II.
COMPREHENSIVE NURSING HEALTH HISTORY
A. DEMOGRAPHIC DATA
NAME OF PATIENT: C.R.C.
ADDRESS: Javier, Leyte
SEX: Female
AGE: 32 years old
DATE OF BIRTH: January 30, 1982
CIVIL STATUS: Single
NATIONALITY: Filipino
OCCUPATION: Nurse
RELIGION: Roman Catholic
WEIGHT: 50 kg.
HEIGHT: 5’2
DATE OF ADMISSION: September 6, 2014
TIME OF ADMISSION: 8: 30 PM
SOURCE OF DATA: Patient
DATE OF INTERVIEW: September 18, 2014
PATIENT DIAGNOSIS: Premature Rupture of Membrane
ATTENDING PHYSICIAN: Dr. Gloria T. Caidic
B. CHIEF COMPLAINT
“Mibuto ako panubigan.”
C. HISTORY OF PRESENT ILLNESS
Prior to admission, the patient claimed that she was sitting at their couch
while watching television when she felt a sudden gush of clear water stained with
blood. By that, she immediately went to hospital hence, admitted.
D. PAST MEDICAL HISTORY
The patient underwent tonsillectomy last 2004 because she always
experienced tonsillitis and was advised by the doctor to have the procedure.
On the other hand, the patient completed her immunizations such as
OPV, DPT, AMV, Measles and Hepatitis B. In addition, she has no allergies to
food, materials such as rubber and has no mental abnormalities hence, does not
undergo counselling.
E. FAMILY HISTORY
The patient’s father is a retired police officer at the of 54; he is
hypertensive with maintenance medication and her mother is a 52 year old house
wife and currently healthy.
GRANDFATHER GRANDMOTHER GRANDFATHER GRANDMOTHER
(HYPERTENSIVE) (HEALTHY) (HEALTHY) (HEALTHY)
__
FATHER MOTHER
(HYPERTENSIVE) (HEALTHY)
__
PATIENT
(HEALTHY)
F. GORDON’S FUNCTIONAL HEALTH PATTERN
Table 1. GORDON’S Functional Health Pattern
ACTIVITIES OF BEFORE HOSPITALIZATION DURING
DAILY LIVING HOSPITALIZATION
NUTRITION The client verbalized “makakaon The client verbalized
ko sa ako mga ganahan labi na “daghan kong imnon na
ang gulay, usahay mu kaon og tubig”
karne unya favorite na nako ang
junkfoods, di ko hinginom og
tubig.”
ELIMINATION “nakakadalawang beses akong “isang beses akong
dumumi sa isang araw. Madalas dumumi sa isang araw,
akong umihi kapag napaparami Bawat oras ay umihi ako sa
ang inom ko, kadalasan ay walo o isang araw,’ As verbalized
di kayay sampu.” As verbalized by by the patient.
the patient.
HYGIENE “dalawang beses akong maligo sa “ngayon lang ako nakaligo
isang araw. Dalawang beses mag uli, puros pagpupunas lang
toothbrush. At lagi kong dati, dalawang beses parin
pinanatiling malinis ang katawan akong mag toothbrush.”
ko.” As verbalized by the patient.
EXERCISE “hindi ako nag eexercise pero “kadalasan nakaupo at
naglalakad naman ako paminsan nakahiga lang ako dito.” As
minsan.” As verbalized by the verbalized by the patient.
patient.
SUBSTANCE USE “wala akong bisyo kasi masama “wala akong bisyo.” As
para sa baby ko.” As verbalized by verbalized by the patient.
the patient.
SLEEP AND “mga anim na oras ang tulog ko “minsan napuputol ang
REST dati, sa hapon nagpapahinga din pagtulog ko, pero
ako ng mga isang oras.” As kadalasan ay limang oras
verbalized by the patient. akong matulog.” As
verbalized by the patient.
ACTIVITY EXERCISE PATTERN
LEVEL 0: Full self-care
LEVEL 1: Requires use of equipment or device.
LEVEL 2: Requires assistance or supervision from another person.
LEVEL 3: Requires assistance or supervision from another person or device.
LEVEL 4: Is dependent and does not participate.
Table 2. Activity
ACTIVITY CODE LEVEL
BEFORE AFTER
FEEDING 0 0
TOILETING 0 2
BED MOBILITY 0 0
DRESSING 0 2
GROOMING 0 0
GENERAL MOBILITY 0 2
COOKING 0 2
SOME MAINTENANCE 0 4
NUTRITIONAL AND METABOLIC PATTERN
The patient drinks at least 1 liter of water daily and 1-2 glasses of juice or soft
drinks occasionally. No changes in her appetite during and after her pregnancy and
patient has no allergies to food.
SEXUALITY REPRODUCTIVE PATTERN
The patient have her first pregnancy. Her menarche is at the age of 14 years old
with irregular monthly period. Every month, she experiences 1-2 days of menstruation
with maximum of 3 pads per day without any discomfort.
