ADVENTIST MEDICAL CENTER COLLEGE

BRGY. SAN MIGUEL, ILIGAN CITY

SCHOOL OF NURSING

HEALTH ASSESSMENT
Related Learning Experience
Second Semester, AY 2020 – 2021

Activity #2: Biographical Data (Vital Information), Reason(s) for Seeking Health Care,
History of Present Health Concern, Personal History, & Family Health History

Name of Student: Trangia, Riann Leigh Date: March 18, 2021

Nursing Interview Guide to Collect Subjective Data

Vital Information Findings Perfect Student’s
Score Score
Code Name Matahom 1
Age 65 years old 1
Gender Female 1
Civil Status Married 1
Date of Birth August 18, 1956 1
Place of Birth Darumawang Ilaya Lala, Lanao del Norte 1
Race Filipino 1
Cultural or Ethnic 1
Cebuano
Background/Group
Primary Language (Spoken 1
Bisaya/ Cebuano
and Read)
Secondary Language 1
English
(Spoken and Read)
Religion (including 1
religious or spiritual Seventh Day Adventist
practices)
Highest Educational 1
College Graduate
Attainment (Client)
Highest Educational 1
High School Graduate
Attainment (Partner/Spouse)
Occupation (Client) Business Woman 1
Occupation 1
Business Man
(Partner/Spouse)
Usual Health Care 1
Doctor
Provider/s
Date of Admission August 14, 2020 04:35 PM 1
Date of Discharge August 16, 2020 10:20 AM 1
Source/s of History: (client, 1
SO, chart, attending
Client Interview
physician)
Reason/s for Seeking Health 1
Care: (Major health problem
or concern; feelings about
seeking health care Due to High Blood Pressure
including fears and past
experiences)
Primary Attending 1
Trino, Angelica Espiritu, MD.
Physician
Consultants/Specialists Trino, Angelica Espiritu, MD. 1
History of Present Health
Concern (COLDSPA)
Character (Describe the sign 2
or symptom. How does it A pounding feeling on the head and chest and a feeling of lightheadedness or
feel, look, smell, sound, dizziness.
etc?)
Onset (When did it begin; is 2
it better, worse, or the same Happen after eating a lot of meat because according to her that the day after
since it began?) she was admitted, she attended a birthday party of her daughter.

Location (Where is it? Does Only in the head and chest. 2

it radiate? Does it occur
1
anywhere else?)
Duration (How long does it
last? Does it recur?)
Severity (How bad is it on a
scale of 1 (barely
noticeable) to 10 (worst
pain ever experienced?)
Pattern (What makes it
better? What makes it
worse?)
Associated factors (What
other symptoms occur with
it? How does it affect you?
What do you think caused it
to start? Do you have any
other problems that seem
related to what you are
suffering now?)
Will you be able to continue
doing your work or other
activities (leisure or
exercise)?
Past Health History
Problems at birth (Can you
tell me how your mother
described your birth? Were
there any problems? As far
as you know, did you
progress normally as you
grew to adulthood? Were
there any problems that
your family told you about
or that you experienced?
Childhood illnesses (What
diseases did you have a
child, such as measles or
mumps?
Immunizations to date
(What immunizations did
you get and are you up to
date now?)
Adult illnesses (Do you
have any chronic illnesses
either physical, emotional,
mental illness? If so, when
was it diagnosed? How is it
treated? How satisfied have
you been with the
treatment? Were you
hospitalized because of this
illness? What medications
have you used in the recent
past and currently, both
those that your doctor
prescribed and those you
can buy over the counter at
a drug or grocery store? For
what purpose did you take
the medication? How much
(dose) and how often did
you take the medication)
Were there other
examinations done? such as
2
It lasted until her breathing is stable and until she is relax.
2
The extremity of the pain according to the patient is 9. For her, high blood is
the worst pain ever she experienced.
2
According to her she will be better if she will take the medicine Losartan 100
mg. And if she will not take any medicine her condition will become worse.
3
She only has that pounding feeling on the head and chest. Other than that, she
doesn’t have other symptoms at all. According to her, high blood really
affects her, like she can’t do any type of work anymore because high blood
may attack to her anytime. If her high blood gets too high or stays high for a
long time, it can cause health problems to her.
2
For now the patient can’t do any type of work because as she mentions that
there are a lot of possibilities that her high blood may attack her. That’s why
she is very cautious and very careful with her actions.
5
As far as she can remember, her mother told her that there are no problems or
any complications during her birth. Also according to her she did progress
normally as she grew to adulthood. In terms of having problems there are a
lot she said. Specifically in health problems there is none in the past but right
now at the age of 65 years old she is experiencing high blood pressure. And
she think that the number cause is her weight.
3
Talking about Childhood illnesses with the patient, she has difficulties on
remembering the past because she is 65 years old right now. But she said that
one thing is for sure is that she experienced having a disease called measles.
3
She could not remember if she had been immunize, she is not sure if
immunization is present during her childhood days because that was very
long time ago.
10
According to the patient, right now that she is old/adult, the only illness that
can made her go to the hospital every time it attacks her, made her stop all the
things she used to do when she was young like working is High Blood. She
can’t manage her business anymore because of her high blood. The patient is
taking up medicine called losartan with a dose of 100 mg and she take 1 tablet
every day.
2
but not limited to PE,
dental, vision, hearing,
ECG, chest X-ray, Pap
smear, mammogram, etc.)

Surgeries (Did you undergo 3

any surgery? If so, what
type of surgery did you
The patient doesn’t experienced undergoing any type of surgery.
have? Were there any
complications?

Accidents/Injuries (Have 2
you ever experienced any The patient did experienced accident. A motor accident. But according to her
accidents or injuries? Please it’s nothing serious at all because she only got small wound in her feet and
describe them?) hands.

Prolonged pain or pain 2

patterns (Have you
Luckily according to the patient, she would only experience pain from the
experienced pain in any part
head and chest if her high blood will attack.
of your body?

Allergies (What allergies 2

have you had? How were
they treated?)
Physical, emotional, social,
or spiritual weaknesses
(Please describe)
Physical, emotional, social,
or spiritual strengths (Please
describe)
The patient does have allergies from eggs and chicken. According to her, the
only treatment of her allergies is to stay away from eating those type of food
because she has no medications with her allergies.
2
Have weaknesses in physical and emotional. Her physical weakness is that
right now she can’t do any type of work. Emotional weakness is when she
can’t control or manage her emotions because of problems.
2
Social strength is the people surrounding her because they never stop taking
care of her and also she said that she is very lucky to have them all in her life.

Recent travel (travel within 2

past year especially with
The patient only travels to Iligan, because she was confine in Mercy
travel to endemic and
Community Hospital located in Camague Iligan City last August 2020.
pandemic places)

Family Health History 10

(Create a Genogram in a
separate paper)
Perfect Score: 85

______________________________________
Signature Over Printed Name of RLE Instructor