NURSING HISTORY

BIOGRAPHICAL DATA :
NAME : Velasco, Emelita ADDRESS : 645 Gerona St. Tondo Manila. AGE : 48 y/o SEX : Female Date of Birth : 4/7/1963 Birthplace : Manila Nationality : Filipino Religion : Catholic Marital Status : Married Admitting Diagnosis : Post CTT insertion, massive effusion , nephrolithiasis, hypothyroidism Admitting Date : 6/28/11 07:15 PM Attending Physician : Dr. Jayvee Rivas Gutierrez Ward/Room/Bed : 6B / 636

Chief Complaint : nahirapan ako huminga as the patient verbalized.

Present History : 2 weeks prior to admission when the patient experienced difficulty of breathing associated with client pain and back pain. No associated cough, fever, cyanosis. No medications and no consult doctors. 1 week prior to admission patient was brought to a private hospital and admitted and treated as a T/C Pulmonary mass and UTI. Few hours prior to admission, patient relative decided to transfer the patient in our institution hence admission.

Past Health History : The client had experienced PTB before she had hospitalized and she is taking the PTB medication as maintenance.

Family History :

Lifestyle : The client prefer eating fish ad vegetables. She doesnt Eat pork that much. In their family the father is a chain smoker and Ms. Emelita was a second hand smoker.

Social Data : Ms. Velasco doesnt have any problems in their family and neighbors. She also have many friends like her kumare and kumpare.

Pattern of Health Care : The client usually visits/seeks medical attention regarding her health matters. She had maintenance medications for her PTB and also takes over-the-counter medications.

REVIEW OF SYSTEMS
Integumentary : hindi naman nangangati ang katawan ko Nervous : hindi naman ako nahihilo Respiratory : minsan nahihirapan ako huminga Cardiovascular : hindi naman tumataas ang presyon ko Gastrointestinal : hindi naman ako hirap dumumi Genitourinary : maayos naman ang pag-ihi ko Musculoskeletal : maayos naman

07/ 03 / 11

PHYSICAL ASSESSMENT

GENERAL APPEARANCE : Ms. Velasco, a 48 y/o woman was conscious. The client was in lying position. She has a brown complexion. VITAL SIGNS : Temperature : 36.5 c Pulse rate : 86 Cardiac rate : 88 Blood pressure : 110/80 Respiratory rate : 19 BODY TECHNIQUE PARTS SKIN Inspection Palpation NORMAL FINDINGS Whitish pink / brown Slightly moisture ACTUAL FINDINGS Brown in color ANALYSIS Normal

Slightly moisture No dandruff No lices Normal

Scalp and hair

Inspection Palpation

No dandruff No lices

Evenly Evenly distribute distributed d

With facial expressio ns

Face

Inspection