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Drugs Stuy(2)

Drugs Stuy(2)

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Published by jhilltot

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Published by: jhilltot on Feb 12, 2010
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01/18/2013

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 Bulacan State University
College of Nursing
Malolos City, Bulacan
Written Output
Submitted by:Fajardo, Alexes Ann A.BSN-2DSubmitted to:Mrs. Daisy Reyes, RN.
 
NURSING HEALTH HISTORY
A. Personal historyDemographic Data Name: CPLAge: 29Civil Status: MarriedPosition in the family: Third among four childrenAddress: Bahay Pari Candaba PampangaDate of birth: December 20, 1980Place of birth: Candaba Pampanga Nationality: FilipinoReligion: Roman CatholicEducational Attainment: Computer Science (second level) Baliuag UniversityDate of admission: January 14, 2010Date of discharge: January 16, 2010Initial Diagnosis: G
3
P
2
(2002)Age of Gestation: 38 weeksFinal diagnosis: G
3
P
3
(3003), NSD + RMLE with repair B. Reasons for Visit or Chief Complaint³Manganganak na yata ako, napakasakit ng tiyan ko.´ ± as verbalized by the client.C. History of Present IllnessOur clients first menstrual period is on her third year highschool but cannot remember the month. Her periods started irregularly, then eventually becameregeular at seventeen. She had her first baby boy when she was 23 yrs old then after 7 years they had another boy.Her last menstrual period is on second week of March 2009. Without any occurrence of signs and symptoms our client knew that she is pregnant already andit was confirmed by the community doctor. Having a history of hypertension, she continue to take medications with the doctors prescriptions.On the night of January 14, 2010 at 8pm, our client felt that her contractions are getting more frequent and intense. So she went to the hospital anticipatingher third birth with her close neighbor. She gave birth to an alive baby girl 5lbs in weight and 48cm in length by 3am.
 
 D. History of Past IllnessesShe remembers having vaccines as a kid but she doesn't know what it is. She received tetanus toxoid in her pregnancy but can¶t remember how many timesshe have received the vaccine. She also had chicken pox and mumps when still a kid. She frequently has colds and cough. She also have hypertension and iscurrently taking medications to lower blood pressure.Obstetric History: Name: CPLAge: 29 years oldMenarche: 3
nd
yr high schoolTPAL: G
3
P
3
(3003)Last Menstrual Period: 2
nd
week of March 2009Age of Gestation: 38 weeks

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