URSING HEALTH HISTORY

Nursing health history is a tool used by nurses to gather important and relevant information that
would help in the patient’s care. It does not only record the client’s problems but describes the client as
a whole and in relation to social and physical environment and other important components that affects
client’s perceptions towards health. The gathered information obtains knowledge of client’s problems
and needs within the context of the particular client’s life that will support therapy and care.

The student had chosen a case in relation to the Care of Clients with Medical Surgical Problem
for the Individual Case Study, all of the information gathered in this report are obtained through a
thorough interview from the patient and the data gathered are limited only from the information
gathered through the said interview. To maintain confidentiality, the student used a pseudonym, Patient
B.

Patient Demographic Profile

Patient B, is a 72 year old male, living in Cabadbaran City. He was born on February 14, 1950 and
was a Christian- Seventh Day Adventist by faith. Patient’s current weight is 50 kg and is 172.5 cm tall.
Patient B, lives at Purok 1, Punt Puting, Cabadbaran City and was living with his wife. Patient works as a
driver sometimes if his son lets him use the motorized tricycle.

Patient Health History

Patient B, has no history of a family comorbidities. However, patient mentioned that he has
arthritis. According to the patient, he have undergone a surgery (year wasn’t mentioned) due to a
vehicular accident where he had an open reduction internal fixation (ORIF). He is also currently taking
his maintenance medication, such Rifampicin 150mg + Isoniazid 75mg (Anti-Tuberculosis) in which he
started taking last November 2021.

History upon Admission

About a month PTA noted difficulty urination with scanty urination which became intolerable
thus advised for consultation. Patient B was then instructed for work up CT stonogram. According to
Patient B, he had started experiencing the intolerable symptoms of ureterolithiasis three days prior to
his admission where he experienced pain that radiates to the lower abdomen and groin. Patient also
said that he experienced urinating in small amounts. He was then admitted at Manuel J. Santos Hospital
in Butuan City, last March 28, 2022 at 8:30PM.
 PHYSICAL ASSESSMENT

Physical assessment is an organized systemic process of using the techniques of inspection, palpation, percussion, and auscultation in
collecting objective data based upon a health history and head-to-toe or general systems examination. A physical assessment should be adjusted
to the patient, based on his needs. It can be a complete physical assessment, an assessment of a body system, or an assessment of a body part.
Nursing assessment do sometimes contribute to the identification of a medical diagnosis, the unique focus of a nursing assessment is on the
patient's responses to actual or potential problems.

Inspection to inspect, carefully look, listen, and smell to distinguish normal from abnormal findings. It is important to deliberately
practice the skill and learn to recognize all the possible pieces of data that can be gathered through inspection alone.

Palpation involves using the sense of touch to gather information. Through touch you make judgements about expected and unexpected
findings of the skin or underlying tissue, muscle, and bones.

Percussion involves tapping the skin with the fingertips to vibrate the underlying tissues and organs. The vibration travels through the
body tissues, and the character of the resulting sound reflects the density of the underlying tissue. The denser the tissue, the quieter is the
sound. By knowing how various densities influence sound, it is possible to locate organs or masses, map their edges, and determine their size.

Auscultation involves listening to sounds the body makes to detect variations from normal. Some sounds such as speech and coughing
can be herd without additional equipment, but stethoscope is necessary to hear internal body sounds.

Patient was assessed last April 5, 2022

Materials used:

 Tape measure
 Ruler
 Thermometer
 BP apparatus
 Wrist watch
 Penlight
 Pulse Oximeter
 LEGEND:

BLACK – NORMAL

RED - ABNORMAL

GENERAL SURVEY

ASSESSMENT OBSERVATIONS
Body build Ectomorph
Posture Erect during sitting and walking
Hygiene and grooming Untrimmed and unkempt finger nails
Attitude Cooperative
Affect/mood Patient is alert during interview session
Quality and quantity of speech Patient was able to speak and respond well to questions.
Relevance of thoughts The patient responds accordingly and responses correlate to the
questions asked.

