Nursing History

Name: F.E Informant: F.E

Age: 53 Relationship to the client: Son
Sex: Female Chief Complaint:
Birthdate: March 30, 1966 Date of Interview: March 4,, 2020
Religion: Roman Catholic
Nationality: Filipino
Address: Puntod Monteclaro, Miagao Iloilo
Marital Status:
Occupation: Farmer
Date & Time of Admission: February 24, 2020 02:00PM
Admitting Diagnosis: BILIARY OBSTRUCTION PROBABLY SECONDARY TO PANCREATIC PATHOLOGY NOT IN CHOLANGITIS
Attending Physician: G.F, M.D

HISTORY OF PRESENT ILLNESS

According to the client 2 weeks prior to admission he experienced persistent epigastric pain and his son notice that his scelra and
is yellowish in color and consulted a physician and it revealed that he has cholecystic and bile sludge , biliary ducted dilation and enlarged
pancreas .

PAST MEDICAL HISTORY

According to the client, he experience childhood illness such as cough, colds, fever and chicken pox. he uses home remedies like
herbal plants to cure her illness. The client stated that he doesn’t have a past hospitalizations and did not undergone surgical procedures. He
stated that it was his first time to be hospitalized. He experience childhood illness such as cough, colds, fever and chicken pox. He uses home remedies
like herbal plants to cure her illness or over the counter medications such as paracetamol.
FAMILY MEDICAL HISTORY
According to the client they don’t have hereditary disease of hypertension and diabetes mellitus on both
sides of the family. There are no other hereditary diseases such as asthma or other diseases on both maternal and
paternal side of the client. Only fever, colds and cough are common in the family but given immediate attention.

SOCIO-ECONOMIC STATUS
their house is made up of bamboo materials and cement, their sources of water is deep well . They use
charcoal or firewood for cooking, they separates the water bottle containers from the other garbage and they just
buried it.
 ACTIVITIES OF DAILY LIVING
NUTRITION
The client eats meals three times a day, he usually eat vegetables such as squash, okra, eggplant. He mostly eats fish, chicken and
pork which is cooked in any kind of way. He also eats fruits such as banana and papaya. He doesn’t have any allergy on food or
medication.

ELIMINATION
Client is able to defecate five times per week without any difficulty to a well- formed stool. And the client was able to urinate a normal
amount and yellowish colored urine without any difficulty.

REST & SLEEP

The client’s way of exercise is walking and farming. The client sleep at 9pm or 10pm in the evening and
wakes up at 5am or 6am in the morning. She also takes a nap in the afternoon. The client stated that he smokes
cigarette because it makes him relaxed.
 PHYSICAL ASSESSMENT

GENERAL SURVEY
The client is awake lying on bed. The client wears comfortable clothes, and he is oriented to time, place and person. IV
adaptor attached in left and right radial vein. The vital signs of the client are BP= 180/80mmHg, PR= 65bpm, RR= 20bpm,
Temp= 36.5ᵒ.

SKIN AND NAILS

The client skin is ward to touch with generalized fair complexion and dry skin folds. There is presence of moles in hir
arms and body. There is poor skin turgor, capillary refill of more than 2 seconds. His nails are concave in shape, his nails are intact
and immobile the skin surrounding her nails are intact.

HEAD & FACE

The client has a round symmetric skull that is appropriate to his body size. There is absence of tenderness upon
palpation on the scalp and no presence of scar. The clients hair is white in color and it is equally distributed without any presence
of dandruff. There is paleness of lips noted, facial structures are symmetric. The temporal artery is noted between the eye and top
of her ears. There is no enlargement of thyroid and has a good gag reflex.

EYES
There is absence of protrusion of eyeballs, his eyes are equally round reactive to light and accommodation. There is
presence of yellowish discoloration surrounding his eyes. He couldn’t see objects and read from afar Eyelashes are equally
distributed. Absence of any discharges and no abnormalities observed.
EARS
The clients hearing ability is poor, he could hear and repeat the words I whisper using his left ear the right ear can hear
but poor. Absence of abnormal discharges and clients ear wax is moist and yellowish in color. There is absence of
deformities upon palpation her ears are symmetrical and the pinna is aligned to the corner of his eyes.

NOSE
Clients nose is centrally located in the midline with presence of nasal secretion and no masses were noted. The
nasal septum is not perforated and no tenderness noted. The client has a good sense of smell and he can differentiate the
smells.

MOUTH AND THROAT

The clients lips are dry with absence of pigmentation, masses and ulceration. There is presence of dental cavities
and slight discoloration of teeth. The gums are pink, no bleeding and absence of pus discharges noted. The trachea is in the
midline and no enlargement of thyroid. The client has a good sense of taste.

THORAX/CHEST
The clients chest is symmetrical in size and shape with respiratory rate of 17 breaths per minute. His breathing
pattern is fast and there presence of crackles sound upon auscultation. Coughing and there is presence of phlem yellow in
color. Complains of difficulty in breathing. Complains chest pain.
Test Name Result Unit Reference Range Significance
Hematology
Hemoglobin L 11.3 g/dL 12.3 – 15.3 Indicates anemia, low production of RBC in
bone marrow
Hematocrit L 0.36 vol 0.37 – 0.47 Indicates dehydration
RBC L 3.8 4.5 – 6.1 Low production of RBC in bone marrow
x10˄12/L
WBC 7.9 x10˄9/L 4.4 – 11.0 Within normal range
Differential Count
NEUTROPHILS 0.68 0.54 – 0.68 Within normal range
EOSINOPHIL 0.02 0.01 – 0.04 Within normal range
BASOPHIL 0.01 0.00 – 0.01 Within normal range

LYMPHOCYTE 0.27 0.25 – 0.33 Within normal range

MONOCYTE L 0.02 0.03 – 0.07
Total Diff 1.00
MCV 92.6 pL 76.0 – 96.0 Within normal range
MCH 29.5 pg 27.0 – 32.0 Within normal range
MCHC 31.9 g/dL 30.0 35.0 Within normal range

RDW-CV H 14.80 % 1.5 – 14. 5

PLATELET COUNT (APC) H 490 x10˄9/L 150 – 450

 Test Name Result Unit Reference Range
COAGULATION
Phrothrombine Time 24.7 sec 11.7-15.3
% Activity 42%
INR 1.92
APTT 27.4 secs 25.0-32.0

Sodium 144.50 mmol/L 135-148

Potassium L 3.39 mmol/L 3.5-5.3
Creatinine L 42.01 Mmol/L

Glucose, FBS
Total Cholesterol H 5.49 mmol/L 4-5.9
*Test done twice 19.31 5.17-6.18
TRIGLYCERIDES 4.59 mmol/L 0-1.69
HDL CHOLESTEROL 0.33 mmol/L >1.55
LDL CHOLESTEROL 16.83 mmol/L 0-2.59

TOTAL BILIRUBIN H 220.37 mmol/L 5.21

DIRECT BILIRUBIN H 159.87 mmol/L 0-3.4

INDIRECT BILIRUBIN H 60.50 mmol/L 5-17.6

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