_DF-002

MSU-Iligan Institute of Technology August 2016

College of Nursing PN-1/Ward

NURSING HEALTH ASSESSMENT I

DEMOGRAPHIC DATA

Name: Patient X Age: 47 Sex: male Status: _ married

Address: Ditucalan , Iligan City Religion: Roman Catholic Occupation. Carpenter/Fisherman

A. Chief Complaint/s: Fever,Productive cough, DOB

B. Impression/Admitting Diagnosis: CAP MR S/P CVA

C. History of Present Illness: (Setting of the complaint, intermittent/constant, progressive/stable or

improving, any prior episodes, duration, aggravating or alleviating features, associated symptoms)

Sept. 11 2016, 12 days PTA pt was admitted at Mercy Hospital Iligan City d/t stroke or cerebrovascular accident
(hemiplegia )and was having cough upon discharged with no medication taken.

Sept. 22 2016, 2 days PTA patient experienced productive cough characterizd as yellowish/greenish sputum ,
intermittent fever with unrecalled body temp above 37 C, difficulty of breathing , headache bilaterally, pressing or
tightening in quality and mild to moderate in intensity with no nausa, which prompted to admission.

D. History of Past Illness/es: (Previous hospitalization, injuries, procedures, infectious disease, immunization/
health maintenance, major illness, allergies, medication, habits, birth and development history, nutrition – for
pedia)

Sept 11, 2016, patient was hospitalized at mercy hospital iligan city d/t stroke or cerebrovascular accident
( hemiplegia), (-) allergies, (-) invasive procedure, (-) infectious disease, (-) injuries, complete immunization with (BCG,
Polio, Hepa B, etc ) and was taking antihypertensive (amlodipine) 5 mg once daily for maintenance.

E. Health Habits
Kind Frequency Amount Period
1. Tobacco N/A N/A N/A N/A
2. Alcohol Tuba,emperador, etc everyday Approx- 3 liter 15 years
3. OTC drugs Not Known Not Known Not Known Not Known

F. Family History with Genogram

History of Heredo-familial diseases: Genogram (up to 3rd generation)
Cancer Legend:
✓ DM deceased male
✓ Asthma deceased female
✓ Hypertension male (DM ,H)
Cardiac Disease female
Mental Disorder
Others: patient H
H – hypertension
DM- Diabetes Mellitus

G. Patient’s Perception
Present Illness: ( Patient unable to talk /verbalize feelings.)
“Unexpected kaayo ang nahitabo sa iyaha dayon nagka grabe pa gyud siya” as
verbalized by the SO.

Hospital Environment: ( Patient unable to talk /verbalize feelings.)

“Hugaw, panalagsa ra malimpyohan walay saktong tubig” as verbalized by the SO.

H. Summary of Interaction: During the interaction of the student nurse and SO, the SO answered all the
questions for the patient cooperatively because the patient unable to talk/verbalize feelings.

Patient’s Name / Room No. | 1