Nursing Health History

1. Health Perception and Health Maintenance Pattern

The client views her health as not as good as before, because she often gets easily tired in doing her daily routine as a wife and as a mother. She takes

supplements like Vitamin C and Vitamin B, and maintenance drugs like Metoprolol, for her hypertension, and Symvastatin, for her hypercholesterolemia.

She thinks that maintaining the intake of these drugs, sticking into her new diet regimen and also following the doctor’s order, she’ll get better. She assumes

that her hypertension started two months ago when she got stressed a lot lately and also when she hadn’t controlled her intake of meats especially beef.

When she felt symptoms, like headache and weakness, she would just take a rest and take her antihypertensive drug, but she said that these symptoms

usually subside for a long period of time. She still uses medicinal plants like Tea plant or “Bignay” for her Urinary Tract Infection.

2. Nutritional and Metabolic Pattern

72 Hours Diet Recall

June 29, 2010 June 30, 2010 July 1, 2010
1 cup of oatmeal and 1 cup of 1 cup of oatmeal and 1 cup of 1 cup of oatmeal and 1 cup of
Breakfast
coffee coffee coffee
1 cup of rice, 1 piece of medium- 1 cup of rice, 1 piece of medium-
1 cup of rice, 1 cup of “Bulanglang
Lunch sized fried Tilapia and 2 glasses sized fried chicken and 3 glasses of
Sitaw” and 3 glasses of water
of water water
3 pieces of Skyflakes crackers 2 pieces of puto and 1 glass of 2 pieces of Skyflakes crackers and
Afternoon Snack
and 1 glass of water water 1 glass of milk
½ cup of rice, 1 medium-sized
½ cup of rice, 3 glasses of water 1 cup of rice, 1 cup of “Mickey
Dinner grilled Bangus and 3 glasses of
and 1 cup of chopseuy Patola” and 3 glasses of water
water
 The client usually eats vegetables and fish. She takes supplements like Vitamin C and B daily. She said that before the onset of her hypertension, she

usually consumes 1.5 L of water for her UTI, but now, she had difficulty in maintaining this. Currently, she can consume at least 6 glasses of water. She

doesn’t have any eating disorder nor any discomfort when eating. Since, she had hypercholesterolemia; she was restricted to eat foods high in bad

cholesterol like fats and oils.

She said that she hadn’t gained nor loss her weight. She also said that her wounds easily heal. She doesn’t have any dental problems and doesn’t use

dentures.

3. Elimination Pattern

June 29, 2010 June 30, 2010 July 1, 2010

Bowel Movement 2 2 2
Urine 5 6 6

Client doesn’t have any discomfort in defecating. She said that her feces don’t have any unusual foul odor. She urinates usually for 5 to 6 times a

day. She doesn’t have any problem in controlling her urination. Before, when she still had UTI, she said that she had experienced pain in urinating, but now,

since her UTI has been treated already, she said that there was no pain when she urinates. She said that her urine is yellowish in color. Before, she doesn’t

perspire much, but now, she said that she experiences too much perspiration since she had her hypertension.

4. Activity Exercise Pattern

 Since she turned 41 years old, she said that she gradually felt weakness when doing her daily routine. She doesn’t do a regular exercise, but she

considers that doing her daily household chores as her form of exercise. For her spare time, she and her family visit the church or go out or just watch the

television.

_0_ - Feeding _0_ - Grooming

_0_ - Bathing _0_ - General Mobility

_0_ - Toileting _0_ - Cooking

_0_ - Bed Mobility _0_ - Home Maintenance

_0_ - Dressing _0_ - Shopping

Level 0 – Full self care

Level I – Requires use of equipment or device

Level II – Requires assistance or supervision from another person

Level III – Requires assistance or supervision from another person or device

Level IV – Is dependent and does not participate

5. Sleep – Rest Pattern

June 29, 2010 June 30, 2010 July 1, 2010

Sleep Range 10:00pm – 5:00am 10:00pm – 5:00am 11:00pm – 5:00 am
Hours of Sleep 7 hours 7 hours 6 hours

Client usually sleeps from 10 in the evening until 5 in the morning and she usually has 7 hours of sleep. She doesn’t experience any sleeping

disorders like, insomnia and doesn’t take any sleeping medications either. Her sleep is continuous but whenever she feels that she needs to urinate, she

usually wakes up. She takes nap whenever she doesn’t feel well. Her form of relaxation is internet surfing, specifically Facebook, watching television,

reading books and also gardening.

6. Cognitive – Perceptual Pattern

Before, she had experienced hearing difficulty when she had obstruction on her left ear, when she was on High School. But currently, she can hear

well. She has astigmatism and also uses glasses with grades of 50 for both eyes. She had her eyes checked up last December. Client admitted that she is

frequently forgetful and believes that it started when she had undergone Dilatation and Curettage. She frequently suffers from migraine and headaches,

which was usually relieved by pain medications like Mefenamic Acid and also by rest. She said that it is easier for her to learn something through reading.