VITAL STATISTICS

ASSESSMENT MEASUREMENTS INTERPRETATIONS

Height 172.5 cm
Weight 50 kg
BMI 16.8 Underweght

VITAL SIGNS

DATE INITIAL VITAL SIGNS LATEST VITAL SIGNS

Temperature Pulse Respiration Blood Temperature Pulse Rate Respiration Blood SpO𝟐
Rate Rate Pressure Rate Pressure
April 5, 2022 36 ℃ 83 bpm 22 bpm 120/80mmH 35.6 ℃ 82 bpm 20 bpm 120/90mmH 97%
g g
April 6, 2022 37.1 ℃ 78 bpm 22 bpm 130/80mmH 36.6 ℃ 78 bpm 22 bpm 130/80mmH 97%
 g g

BODY PART INSPECTION PALPATION PERCUSSION AUSCULTATION

SKIN Skin color is uniform Skin is dry. Skin turgor N/A N/A
thorough out the body. returns within 2 seconds
after pinching and no
edema noted.
HAIR Hair is grey, baldness Hair is dry. N/A N/A
noted. No pediculosis or
dandruff noted. Heart
shape hairline noted.
NAILS Finger nails are Nails are smooth and firm. N/A N/A
untrimmed and unkempt. During the capillary refill it
Nail plate are attach to returns within 2 seconds
the nail bed. to blanched nail beds
when pressure is
released.
SKULL Head is rounded, No nodules palpated N/A N/A
normocephalic and
symmetrical.
EYES Eyelashes are curled out No pain felt in the lacrimal N/A N/A
and symmetric. Eyebrows gland and nasolacrimal
are symmetrical in sac.
movement. Pupils are
black, equal in size and
constrict to light. Cornea
is transparent and shiny
Sclera and conjunctiva are
clear and free of
discharges, lesions and
redness.
EARS Auricles are same in color No nodules and palpated N/A N/A
as facial skin and recoils over the ears and in the
 back The outer canthus of
eyes is aligned in the top
pinna and having a 10
degree angle. No cerumen
noted on both ear.
NOSE Nose in midline in face,
septum is midline and
intact.
MOUTH AND THROAT Lips are dry, no lesions
present. No dental caries
seen. Buccal mucosa is
pink and no lesions. Uvula
is in midline. Tongue is in
midline, pink and no
lesions. Palates are pink
and no lesions present.
NECK No bulging masses seen.
Coordinated muscle
movements and no
discomfort if neck is move
from side to side. Jugular
vein is not visible.
CHEST & LUNGS Symmetric in shape.
The chest expands
symmetrically during
breathing.
HEART AND CENTRAL No visible veins present.
VESSELS No visible pulsation seen
on the pericardium
ABDOMEN Umbilicus is midline. No
visible pulsation and
vascular pattern seen
mastoid process
No tenderness palpated N/A N/A
over the sinuses.
Not able to assessed N/A N/A
because patient is
uncomfortable in the
procedure.
No nodules and lymph N/A N/A
nodes noted. Trachea is in
midline
No masses or nodules No adventitious sounds
noted For tactile fremitus, heard.
bilateral vibrations/ sound
waves is felt
N/A N/A No bruit auscultated No
heart murmurs heard
Bowel sounds are heard
at a rate of 10 clicks per
minute.
No bruit heard over
abdominal aorta. No
 friction hub over liver and
spleen is present
GENITALIA Was not able to assess Was not able to assess N/A N/A
because patient is because patient is
uncomfortable uncomfortable
ANUS Was not able to assess Was not able to assess N/A N/A
because patient is because patient is
uncomfortable uncomfortable
BACK AND EXTREMITIES Erect posture during No edema or tenderness N/A N/A
sitting and standing palpated over extremities.
Extremities are
symmetrical in size. Arms
and legs doesn’t show full
ROM without assistance.
 LABORATORY RESULTS

Laboratory tests check a sample of a person’s blood, urine, or body tissues. A technician or
your doctor analyzes the test samples to see if the results fall within the normal range. The tests use a
range because what is normal differs from person to person (Smith, 2019). In the case of Patient M, he
was ordered to be test for CBC (Complete Blood Count), ultrasound and a urinalysis which results are
provided below.

Hematology: Complete blood count

A complete blood count (CBC) is a test that measures the cells that make up the patient’s blood. In the
case of excessive vagina bleeding, CBC is ordered to look for altered count results of test typical of the
later stages of diagnosis. Also, used to help detect a variety of disorders including infections, anemia,
diseases of the immune system.

