NURSING HISTORY A. Biographical Data Patients Name: MRS.

MIKY Address: Coloocan City Date of birth: Octobor 9, 1983 Birth place: Samar Occupation: Sales Lady Source of health assistance: Hospital Source of referral: None Admission Date: Septemper 1, 2011 Time of Admission: 1:20 pm B. Reason for Seeking Health Care: The client who is G1 complaint that she experience difficulty in breathing while walking in her 29weeks and 1day of gestation . C. History of Present Illness: 2months prior to admission, the client had onset of productive cough and colds associated with Paroxysmal- nocturnal dyspnea (PND), and then difficulty of breathing (DOB) was also experienced and was relieved by rest and OTC drug (Carbocisteine 1 cap. Twice a day) in her 20weeks of gestation. No consultations done.

1month prior to admission DOB got worst, aggravated when walking and talking, cough was resolved with persistence PND, there was also onset of easy fatigability, light-headedness, headache and dyspnea or exertion and was relieved by rest. Patient claimed to have consulted at OPD; laboratory test was requested and was advised to come back once results were completed. 2weeks PTA, dyspnea on exertion was no longer relieved by rest. One day PTA, there was onset difficulty of breathing while walking and had a productive cough with characteristic of pinkish, frothy sputum. Persistence of symptoms prompted consult, hence admission on September 1, 2011

D. Past Health History: Regarding to his past illness, patient had chicken pox 1year ago and treated with home remedies and unrecalled medications. She had a Medical History of Hypertension and taking nifedipine 60mg P.O. OD, no past surgery had done to her. Mrs. MIKY stated that she has no allergies to foods and medication. As she recalled, her immunization was Complete. E. Family Health History MRS.MIKY stated that both of her parents has a history of Hypertension. F. Social History The client described her environment, as well ventilated and has an adequate space. They had their own comfort room with a flush type bowl. Before she was diagnose of being pregnant she smokes 5x/day, but Mrs. Miky stated that shes a non-alcoholic drinker. Because of Mrs. Mikys condition, she and her husband decided to have no sexual intercourse during her pregnancy. Last September 2010, the client travelled to Samar for vacation and stayed for 10 days and on 2008 she travelled to Hongkong and stayed there for 1month. Her form of exercised, was walking in their village with her dog named cloudy, but because of having difficulty in

breathing, and easy fatigability, Mrs. Miky cant do the things shes been doing before. The client was a College Graduate with the Degree of Business Management Major in Accounting. As of now, she chose to be a housewife because of her pregnancy and her husband was a Certified Public Accountant, whos responsible for providing their physiologic needs. VI. Home Medication/Alternative Medicine: Mrs. Miky was taking Nifedipine 60mg P.O. Od for her Hypertension, she also takes iron Supplement. VII. Psychosocial History The client stated that she is a non-alcoholic drinker, and no history of using any form of prohibited drugs. VIII. Obstetrical History Menarche: Mrs. Miky started her menstruation when she was 11 years old. She said that her menstruation is regular and a 28days cycle. OB SCORE: G1 LMP: March 11, 2011 EDC: December 28, 2012 AOG: 29weeks and 1day