Nursing Health History

Name: SEFATAKRAW
Age: 65 years old
Sex: Female
Birthday: August 22,1950
Birthplace: Palapag Northern Samar
Address: Brgy. SangayPalapag Northern Samar
Religion: Roman Catholic
Admitting date/ time:March 31, 2016 at 4:15 pm
Discharge: April 5, 2016 at 8:30 am
Admitting Physician: Dr. Gatchalian, Dr. Balano, Dr. Tecson
Health care financing: PhilHealth
Source of Medical Care: Eastern Visayas Regional Medical
Center

Chief Complaint: Left eye pain with cloudy vision,

Headache

HeadAche
C: It sakit hit ulokobagahiyahin gin mamalmaltakulo as
verbalized by patient
O: 1 week prior to admission- intermittent.
L: Non-applicable
D: Danaynabugosnaadlawhiya, danaygeapwaraysakit as
verbalized by the patient.
S: In a scale of 1 to 10 (10 as the highest) patient rated her
headache as 7.
P: Intermittent
A: Nausea

Left eye pain with cloudy vision

C: Takpangitaankaybagatpermi may askotasdanymasakithiya
as verbalized by the patient
O: 1 month prior to admission
L: Eyes
D: Danay gin kakturugankonalahiyakay dire
gudaknakakitamasaparaba as verbalized by the patient
S: Non-applicable
P: Non-applicable
A: Pain

Admitting Diagnosis:
Acute Angle Closure Glaucoma, OS

Final Diagnosis:
Acute Angle Closure Glaucoma, OS

History of Present Medical Condition

February 2016 patient was admitted at EVRMC seen by Dr.
Gatchalian and diagnosed the patient to have Chronic Angle
Closure Glaucoma.
1 month prior to admission, patient complained to have decrease
vision on left eye with headache. There was no consult done and
no medications taken.
Hours prior to admission persistence of above condition
prompted consult, hence admission.

Obstetric History
Menstrual History:
M- 16 years old
I- Irregular
D- 5 days
A- 5 pasador / day
S (+) dysmenorrhea

Patient is a G6P6 mother. She had her first conception on

September 5, 1982 at their house by a midwife via normal
spontaneous vaginal delivery, cephalic presentation. `

Past Medical History

Patient was admitted on February 2016 at EVRMC with a
diagnosis of Chronic Angle Closure Glaucoma
No known allergy to food and drugs
Hypertensive for 15 years (50 years old) .
Non asthmatic
Non-diabetic.

History of Past Illness

Childhood Illness
Patient had mumps when she was 10 years old.
Patient had Measles when she was 15 years old.

Childhood Immunizations
Patient could not recall vaccinations given to her.

Accidents
Nahulogitonhiya ha double deck 1 year
ago.Kumadtokamihadto ha Catarman Provincial Hospital kay gin
tahiitoniyaulo. As verbalized by the watcher
Waray man akohadto nag sinuka, nag sinakit la an akon ulo as
verbalized by the patient.

Family Health History

Maternal Side:
Deceased on November 7 caused by hypertension
Glaucoma

Paternal Side:
Deceased on 1980 caused by hypertension.
Naghihinagongnadaw la adtotasnamataynaladawhiya as
verbalized by the patient.

Lifestyle
Diet:
Eat 3 times a day sometimes with snacks in between, would
consist of rice, fish and vegetables and sometimes with banana if
it is present. Would drink 2 glasses of water after eating and
would sometimes drink any carbonated beverages and coffee
every morning. She has no allergies to food or drugs. She wasnt
able to visit a dentist due to financial constraints. Her snacks are
taken that would consist of whatever food she would like to eat.
Han una pirmi gud ak nag kikinaon hin chicharon kun nakadto
kami ha pantalan as verbalized by patient.
No known allergies food and drugs.
Previous Weight: 72 kg (February 2016)
Current Weight: 64 kg (April 4 2016)
Height: 155 cm

Previous BMI: 29.02 (Overweight)

Current BMI: 25.80 (Overweight)

Elimination:
The patient noted passing out brownish-yellowish stool, 1-2
times a day. Yellow urine noted. In the 24 hour shift a total of 630
cc urine output was monitored. (April 3, 2016)
Sleep and Rest Pattern:
Sleeps at 8 PM and wakes up at 5 AM, is not easily aroused by
environmental noise before hospitalization.Usually gets 8 hours
of sleep daily. No naps in between. Doesnt use sleeping pills.
Doesnt have complaints in difficulty of sleeping.
Activities of Daily Living:
She usually stays at home and do household chores that
basically make up her day and moves constantly and walks to
from herhusband work serves as her daily exercise.

Social Data:
Family Relationship:
Waray man kami problema tam pamilya, kun nagkaka
mayda man, gin pag storyahan man ito namun. Ha
pantalan la kami natuturo-tarampo para mag risyo upod hit
akon mga anak ngan mga apo as verbalized by the
patient.

Educational History:
Her family sent the patient to elementary, high school. She
finished her 3rd year highschool at Catarman Central School.
Economic Status:
Patients family gets their financial support from the work oh her
husband as a coconut farmer.

Home and Neighborhood Condition

The neighborhood is not congested. Type of house they live in
is concrete. Most of the families in their vicinity are their friends
and some are close family members.
Coping Stress Tolerance Pattern
If she would experience any problem, the client would like to
talk to someone to lessen her depression or stress. Now, with
the help of her daughter, she can cope with them by using
nonverbal actions.

Values and Beliefs

Natuod kami hin tambalan danay nakadto kami

magpapahilot danay danay bis inin aak mata gin testingan
nam as verbalized by the patient.
Catolico man kami para simba man kami kada dominggo,
nangangadi gihapon, natuod kami hin tambalan danay
nakadto kami pag papahilot danay, as verbalized by the
patient.

Patterns of Healthcare
Patient has Philhealth as a healthcare resource. If the patient
experiences simple cough and colds, she medicates herself first
either through water therapy or medications such as paracetamol
and neozep. But if self medication does not improve her
condition, she sought consult in their near by hospital.