NURSING ASSESSMENT

Present Health History

The present health history started 8 days ago prior to admission. The patient had a
sudden onset of headache; no medication and consultation to the doctor was done.
Few days prior to admission, the patient had high grade fever at 42°C accompanied
with throbbing headache. She self-medicated with equaline 1000mg TID and
afforded temporary relief. Due to persistence of the said signs and symptoms, the
patient seek consultation and hence admitted at East Avenue Medical Center with
Dr. Rivera as attending physician. She was admitted last September 20 at around
12:30 am. On September 23 at 11:25pm, she was transferred from Ward I to
Female Surgical Ward.

Past Health History

Prior to her hospitalization at East Avenue Medical Center, she denies in having any
record or medical history of being admitted due to trauma, accident and disease.
She also denies having allergies to food and drugs. She says that she is allergic to
dust and particles.

Family Health History

No hereditary disease can be attributed from her father side, but her mother had a
family health history of hypertension. Other than the latter, no other hereditary
disease from both of his parents are within the patient’s knowledge.

M – edication
Intake of appropriate vitamin supplement and diuretics to increase protection
mechanism of the immune system and decreases renal vascular resistance and
may increase renal blood flow, respectively.

E – conomic
The use of nonpharmacotherapy such as drinking plenty of water will promote
increase plasma in blood to increase immunity and proper hygiene and promotion
of cleanliness at home and work area.

T – reatment
Management of such condition would be through hydration and doing control
measures to eliminate vector by promoting cleanliness in the environment through
proper disposal of rubber tires, changing of water of lower vases once a week,
destruction of breeding places of mosquito and residual spraying with insecticides.

H – ygiene
Advise to follow proper body hygiene and to maintain cleanliness on surroundings.
This would prevent additional cases of DHF.

O – ut Patient/ Follow-up
Any odd signs such as fever, petechiae, recurrence of fever,etc. must be
immediately reported to the physician.
D – iet
Instruct to eat foods that are low fat, low fiber, non-irritating and non-carbonated.
EVALUATION

CONCLUSION

The patient in this study had undergone supportive and symptomatic management.
She was admitted last September 20, and was transferred from Ward 1 to the
Female Medical Ward last September 23.

Proper nursing care such as water therapy and administration of prescribed drugs
were done to promote comfort and repression of symptoms. Hygiene was also
strictly implemented to avoid risk for further infection. Nursing assistance was also
given to help him in his activities of daily living.

Health teaching is a very important role on the part of the nurses. This is of great
significance to the knowledge deficit of patients regarding health and illness.

Recommendation

Strict compliance to the medical treatment, health teachings and medical check-up
is advised. With proper nutrition and conformity to the medications & therapy,
recovery would be easier and faster.