III.

Nursing History
A. Demographic Data
Name: Mrs. G
Age: 36
Address: Purok 2, Abra, Santiago City, Isabela
Sex: Female
Nationality: Filipino
Religion: Roman Catholic
Occupation: Teacher
Birthdate: September 13, 1985
Civil Status: Married
Height: 5 feet 4 inches
Weight: 76 kg
Date of Admission: June 5, 2021
Time of Admission: 9 AM
Chief of Complain: Right Upper Quadrant Pain
Admitting Diagnosis: Severe Preeclampsia with sign and symptoms of HELLP syndrome
Admitting Physician:
Initial Vital Signs:
T: 37.1 C
RR: 23 cycles/min
PR: 85 bpm
BP: 170/110 mmHg
O2Sat: 92%
FHT: 153 bpm RLQ
FH: 34 cm

B. Past Health History

The patient had stated that she haven’t undergone any medical or surgical operations. a
C. History of Present illness
12 hours prior to admission the patient had experienced Right upper quadrant pain on her
abdomen with a scale of 8. She was consulted at Santiago Isabela Medical Center with elevated
blood pressure ranging from 160/110 mmhg to 170/110 mmhg with decreased O2 Saturation.
D. Familial History
The patient stated that they don’t have any familial history of hereditary illnesses such as
hypertension or diabetes mellitus for instance, but the patient has familial history of anemia on
her mother side.
E. Obstetrical score
Mrs. G had her menarche when she was 11 years old. She had regular menstruation with 7 days
duration consuming 2 pads per day. She did not use any contraceptive methods. Her last
menstrual period was on October 10, 2020 and this is her 1 st pregnancy. With the age of gestation
of 34 weeks and her expected date of delivery will be on July 17, 2021. Her obstetrical scoring
is: G-1, P-0, T-0, P-0, A-0, L-0).
IV. Physical Assessment
General Survey
B. Cephalocaudal Assessment
AREAS METHODS FINDINGS INTERPRETATION
Head Hair Inspection  + Dandruff  Due to poor
Scalp Palpation  Greasy hair hygiene
Face  + edema on the face  Normal due to
increased sebum
production in the
hair follicles.
 Due to severe
anemia
Eyes & Inspection  Eyes are  Normal
Vision symmetrical  Normal
 Pupils Equal,
Round, Reactive to
Light and
Accommodation.
(PERRLA)
Ears & Inspection  Clean ears  Normal
Hearing  Symmetrical ears  Normal
 Can distinguish and  Normal
locate sounds  Normal
 No lesions
Nose Inspection  No swelling of the  Normal
Palpation mucus membrane  Normal
 No palpable masses
Mouth & Inspection  Lips are pale dry  Inadequate fluid
esopharynx  Presence of carries intake
 Due to poor dental
hygiene
Neck Muscles Inspection  No lesions  Normal
 Patient is able to  Normal
freely move her neck
Lymph Palpation  Non-palpable  Normal
nodes
Thyroid Inspection  Not Visible  Normal
 gland Palpation  Palpable  Normal
Upper Skin Inspection  Brown skin  Normal
extremities Nails  Nails are short and  Normal
clean  Normal
 Good capillary Refill
(>2 seconds)
Muscle Inspection  Able to grip  Normal
strength and Palpation
tone
Joint Range Inspection  Can move arms  Normal
of Motion through active ROM  Normal
(ROM)  Able to extend arms
in front but slowly
Brachial and Palpation  Palpable brachial and  Normal
Radial pulse radial pulse
Sensation Palpation  Able to distinguished  Normal
touch, pain, hot and
cold
Chest & Skin Inspection  (-) lesions  Normal
back Palpation  No report of pain  Normal
during inhalation and
exhalation
Thorax Inspection  Symmetrical in shape  Normal
shape and
size
Lungs Auscultation  Absence of  Normal
Percussion adventitious breath  Normal
sounds
 Resonant
Heart Auscultation  Has an audible heart  Normal
sound
Spinal Inspection  (-) deformities
column Palpation
Breast and Inspection  Dark under arms  Normal
Axillae Palpation  (-) lesions  Normal
 Symmetrical in shape  Normal
 Breast was firm  Normal
 No bumps  Normal
Abdomen Skin Inspection  (+) striae gravidarum  Normal
 (+) linea nigra  Normal
 34 cm fundic height  Normal
Abdominal Auscultation  (+) borborygmi  Normal
sound Palpation sound  Normal
 FHT:153bpm(RLQ  Normal
 )  Normal
 Fetal back (Right)
 Fetal extremities
(Left)
Femoral Palpation  Palpable  Normal
pulse
External Vagina Inspection  No lesion  Normal
Genitalia  Presence of pubic
hair
Anus Inspection  No lesion
Lower Skin and toe Inspection  Nails are short and  Normal
Extremeties nails Palpation clean  Due to edema
 Swollen feet  Due to decrease
 Poor capillary refill peripheral tissue
(>3seconds) perfusion
Gait & Inspection  Unable to sit and  Weakness due to
balance stand on her own decrease arterial
blood flow
Joint ROM Inspection  Unable to move her  Weakness due to
Percussion legs without assistance decrease arterial
 +2 blood flow
 Normal
Popliteal, Palpation  Palpable  Normal
Posterior
tibia,
Dorsalis
pedis pulses