Aila O.

Fernandez Health Assessment

BSN1A

COMPONENTS OF A NURSING HEALTH HISTORY

BIOGRAPHIC DATA:
Client’s Name: Maria S. Robles
Address: 255 San Martin Eastern Cavinitan, Virac, Catanduanes
Birthdate: October 16, 1966 Age: 53
Sex: Female Marital Status: Widow
Occupation: Sari-Sari Store Religion: Roman Catholic

REASONS FOR SEEKING HEALTH CARE:

 “I am suffering an achy pain in my lower back. My back is in pain when I move in
a certain position. For example, when I bend my body in front because I am trying
to get a thing that falls.”
 “I can’t sleep properly because of the pain I am suffering so I really feel that I’m not
comfortable.”
 “Sometimes my knees and my other joints are in pain too.”

HISTORY OF PRESENT HEALTH CONCERN:

 The client reports that she has pain in her lower back and it begins 1-2 weeks ago
and tells that she can’t sleep properly because of the back pain in her lower back.
She described the pain as an achy pain in her lower back and she tells that it
radiates in her hips and her knees. Mrs. Robles said that the pain in her lower back
lasts for 30 minutes and sometimes an hours and she said that the pain is
recurring. She also said that the pain is in high when she gets tired all day in her
store especially when she reaches a thing in a high place and when she bends.
The client rates the pain in 6 within the range of 0-10. The pain becomes less when
she takes a medicine, from the scale of 6 in pain it takes 3-4 scale in pain. The
medicine that she takes alleviates the pain that she suffers and also taking rest
alleviates the pain, but the pain that she feels doesn’t goes away. Mrs. Robles said
that sometimes when her lower back aches she feels an aches in her head and
her neck too.
PAST HEALTH HISTORY
 Mrs. Robles said that she is anemic and diabetic, she had undergo operations in
the gallbladder and operations in the eye, cataract. She has varicose veins in her
legs. The client said that she has an allergy in seafood.

FAMILY HEALTH HISTORY:

 Mrs. Robles said that her mother died in cancer in the mouth at the age of 64 and
has a rheumatoid arthritis and her father also died in cancer in the lungs at the age
of 66. Her sister has osteoporosis. Her aunt has gout, and her uncle has an
arthritis. She doesn’t denies that she had a family history of arthritis, osteoporosis
and cancer.

LIFESTYLE AND HEALTH PRACTICES:

 Mrs. Robles denies use of tobacco or alcohol. She takes milk every morning for
her bones. She usually feels tired in the evening because of everyday living,
managing her store alone because her husband already gone and her children
aren’t there. She eats her meals three times a day and it is regular. Activities in
everyday living includes: awakens 5:30 in the morning for preparing foods to be
cook and to be sold for meals and also for preparing the store. She avoid food that
can cause allergies to her and also foods that are restricted for her by the doctor.
She admits that it is difficult for her to walk in a long distance because her legs will
suffer pain in walking long distance.
She purchases and prepares her meal for everyday, her way of exercise is
by walking back and forth, sometimes she can’t sleep properly because of the pain
in her lower back. She watch television as her way of fun and relaxation. She
sustain her needs and wants through managing her sari-sari store.

NURSING DIAGNOSES:
ALTERED COMFORT RELATED TO LOWER BACK PAIN