PRESENT HEALTH

HISTORY
GROUP1

Agacid, Adrian Dominique Buenavista, Julimaricon

Agcaoili, Ma. Allysa
Cabuyadao, Graziella Beatriz
Anacleto, Aira Faith
Cadiz, Ira Klein
Almazan, Justine Ira
Dagdagan Joyce Anne Suerte
Baltazar, Janna Lizette
Daquep, Francess Joryne
Brigado, Nerie Anne

BSN 1-B

Submitted to:
Mrs. Mary Ann G. Magtoto
Clinical Instructor
Mr. Ira Cadiz, 19 years old, resident of Bacarra, Ilocos Norte visited MMMH-MC Saturday
morning with a chief complaint of difficulty of breathing along with chest pain. Dr. Pablo, the
attending physician, did emergency interventions to him and allowed him to rest afterwards.
Hours later, Dr. Pablo asked Ms. _________, a student nurse to gather more informations
about the patient’s chief complaint.
NURSE PATIENT RATIONALE/ANALYSIS
*Knock the door* Come in.

*Smile* Hello Mr. Ira Cadiz, good Yes hello. Technique: Giving
morning recognition
How are you? I’m fine now, thank
you. Greeting patients at the first
meeting by their name
indicate acknowledgement to
the client. This creates a good
impression to client and a
start of developing rapport.

I am______________, your student Sure. Technique: Giving

nurse for today. I’ve been sent by information
Dr. Pablo to have an interview with
you regarding your chief complaint. Giving information or
I’ll be asking you questions that explaining to the client your
will help on addressing your purpose or what has to be
current concern sir. And then I’ll done helps the client in
relay those informations back to preparing themselves.
Dr. and then she’ll come back to
you after that. Is that okay with
you?

Okay thank you. Uhm, so how Just Sir is fine. (Asking this questions to the
would you like me to address you? client contribute in enhancing
rapport; to gather accurate
Alright Sir, thank you. Sure information from a ready
Hm, is it okay with you to do the client.)
talk at this time?

Okay thank you Sir. So, we’re Uhm sure. Actually it’s Technique: Providing general
going to start out by talking a little been days when this leads
bit about your chief complaint that pain in my chest have
brings you here today. Can you tell been bothering me. It Providing general leads
me how it is? happens almost every encourage the client to
day at night and this verbalize or elicit more
makes me hard to informations about his/her
breathe, especially chief complaint.
when I lie down. *a
little bit of silence and
taking away eye
contact* Uhm really,
 that’s primarily the
reason why I came in.
Hm, okay so before we talk a little None
more about that Sir, is there
anything else that you’d like to talk
with either me or Dr. Pablo today?
Alright. Tell me more about this The pain feels like my
pain Sir, I’d like to hear more about chest is about to tear
it. apart, that’s especially
when I lie down
straight; I would feel
like I can’t breathe.
*nodding* And it bothers me so
much that I can’t sleep.
I noticed that you’re guarding the Yes, I’m okay right
center of your chest whenever you now. This is just where
tell me about the pain. Are you I always feel the pain,
okay Sir? on the center of my
chest.
Hm, okay. Can you recall when did I think it was Friday
this pain started Sir? Has it night when this started,
happened before? and still part of what I
have felt the night.
At Friday night, I was
How was it? reading my lessons for Technique: Exploring
exams the next
morning, with a prone
Technique: Broad openings
Asking this question to client
provides encouragement for
the client not to hesitate on
talking more. Broad openings
may make him/her take the
initiative.
Technique: Using open-ended
statement
Open-ended statements or
questions encourage the client
to explore moreabout his/her
concern.
Nodding is an ‘Accepting’
technique. It simply indicates
that the nurse or even the
client is listening and is
following what one is saying
.
Technique: Making
observations
Making observations on the
client’s non-verbal gestures
may show informations that
the client is not saying

Uhm, let me just clear, do you No, the other week.
mean Friday yesterday?
Okay. So it first happened Friday *nods*
last week at night. *Paused*
Was that after dinner?
Can I ask, what are your thoughts
regards to your distress? What do
you think of suddenly experiencing
this?
Exploring more about the
position. Then I client’s concern provides in-
suddenly felt like I depth understanding.
couldn’t breathe, so I
sat. But then, I feel like
I am going to pass out,
but thankfully I didn’t.
.Technique: Seeking
clarification
Seeking clarification is
making accuracy. Confessing
confusion makes the client or
even the nurse clarify the
information and that will
provide accurate data.
Technique: Restating
Restating the given
information makes the client
know that the idea is now
clear and understood.
Uhm yes, and also, after Technique: Clarifying time or
drinking a coffee. sequence
To be able to gain
perhapssome related or
unrelated data in the sequence
of event; to determine any
inconsistency
Uhm, I’ve been Technique: Encouraging
thinking that this might expression
be because of stress. I
think it’s because I am Encourages the client to make
anxious about I would his own judgement regarding
end up in my chosen his own concern, rather that
course. I think I would accepting the appraisal of
be having difficulties to other
catch up. And then, I’ve
been always wanted to
 go home. You see, I’m
a student and I need to
stay at a dormitory. I
am not used to live
without my family
around. It seems like I
can’t focused when I’m
with other people. And
also,I always wonder
how they are doing, if
they are all fine.

Sounds like you are worried about *nods and bows down* Technique: Focusing
how your family is doing and about I do not know how will
your study. I get through this. This helps the client expands
on and develop a topic of
What can I do? importance.

