CHAPTER I ASSESSMENT

A. NURSING HEALTH HISTORY

COMPREHENSIVE ADULT HEALTH HISTORY
I. Demographic Profile
Client SJS is a 22 years old female client, born on the 17 th day of March at Fairview, and
is currently living in Sta. Mesa, Quezon City. She is a Filipino Catholic who graduated high
school. She currently doesnt have any work. She is also currently living with his lived-in partner
and their 4 years old son.
II. Admission Data
Upon admission, the client is complaining of sudden onset of chest pain characterized by
feeling of squeezing and tightness in chest area, Masakit dibdib ko, as verbalized by the client,
and accompanied by difficulty of breathing and epigastric pain. The client was admitted on the
17th day of September (Saturday) at the emergency room of Ospital ng Sampaloc. The client also
said that prior to admission, chest pain started Friday morning after washing clothes but still it
was tolerable. Also prior to this, patient was recently had a miscarriage last August 18, 2016 on a
2 month old fetus. Clients initial diagnosis is Atrial Fibrillation with sinus tachycardia.
III. History of Present Illness
As stated by the client, she was washing their clothes on Friday morning, when she stood
up and carry the washed clothes to bring upstairs and hang the clothes, she felt chest pain. She
said that it was still tolerable so she continued what she was doing and just bring the clothes little
by little upstairs due to some difficulty and chest pain experiencing. The day after, chest pain felt
by the client became severe accompanied by other signs and symptoms like difficulty of
breathing, epigastric pain, headache and dizziness which prompted her to be rushed in the
hospital.
IV. Past Medical History
Client was aware of her heart problem back until 2011 where she consulted a physician
but never return back until then. The patient frequently feels tiredness and easily get tired such in

simple things like walking and going up on stairs. She has been feeling this back when she was
still young. The client doesnt take any kind of medications.

V. Family Health History

Legend:
Male
Deceased
Female
Heart Disease

Patient

Genogram
82 y/o
Grand Mother

Grand
Father

Grand
Father

44 y/o

47 y/o

28 y/o

10 y/o

22 y/o

26 y/o

20 y/o

24 y/o

12 y/o

VI. Personal and Social History

The client is currently living with his lived in partner and their 4 years old son. The client
is a housewife who is in-charge of house chores because she has difficulty in finding work due to
her medical condition. Her last job was parking attendant. She doesnt have any vices such as
drinking alcohol and smoking. The client only stays at home.

VII. Review of Systems

The client perceives herself in general to have lack of energy, recent weight changes, loss
of appetite, and fatigue. The client also experience headache and dizziness. She is also having
difficulty and shortness of breath. Due to clients condition, she is having tachycardia, irregular
heartbeat, chest pain and discomfort, heart murmurs, palpitations, and dyspnea. For genitourinary
system, patient also has urinary tract infection. For gastrointestinal system, the client has
epigastric pain.
She doesnt have any integumentary, eye, ears, nose and sinuses, throat, genital,
peripheral vascular, musculoskeletal, psychiatric, hematologic, neurologic. endocrine, and
immunologic problems.

B. PHYSICAL EXAMINATION
I. Physical Presence
The patients stated chronological age, which is 22 years old, is congruent with her
apparent age. The patient exhibits body symmetry, no obvious deformity, and has a well
appearance.
II. Psychological Presence
III. Distress
IV. Skin
V. Hair
VI. Nails
VII. Skull and Face
VIII. Eyebrows, Eyes, Eyelashes
IX. Ears
X. Nose and Paranasal Sinuses
XI. Mouth and Oropharynx
XII. Neck
XIII. Thorax and Lungs
XIV. Heart
XV. Breast
XVI. Abdomen
XVII. Extremities
XVIII. Genitourinary System