VALUE-BELIEF PATTERN
The patient is a firm believer with God and claimed that “everything happens for
a reason” as verbalized. She regularly attends mass every Sunday.
G. PHYSICAL ASSSESSMENT
A. GENERAL SURVEY
The patient is 32 years old, weighing 50 kg., 5’2 in height, alert, coherent, and
responsive. There was no IVF and oxygen attached. She is wearing a loose
sleeveless dress without unpleasant odor noted. Vital signs: Temperature: 36.5
degrees Celsius, Pulse rate: 96 bpm, Respiratory rate: 19 cpm, and Blood
Pressure: 100/60 mmHg.
SKIN
INSPECTION
Skin is intact with no reddened areas
Linea nigra and striae gravidarum Is present in the abdominal area
Skin color is generally fair except in the areas exposed to the Sun
No body odor noted
Has scar of 1cm, Noted on her left knee
Moisture in skin folds and the axillary area
PALPATION
When pinched, skin springs back after 1 second
No presence of nodules or masses noted
No presence of callus and cracks on the sole of the feet and palm of her
hands were observed
EYES
INSPECTION
The hair is evenly distributed
Eyebrows are symmetrically aligned
Eyelashes are curled and slightly outward
Eyelids are intact and no liquid discharges noted
Pupils are black in color, equal size round and smoot border
PALPATION
No edema, tenderness over lacrimal glands
No edema or tearing over the lacrimal sac and nasolacrimal duct
HAIR
INSPECTION
The hair is black, curly and slightly dry upon observation
No unpleasant odor and infestations of parasites or lice but there was
dandruff noted
NAILS
INSPECTION
Nail bed color is pinkish
Both fingers and toes are clean
Angle of nail plate is about 160 degress
PALPATION
Prompt return of usual color within 3 seconds
SKULL AND FACE
INSPECTION
The skull is symmetrical, round and smooth in contour
Face has symmetrical facial features and facial movements
PALPATION
There were no presence of nodules or masses and depressions
Face is smooth and uniform is consistency
No edema or tenderness over lacrimal gland
No tearing and edema between the lower lid and the nose
EARS AND HEARING
INSPECTION
Ears are equal in size
Auricles color is same as facial skin and aligns with the corner of each eye
There were no lesions or nodules noted
PALPATION
This auricles are mobile, firm and not tender
Pinna recoils after it is folded
NOSE AND SINUSES
INSPECTION
Nose is symmetric and straight
There were no presence of lesions in nose
No discharges of flaring in the nose
Color Is the same as the rest of the face
PALPATION
No masses nor tenderness on the external, frontal and maxillary areas in the
nose
MOUTH AND OROPHARYNX
INSPECTION
The lips is smooth, pink in color, moist without lesions or swelling and pale
pinkish in color
Have 31, white teeth was noted and one is missing in lower third molar
Gums are pink, firm, moist, no reaction when pulled away from the teeth and
no bleeding
Tongue is in central position, moist, thin, whitish coating present, smooth and
no lesions, moves freely without tenderness.
Salivary glands are same color with the buccal mucosa and floor of the mouth
Palates and uvula are in midline position, light pink in color
PALPATION
The lips is smooth
Tongue is smooth with no palpable nodules
NECK
INSPECTION
Neck is symmetrical with head centered
Neck moves smoothly
PALPATION
Trachea is in midline
No tenderness noted in the neck
LYMPH NODES
PALPATION
There were enlargement of lymph nodes noted
THYROID GLAND
INSPECTION
Not visible during inspection
Glands ascends during swallowing
PALPATION
Lobes is not palpable
AUSCULATATION
No bruit sound noted
CHEST
INSEPCTION
Quite rhythmic and effortless respiration of 19 cpm was noted
Skin is intact and uniform
PALPATION
Full and symmetric chest excursion and thumbs normally separate 3 cm
No tenderness, no masses when palpated
AUSCULATION
Broncho-vesicular sounds in between the scapulae and lateral to the sternum
at the first and second intercostal spaces while vesicular sound
POSTERIOR THORAX
INSPECTION
The chest is symmetric
Skin and chest wall is intact
Breathe is rhythmic and effortless
PALPATION
Uniform temperature, no tenderness and masses noted on the posterior
chest wall
Vocal fremitus: vibrations felt through the chest wall when the client speaks
AUSCULATION
Broncho-vascular that is in between the scapulae and lateral to the sternum
at the first and second intercostal spaces and vesicular that is over peripheral
lung breath sounds
HEART AND CENTRAL VESSEL
INSPECTION
No pulsations
AUSCULTATION
Symmetric pulse volumes
Heart rhythm is regular
BREAST AND AXILLARY
INSPECTION
Breast is round in shape and slightly symmetric in size
Skin color is uniform as of the abdomen
Striae noted in the abdomen
Areola is enlarged, darker color than the rest of the breast
No discharges noted when nipple is pinch
PALPATION
No tenderness, masses or nodules noted when axillae was palpated
No tenderness, masses or nodules noted in areola and nipples upon
palpation
ABDOMEN
INSPECTION
Skin color is uniform as the breasts
Linea nigra and gravidarum striae was noted in the abdomen
Dry dressing of 6-8 cm was in the hypogastric area noted
GENITALS, ANUS AND RECTUM
Unable to assess the genital parts, anus, and rectum
MUSCULOSKELETAL SYSTEM
INSPECTION
No contractures and tremors in the feet noted
There has no deformities noted
Smooth coordinated movements but little flaccid in the feet noted
PALPATION
Joints: no tenderness or nodules presence
Table 3. Musculoskeletal Assessment
GAIT ASSESSMENT
WALKING GAIT One leg is dragged
ROMBERG TEST Negative Romberg test:
may sway slightly but was
able to maintain upright
posture and foot instance
HEEL-TOE WALKING No assessment
TOE OR HEEL WALKING No assessment
NEUROLOGICAL SYSTEMS
MENTAL STATUS
Upon interview the patient is alert, coherent, responsive, and completely
oriented to time, place, day and month.
