iv.

History of Present Illness: The patient reported that he had been experiencing discomfort in the area
of his kidneys for about two weeks and gave it a pain rating of 10/10. He inquired about it with his wife,
who quickly drove him to the hospital because he appeared different and was in excruciating agony.
They were received medical care at a facility in San Fernando, La Union.

v. The patient has been hospitalized. The Patient also states that he has a history of Pulmonary
Tuberculosis which he has been home for for about three and a half to four years. He states that he was
diagnosed with Pulmonary Tuberculosis 10 years ago since he used to smoke 3 packs of cigarettes per
day and was now trying a cigarette free lifestyle. The patient claims that he has used a lot of medication
over the years to treat his ailment and that his chest tightness, dry cough, and shortness of breath have
both bothered him for years. He claims that smoking gave him comfort, but after getting diagnosed,
quitting took him the longest. However, with the aid of TB Dots, he healed and is now clear of
tuberculosis. Five years prior, he had seen a doctor after noticing that he had acute joint discomfort. The
patient was diagnosed with gout after an examination by his doctor in Pangasinan. The patient was
prescribed nonsteroidal anti-inflammatory medicines (NSAIDs) and corticosteroids, the names of which
he could not recall.

FAMILY HEALTH-ILLNESS HISTORY

The patient claims that none of his relatives have the current health problems he does.

Nursing Health History-B (13 areas of assessment)

• Psycho-Social Evaluation

o The client describes himself as a hardworking, kind and a loving man.

o The client claimed that knowing about his illness saddened him and unable to accept that he has that
condition

o The client also claimed that she always thought of the negative things that might happen to her..

• Mental & Emotional Status

o The client says he had experienced happiness and feelings of hopefulness because he was given a
second chance of life.

o The client also claims that due to his health concerns, he has lost interest in formerly joyful activities
and has a lot of appetite for food, especially when it is his favorite.
• Environmental

o The client says he had no exposure to any chemicals.

• Sensory perception

o Visual Status: The patient’s both eyes are normal, he can read without using eyeglasses, and can
respond by opening and closing of the eyelids; pupils are reactive to light and equally round.

o Auditory: The patient can distinguish voice when you come close to his ear; no corrective auditory
deficit and no auditory device noted being used by the patient

o Olfactory status: The patient was able to discriminate an odor from the other. We use an alcohol and
coffee in assessing in this status.

o Gustatory status: The patient cam able to discriminate sweet, sour, salty and bitter tastes from each
other as stated by her wife

o Tactile Status: She was able to determine that the patient is able to discriminate sharp and dull, light
and firm touch, able to perceive heat, cold, pain in proportion to stimulus, able to differentiate common
object by touch.

• Motor Stability

o The client says she had no history of stroke but he has a gout.

o The client says he found it difficult to stand or walk when he had attacks of gout in his feet, ankles or
knees because of the severe pain and swelling..

o The client says his body is unstable.

• Nutritional Status

o The client says he eats 3 times a day.

o Client says he eats bland foods like Quaker Oats and Kamote

o The client says that he consumes 1 liter of water per day.

• Elimination Pattern

o Client says she defecates once a day with a brownish stool.

o Client says they change his diaper 3 times a day.

• Respiratory

o The client has history of smoking

o He has past history of PTB.

o He has no history of Lung cancer nor has a family history of lung cancer.

• Body Temperature

o The client describe that he’s not feeling hot.

o The client’s temperature is 37°C, which means the client’s body temperature is normal because it fits
in the normal range of body temperature.

o The client says he has no history of convulsions or febrile seizures related to hyperthermia.

• Sleep rest-pattern

o The client always wake up in the same intervals.

o The client had stated that she experienced sleep difficulties after he was discharge from the hospital
but 2 weeks prior to that, he now sleeps peacefully.

• Fluid & Electrolytes

• Circulatory

o No history of hypertension
• Integumentary

o For her hair, the client takes baths at least once a day. She uses Head and Shoulder for his hair and
Safeguard for his body.

o Client does not make use of styling products for the hair.

o Client says he has history of other skin problems such as swelling which is his gout.

o Does not feel pain upon light or deep palpation.

o The client has history of skin allergy but his family have no history of skin allergies or skin cancer.

o Does not have any birthmarks or tattoos.

o No problems with perspiration or odor.

o Has no current history of excessive hair loss, infestations, or change and appearance in the hair (such
as excessive dryness or brittleness).

o Client does not sunbathe, and is not constantly exposed to chemicals which may harm the skin such as
paint, weed killers, insect repellents, and bleach