. Free from
lesions.
Nose Inspection Midline With midline Normal
symmetrical symmetrical
to face. No to face. No
lesions, no lesions, no
nasal nasal
discharges or discharges or
flaring, flaring,
uniform in uniform in
color. Air color. Air
moves freely. moves freely.
Mouth Inspection Proportional Proportional
and and Normal
symmetrical symmetrical
with face with face
Lips Inspection Pink in color, Pink in color,
 smooth, no smooth, no Normal
lesions. lesions.
Teeth Inspection Complete Complete
without without Normal
dentures. dentures.
Tongue Inspection Tongue floor Tongue floor
is in central is in central
position, pink position, pink Normal
in color, moist. in color, moist.
No lesions or No lesions or
swelling swelling
Neck Inspection Proportion to No discomfort
size of body on moving,
and head, proportion to
coordinated, size of body Normal
smooth and head,
movements, coordinated
no discomfort. and smooth
movement.
Palpation No lumps and With palpable
tenderness. Adam’s apple, Normal
Adam’s apple no lumps and
is palpable tenderness.
Chest Inspection Symmetrical Symmetrical
during lung Lung Normal
expansion and expansion and RR= 17 bpm
recoil. recoil.

Auscultation No abnormal Normal

breath No abnormal
sounds. breath
sounds.
Heart Auscultation Normal rate, Normal rate,
rhythm, no rhythm, no Normal
murmur murmur
Skin Inspection Fair Yellow in The skin is
complexion, complexion, yellow that
absence of fair presence indicates
scars and of lesions on that the
lesion. Good the abdominal client needs
skin turgor. area. But has to take iron
good skin supplement
turgor. to supply
the loss of
the blood
during the
CS
procedure.
Abdomen Inspection No abdominal No abdominal
enlargement enlargement
noted, noted,
symmetrical symmetrical Normal
without without
discoloration. discoloration.
 No abnormal No abnormal Normal
Auscultation bowel sounds bowel sounds
heard. heard.

Palpation No lesions, with lesions, Lesions due

masses or masses or to the CS
tenderness. tenderness. procedure
that has
been done
to the
patient risk
for infection
because of
open wound.

Upper Inspection Symmetrical Symmetrical

Extremities to the body, to the body, Normal
no lesions. no lesions.

Palpation No No tenderness
Tenderness, and palpable Normal
no palpable mass noted. PR=72 bpm
mass noted. Palpable
Palpable peripheral
brachial and pulse.
Range of Inspection on radial pulse.
motion Adduction,Abductio Able to move
n, Flexion and Able to move freely without Normal
Extension freely without discomfort;
discomfort; able to
able to adduct,
adduct, abduct, flex,
abduct, flex, and extend
and extend
Palms Inspection Pink in color, Pink in color,
hand warm to hand warm to Normal
touch. No touch. No
lesions noted. lesions noted.
Fingernails Inspection Nails are Nails are
clean. Pink clean. Pink Normal
nail beds. nail beds.
Palpation

Capillary Refill Normal

Capillary Refill of 2-3
of 2-3 seconds.
seconds.
Lower Inspection Symmetrical Symmetrical
Extremities to the body, to the body, Normal
no lesions. no lesions
Muscles noted.
appear equal Muscles
with good appear equal
muscle tone. with good
 Palpation muscle tone. Normal
No
tenderness, No
Range of Inspection on masses tenderness,
motion Adduction,Abductio masses
n, Flexion and Able to move Normal
Extension freely without Able to move
discomfort; freely without
able to discomfort;
adduct, able to
abduct, flex, adduct,
and extend abduct, flex,
and extend
Toenails Inspection Pink nail beds Pink nails bed,
with capillary capillary refill Normal
refill of 2-3 of 2-3
seconds. seconds.