CRANIAL NERVES
Table 4. Cranial Nerves
CRANIA NAME TYPE FINDINGS
L
NERVES
I OLFACTORY SENSORY Patient is able to identify
smell of ethyl alcohol and
Johnson’s baby cologne.
II OPTIC SENSORY Patient is able to read the
letters without assistive
devices like eyeglass or
contact lenses.
III OCULOMOTOR MOTOR Patient can follow the
movement of the pen with
no problem with the six
ocular movements.
IV TROCHLEAR MOTOR Patient’s eyes move
smoothly, coordinated
motion in all directions.
V TRIGEMINAL SENSORY Patient have no problem
with the sensation between
sharp and dull using hairpin
and can identify the objects
(ballpen. Jot down
notebook) easily while eyes
closed.
VI ABDUCENS MOTOR Patient can move her
eyeballs laterally without
any problem.
VII FACIAL MOTOR Patient can smile, puff out
AND cheeks, raise eyebrows,
SENSORY frown and able to identify
various taste such as sour,
bitter and sweet.
Movements are symmetric
VIII ACCOUSTIC SENSORY No problem with sense of
hearing and can able to
hear sounds loud and clear.
IX GLOSSOPHARYNG MOTOR Gag reflex of the patient is
EAL AND intact.
SENSORY
X VAGUS MOTOR Patient swallows without
AND difficulty.
SENSORY
XI SPINAL MOTOR Patient has strong
ACCESSORY contraction of the trapezius
and sternocleimastoid
muscle on side opposite the
turnes face.
XII HYPOGLOSSAL MOTOR Patient tongue movement is
symmetric and smooth and
bilateral strength is
apparent.
IV. CLINICAL MANAGEMENT
A. MEDICAL MANAGEMENT
LABORATORY AND DIAGNOSTIC EXAMINATION
HEMATOLOGY
DATE TAKEN: September 10, 2014
Table 6. Complete Blood Count
PARAMETER NORMAL PATIENT’S INTERPRETATION SIGNIFICANCE
VALUES VALUE
COMPLETE BLOOD COUNT
WBC COUNT 4-10/L 14.11/L Increased It increases
during infection,
inflammation.
HEMOGLOBIN 140-180g/L 113 g/L Decreased It decreases
during bleeding
or anemia.
HEMATOCRIT 37-47% 32% Decreased Percentage of a
blood that
consists of
RBCs.
DIFFERENTIAL COUNT
LYMPHOCYTE 20-40% 15% Decreased It decreases
when there were
low foreign
tissue.
NEUTROPHIL 50-60% 80% Increased It increases
during infection.
MONOCYTE 2-8% 03% Normal Normal
EOSINOPHIL 0-4% 02% Normal Normal
ULTRASOUND OF THE PELVIC
DATE TAKEN: September 8, 2014
Obstetrical ultrasound using 3.5 mhz transducer pelvic sonogram shows enlarged uterus with a
single, live intrauterine, pregnancy in breech presentation, longitudinal lie. Evaluation of the
fetus shows no gross abnormalities of the visualized head, thorax, and abdomen.
BPD - 35 MM (16 WKS 6 DAYS)
FL - 28MM (18 WKS 5 DAYS)
HC - 138MM (17WKS 1 DAY)
AC - 88MM (15 WKS 0 DAY)
Normal fetal movement, regular cardiac pulsations was observed FHB = 148 BPM
The placenta is implanted posteriorly Grade 1 maturity, and completely covering the Internal OS
Amniotic Fluid is decreased, 2.3 cm in Single Vertical Packet.
IMPRESSION:
-Singe live intra-uterine pregnancy
-In breech presentation with composite gestational age of 17 WKS
-EDC 2/16/2015
-Oligohydramnios
-EFW 173 grams
-Guarded fetal well being
-Placenta previatotalis
-Grade 1 maturity