Uhm, what do you think would be Technique: Reflecting

helpful?
This helps the client to
explore their own ideas and
feelings about the situation

*holds and patted the hand of the Thank you Technique: Use of touch
client; eye contact*
Think that you are studying for To give the client comfort
your family that you love. and to show care and
sincerity.

Uhm, do you still want me to No no, I’m fine. Just Technique: Encouraging
continue? Tell me if you feel like continue. description of perceptions
you want to stop here, we can
continue it again later. To understand the client, the
nurse must see things from
his or her perspective.
Encouraging the clients
perceptions

Uhm. Going back to the pain It’s been 7 days Technique: Being specific
you’re feeling, how long have you already. and tentative
been experiencing difficulty of
breathing and chest pains? Providing question that has
 only limited choices of
answers to keep the
conversation at pace with the
topic.

Does the pain only attacks at night? Technique: Being specific

Or in any particular time of the It attacks often at night. and tentative
day?
Providing question that has
only limited choices of
answers to keep the
conversation at pace with the
topic.

Can you describe the pain? Was it Most of the time I feel Technique: Encouraging
something like your chest is being like it is being gripped. comparisons
stabbed? Gripped? Or has burning It makes me so
sensations? uncomfortable and Comparing ideas, feelings
making me hard to and experiences with the
breathe. client can bring out many
recurring themes.

How painful is it? Can you rate it Technique: Being specific

from 1-10? Wherein 1 is with least *Silence for a bit*
pain and 10 has greatest pain?
I think it would be 7 to
8, maam.
“How long does the pain last?”
“I think it would be 30
seconds or so. But last
night, the pain lasted
for about a few minutes
so i decided to have my
check-up today.”
and tentative
To validate what is heard or
observed
Technique: Using open-ended
questions
To specify only the topic to
be discussed and to invite
more answers related to the
topic

Does it recur? Technique: Being specific

Yes. Every day for two and tentative
weeks now.
Provides the client a question
with limited choices of
possible responses.

Okay. Does the pain occur Well, I have pain on the Technique: Exploring
anywhere else? middle of my chest, but
sometimes it radiates on Exploring helps to examine
 the issue further.
the right side of my
chest.

What are the managements done to Technique: Using open-ended

make you feel better? Well for me, I would questions
use piles of pillows to
rest my back. Or i Helps to specify only the
would sit in a straight topic to be discussed and
position. invite lengthy answers related
to the question to explore
further.
What makes it worse? Technique: Using open-ended
When I overwork questions
myself. I noticed that i
easily get tired just by Helps to specify only the
climbing up the stairs; topic to be discussed and
By walking from the invite lengthy answers related
gate to the department to the question to explore
building; by running further
from the gate to 7/11.
*paused*
*Silence*
“Well, I also noticed Technique: Using silence
*Makes eye contact with the client* that my sleeping
position makes it worst. It encourages the client to
Before, I won’t need a verbalize, provided that it is
lot of pillows. But right interested and expectant.
now, lying in a straight
position makes me
catch my breath. I can’t
sleep because I cannot
breathe properly. So i
would use a pile of
pillows or would lie in
a right facing direction
or left facing direction.
*Nodding* Technique: Accepting

It indicates that the nurse has

heard and followed the
client’s thoughts.
Technique: Exploring
Have you got any other symptoms? I didn’t check my body
Fever? Cough? Body pains? temperature yet. And I Exploring can help the nurse
have been coughing for examine the issue more fully.
 days now.

*checks the body temperature* Technique: Giving

information
Its. 37.3⁰C, sir. You have a light
fever. Informing the client with
facts increases his or her
knowledge about a topic or
lets the client know what to
expect.

Can you tell me more about what Well, at first, I woke up Technique: Exploring
have you been feeling for the last feeling tired and with
days? heavy-head. And Exploring can help the nurse
then…*paused* examine the issue more fully.

Go on, sir. I had been sleeping for Technique: Providing general

only 2-3 hours since we leads
had a very hectic
schedule. I have to It indicates that the nurse is
study at night and wake actively listening and
up early to prepare for following what the client is
my class. I have been saying.
having that routine
since the class started
but last Monday, I
woke up feeling unwell.
I knew I would be sick
that time but I ignored
it since I was so busy.

And then? And then my throat Technique: Providing general

starts to itch and leads
become painful. I It indicates that the nurse is
started having a dry actively listening and
cough for days and sore following what the client is
throat which lasted for saying.
2 or 3 days I think.
Okay. It was last Monday when
you started to feel unwell but you
ignored it. Does it mean that you
didn’t do any management that
could alleviate the symptoms?
Well, yes. I did not take Technique: Restating
any medications yet but
I did some water It encourages the client to
therapy. I only drink clarify his thoughts if he has
water to reduce the been misunderstood.
itchy feeling in my
throat.

You also mentioned that you had It was Monday. It was 7 Technique: Being specific
been having dry cough for days, days ago. and tentative
when did it start to appear?
Provides the client a
question with limited choices
of possible responses.

Okay. You also had sore throat for Yes Technique: Being specific
three days? and tentative

Provides the client a question

with limited choices of
possible responses.

Is there anything more I should No more, I think I have

know about sir? already mention all.

Okay then we’re done Sir. So, Yes, I also thank you. Technique: Summarizing and
during the past hour, we have Planning
talked about your chief complaint
and distresses. And like what I said
earlier, this data will be reviewed
by Dr. Pablo, and he’ll be back
after. Now, you can rest Sir while
waiting for her. Thank you so much
for your cooperation. *smiles*