TESTS RESULT REFERENCE INTERPRETATION

Hemoglobin 74 136-167 Below normal range
Hematocrit 0.22 0.40-0.50 Below normal range
WBC 6.85 5.0-10.0 Within normal range
Segmenters 0.54 0.37-0.72 Within normal range
Lymphocytes 0.28 0.20-0.50 Within normal range
Eosinophil 0.07 0.00-0.06 Slightly above normal range
Monocytes 0.11 0.08-0.14 Within normal range
Basophils 0.00 0.0-0.01 Within normal range
Platelet 453 150-390 Slightly above normal range

Electrolyte Panel

TESTS RESULT REFERENCE INTERPRETATION

Potassium 4.6 3.5-5.3 Within normal range
Sodium 140.0 135-148 Within normal range

Chemistry Section

TESTS RESULT REFERENCE RESULT REFERENCE INTERPRETATION

(c.u.) (s.i.)
Creatinine 2.40 0.90-1.50mg/dl 213.312 80.00-133.00mmol/L Above normal
range
BUN Blood 18.0 8.12-22.97mg/dl 6.426 2.90-8.20mmol/L Within normal
Urea range
Nitrogen
Name of Drug Date Classification Dose/ Mechanism of Contraindications Side Effects Nursing
Ordered Frequency Action Responsibilities
Generic 4/6/22 Antiurolithic 500mg 1 For renal and urinary None known. No untoward - Liquid intake
Name: tab TID disorders including Special warnings side effects should be
Pinene alpha urolithiasis. and precautions have been increased
+ beta, for use reported during therapy.
Camphene, ROWATINEX Rowatinex® is not
Cineol, promotes diuresis suitable for use in - Store at
Fenchone, and relaxes urinary patients with temperatures
Borneol, tract spasm, thus severe colic, not exceeding
Anethol and assisting the passage anuria or severe 30 degrees
Olive Oil of stones. The infection of the Celcius
therapeutic effect of urinary tract.
Brand Name: the balanced
Rowatinex combination of
terpenes reduces
urinary tract
inflammation,
stimulating renal
blood flow through
the kidneys and
increasing the
output of less
concentrated urine.

Generic 4/6/22 Ketoanalogues, 600mg 1 For prevention and Hypersensitivity Metabolism and - administer
Name: essential tab TID treatment of to the active nutrition with food to
Ketoanalogue amino acids damages due to substances or to disorders: Very prevent GI
faulty or deficient any of the rare: upset
Brand Name: protein metabolism excipients. hypercalcaemia. - instruct
Aminolog in chronic kidney Hypercalcaemia. If patient to
disease in Disturbed amino hypercalcaemia report
connection with a acid metabolism. occurs, the immediately if
limited dietary intake of symptoms of
protein intake of 40 vitamin D hypercalcemia
g/day or less should be occurs like
(adult).  reduced. In case muscle
of persisting weakness,
AMINOLOG allows hypercalcaemia, constipation
the intake of the dose of the - monitor signs
essential amino product as well of
acids while as the intake of hypercalcemia
minimizing the any other and electrolyte
amino-nitrogen calcium sources levels
intake. Following has to be
ingestion, the reduced.
ketoanalogues are
transaminated by
taking nitrogen from
non-essential amino
acids, thereby
decreasing the
formation of urea by
re-using the amino
group. The levels of
accumulating uremic
toxins are
decreased. Keto-
and/or hydroxy-
acids do not elicit
hyperfiltration of
residual nephrons.
Ketoacid-containing
supplements have a
positive influence on
the renal
 hyperphosphatemia
and secondary
hyperparathyroidis
m and can improve
renal
osteodystrophy.
The use of
AMINOLOG in
association with a
very low protein diet
allows a reduced
intake of nitrogen
while avoiding the
deleterious
consequences of
inadequate dietary
protein intake and
malnourishment.

Contraindicated
Generic 4/6/22 Iron 1 tab BID Ferrous sulfate is with allergy to any CNS: CNS - warn patient
Name: Preparation given to the patient ingredient; toxicity, that stool may
Ferrous for the prevention sulphite allergy; acidosis, coma be dark or
sulfate and treatment of hemochromatosis, and death with green
irondeficiency hemosiderosis, overdose
Brand Name: anemia brought haemolytic - arrange for
Hemarate FA about by the illness anemias GI: GI upset, periodic
anorexia, monitoring of
Elevates the serum nausea, Hct and Hgb
iron concentration, vomiting, levels
and is then constipation,
converted to diarrhea, dark
Hgb or trapped in stools,
the temporary
reticuloendothelial staining of
cells for storage and teeth (liquid
eventual conversion preparations)
to
a usable form of iron