Nursing History

Submitted by:
Meliza M. Padagdag
BSN/222

Subitted to:
Mrs. Loren Espina
(Clinical Instructor)

East Avenue Medical Center (EAMC)

Nursing History
I. Biographical Data

Name: Lucia Barboza

Address: 286 San Roque II Agham Street, Bagong Pag-asa,
Quezon City
Civil Status: Married
Religion: Roman Catholic
Age: 40 y/o
Birthday: November 7, 1971
Occupation: House Wife

II. Chief complain: fever

III. History of Present Illness

1 week prior to consultation the patient experienced

intermittent fever, vaginal bleeding 2 pads per day and abdominal
pain after the operation of D&C – Dilation and Curettage was held
on February 07, 2011.

IV. History of Past Illness

o Asthma – Attack on 2009

- Medication: salbutamol
o D&C – February 7, 2011 due to induced abortion in
East Ave Medical Center

V. Family History

− mother side = (+) brain cancer

− father = (+) asthma

VI. Menarche

M – 14 y/o
I – 28 days
D – 4 days
A – 2 pads
S – dysmenorrhea

VII. Coitarche

 Age of first sex contact:

 - 24 y/o
 Number of partner:
- 1 partner

VIII. OB History

G6P5 (5015)

Patterns of Functioning:
 A. Elimination Pattern:

The patient defecates 3-4 times a week. Her stool is soft,

brown color and easy to pass. Urinates regularly and about 900-
1000cc a day.

B. Sleep and Rest Pattern:

The patient is generally rested and ready for activity. She

sleeps 6-8 hours at night and sometimes sleeps/naps at noon for 1-2
hours.

C. Nutrition – Metabolic Pattern:

The patient eats 3 meals a day, usually vegetables and

sometimes meat and drinks 6-8 glasses of water a day. Her BMI index
is normal.

D. Activity and Exercise Pattern:

The patient is doing some simple exercises during morning

(stretching exercises). Daily activities: cleaning the house, washing
the clothes, cooking, and taking care of her children.

E. Health Perception:

The patient thinks that she is perfectly fit and have a healthy
life style.
Name of Student: Meliza M. Padagdag Date of Assignment: February 15, 2011
Name of Patient: L. B. Civil Status: Married
Dx of Clinical Impression: Age: 40 y/o

Assessment Nursing Background Goal and Nursing Rationale Evaluation

Diagnosis Knowledge Objectives Interventions
Subjective: Hyperthermia Dilation and curettage After 4 >Identify the >To know the After 30
“Ang init ng related to – refers to the dilation hours of underlying cause of minutes of
pakiramdam increase body (widening/opening) of nursing cause. hyperthermia. nursing
ko” temperature the cervix and interventions >Monitor vital >Provide interventions
(39°C). surgical removal of on February signs comparative on February
Objective: part of the lining of 15, 2011 baseline. 15, 2011 the
the uterus and/or patient’s >Do tepid >Heat loss by patient’s
T = 39°C contents of the uterus body sponge evaporation body
PR = 85 by scraping or temperature bath/immersion and temperature
bpm scooping (curettage). will decrease . conduction. is now
RR = 17 It is a therapeutic from 39°C to >To relieve decreased at
bpm gynecological 37°C. >Administer the fever. 37.6°C.
BP = procedure as well as a paracetamol as
110/80 rarely used method of Objectives: the doctor
mmHg first trimester of - Encourage prescribed. >To indicates
abortion. If you seen the patient >Review the s/s need for
-Flushed the s/s like vaginal to increase of prompt
skin, warm bleeding, abdominal fluid intake. hyperthermia. intervention.
to touch pain and fever must - Encourage
notify the attending the patient
physician because to maintain
may arise from either bed rest.
the - Provide a
introduction/spreading high-calorie
of infection or other diet.
complications.
Name of Student: Meliza M. Padagdag Date of Assignment: February 15, 2011
Name of Patient: L. B. Civil Status: Married
Dx of Clinical Impression: Age: 40 y/o

Assessment Nursing Background Goal and Nursing Rationale Evaluation

Diagnosis Knowledge Objectives Interventions
Subjective: Acute pain Dilation and After 4 hours >Encourage >For relaxation. After 4 hours
“Masaki tang related to Curettage - nursing to comply nursing
tiyan ko” post internal Miscarriage, interventions with interventions
surgical incomplete on February prescribed on February
operation. abortion, 15, 2011 the bed rest and 15, 2011
induced patient positioning. abdominal
Objective: abortion or
patient’s >Encourage >To promote pain reduced
Pain scale= childbirth.
abdominal the patient to non- with pain
8/10 Abnormal
bleeding may pain will alternate pharmacological scale.
T = 39°C
result if some lessen from lying, sitting, pain
PR = 85 bpm
of the products 3/10 pain and walking management.
RR = 17 bpm
of pregnancy scale. activities and
BP =110/80
remain in the advised to
mmHg
uterus after a Objective: avoid sitting,
miscarriage or -enough bed standing, and
induced rest. walking for a
abortion, or if -positioning long period
parts of the (semi- of time.
placenta are fowler’s >Encourage
not expelled position) verbalization >For the
naturally after
-provide of feelings update
childbirth.
comfort about the regarding to
These retained measures pain. condition.
products can >Encourage
be scraped out diversional > To decrease
by D & C. activities. pressure to
A woman who >Administer pain.
has had a D & analgesic as >To relieve
C performed in
prescribed by pain.
a hospital can
usually go the
home the same physician.
day or the next
day. Many
women
experience
abdominal
pain due to
surgical
sutures,
backache and
mild cramps
after the
procedure, and
may pass small
blood clots for
a day or so.
Vaginal
staining or
bleeding may
continue for
several weeks.