UNIVERSIDAD DE MANILA

Republic of the Philippines

City of Manila

COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF NURSING
NCM 101 - HEALTH ASSESSMENT – RLE
Name:_________________________________________ Year/Section:_______________
Instructor:______________________________________ Group: ________

THE NURSING HEALTH HISTORY

QUESTIONS DATA /FINDINGS NARRATIVE DOCUMENTATION

I. BIOGRAPHICAL DATA
Name: Florence Nightingale This is a case of Florence Nightingale, 35 years old,
Age: 35 female and a Filipino. She is a nurse, working in Ospital
Female ng Maynila Medical Center. She hailed from Bicol
Gender:
Region but currently residing in Ermita Manila. She is a
Birthday: May 12, 1985 Roman Catholic and married to her husband whom she
Nationality: Filipino considered her support person.

Ethnicity: Bicolano
Address: One Mehan Gardens Ermita Manila

Religion: Roman Catholic

Marital Status: Married
Occupation: Nurse
Place of Occupation: Ospital ng Maynila

Educational Attainment: College Graduate

Caregiver/Support Person/SO Husband

II. CHIEF COMPLAINTS

• “What is the reason for
seeking consultation?”
III. HISTORY OF PRESENT ILLNESS
a. Usual health pattern
b. Investigation of symptoms
(chronological story)
• Onset
• Course since onset
• Location
• Quality
"i had body malaise and developed
persistent fever for three days,
accompanied by cough, sore throat,
and and chills"
usually of good health
3 days PTC, suddenly developed
fever
persistent, not relieved by OTC
fever medication
____ use directional terms and
anatomical landmarks if
applicable
high grade fever, dry cough, recurring
chills
The client complained of persistent fever for three days
that is preceded by body malaise and accompanied by cough,
sore throat and chills.
The client was apparently well and usually of good health
until three days prior to consultation, she started feeling
body malaise and suddenly developed fever. She also
had sore throat, with persistent dry cough and episodes of
chills. Her body temperature ranges from 39*c up to 40*C
since onset. She felt anxious and would experience shortness
of breath when moving around. Some of her family members
also experience the same but milder symptoms like hers. She
was unable to report for work and stayed in bed most of the
time.

• Quantity 39*C- 40*C

• Setting ____ determine place or setting

symptoms occur if applicable

• Associated phenomena feeling of anxiousness

• Alleviating or aggravating developes shortness of breath when

factors ambulating

c. Relevant family information some family members with same

symptoms but mild

d. Disability assessment unable to report for duty for 3 days,

confined in bed

IV. PAST HEALTH HISTORY

a. Past general health The client claimed she was generally healthy with only
generally healthy with occasional bouts
occasional bouts of flu like symptoms. During her
of mild flu like symptoms
childhood, she was afflicted with Measles, Chicken Pox and
b. Childhood illnesses Measles, Chicken Pox, Acute Gastroenteritis diarrhea. She had also bouts of seasonal mild influenza.
She had no history of major accidents nor experienced
disabling injuries She was not hospitalized for medical
c. Acute/Chronic Illnesses Mild Influenza reasons and never had any kind of surgery. She is fully
vaccinated for COVID19, had syearly shot of Flu vaccine
and was also given PCV

Public service through quality education.

Justice Cecilia Muñoz – Palma corner Mayor Antonio J. Villegas Street Mehan Gardens, Ermita, Manila, Philippines 1000
Tel. Nos. (+632)5336-6582/(+632)5336-8956/(+632)5336-8966 Fax No.(+632)336-6554 www.udm.edu.ph
 UNIVERSIDAD DE MANILA
Republic of the Philippines
City of Manila

d. Accidents and disabling none fall, fracture, amputation She only had one pregnancy and delivered to a live baby
injuries burn etc.. boy via NSD in 2015. Her last menstrual period was on____.
e. Hospitalization/ Surgery 2019 -hospitalized for 2
none
weeks due to HPN, OMMC
2020 - Appendectomy
OMMC
f. Immunization IPV 2015
Flu Yealy
Covid - Booster 2021
g. Medication and transfusions none OTC medications
Prescription medicines
Specify
h. Allergies none food allergies, drug allergies, etc.

i. OB History Menarche, LMP, GPTPALM

Mode of Delilvery (NSD, CS, Forceps) include year
AOG if currently pregnant
V. FAMILY HEALTH HISTORY
blood relatives - father was deceased due to HPN Genogram
- mother with diabetes
x
HPN DM 2

spouse - COPD
COPD

children -ADHD ADHD

VI. OCCUPATIONAL AND ENVIRONMENTAL HISTORY

hospital nurse, The client is a nurse employed in OMMC and recently
frequently on night shifts assigned in the COVID Ward. Most of the time she reports
exposed to COVID patients for hospital duty on night shifts.

VII. PSYCHOSOCIAL HISTORY

a. Smoking non-smoker in pack years The client is a non smoker, non drinker of alcoholic
(PY = Packs * Years) bevarages though she would drink a bit when there are
2 bottles a day, occasions. She does not use illicit drugs. She usually ate
b. Alcohol Intake non alcoho drinker social drinker her meal in the hospital cafeteria, but skipped meals
c. Use of illicit drugs no cocaine user when schedules were hectic. She does not play sports
with no special hobbies.
d. Food Habits preferences, patterns, fads
Ms. Nightingale was cooperative during the interview.
e. Recreational Activities sports, hobbies, She answered questions with coherence and expressed
f. Social group affiliation orgs, rotaries, herself well verbally.

g. Cognitive abilities IQ, abstract reasoning etc.

Grading Criteria
Criteria Excellent Very Satisfactory Satisfactory Poor
16-20 11-15 6-10 1-5
Accuracy of Data
Completeness of Data
Organization and
Coherence
Grammar and
Mechanics
Clarity and Neatness
Subtotal

Total Score: ___________________

Conformed: Evaluated by:

___________________________________ ____________ _________________________________

Student Date: Instructor
Public service through quality education.
Justice Cecilia Muñoz – Palma corner Mayor Antonio J. Villegas Street Mehan Gardens, Ermita, Manila, Philippines 1000
Tel. Nos. (+632)5336-6582/(+632)5336-8956/(+632)5336-8966 Fax No.(+632)336-6554 www.udm.edu.ph