NURSING HEALTH HISTORY

Vital Information
Code Name: Mrs. Mariga
Age: 27
Gender: Female
Civil Status: Married
Date of Birth: March 23, 1989
Place of Birth: Pangarungan Village, Marawi City
Race: Filipino
Cultural or Ethnic Background/Group: Maranao
Primary Language: Maranao
Secondary Language: Bisaya, English, Filipino
Religion: Islam
Highest Educational Attainment (Client): College Graduate
Occupation: Professor
Highest Educational Attainment (Partner/Spouse): College Graduate
Occupation : Employee in DPWH
Usual Health Care Provider/s: OPD Physician
Date of Admission: March 14,2017 at 12:50 pm
Date of Discharge: March 17,2017 at 05: 30 pm
Source/s of History: Client 60%, Chart 40%
Reason/s for Seeking Health Care: Profuse vaginal bleeding and body weakness
Primary Attending Physician: Dr. Gemma Serrano
Anaesthesiologist: Dr. E Sumndad
Initial Impression/Diagnosis: Dysfuncional uterine bleeding
Final Diagnosis: Abnormal uterine bleeding
History of Present Health Concern

2 months prior to admission Mrs. Mariga was watching T.V when her present condition
started with an onset of heavy bleeding associated with dizziness and difficulty of breathing. She
can consume 2 large children’s diapers a day. Her menstrual period would last for 5-15 days
with an interval of 2-3 days of cycle. No consultation and only sangobion once a day was taken.
She tolerated the condition until 2 weeks prior to admission and started to feel weakness
associated with episodes of dizziness and loss of appetite.
2 days prior to admission Mrs.Mariga’s vaginal bleeding spontaneously regressed. She had
pyrexia and took OTC such as Biogesic and Ibuprofen. Persistent of symptoms prompted to
seek consultant for OB- GYNE, due to weakness she was advised for admission.
Her vital signs are as follows: T:36.2, BP: 100/60, HR: 112, R: 20. Transvaginal exam was
done with the result of slightly enlarged retroverted uterus with thickened endometrium. She was
advised to undergo dilatation and curettage.
Blood transfusion was given with 3 units of PRBC @ left metacarpal vein, blood type o; 1st
unit on March 14,2017 at 12:50 pm, completed at 5:50 pm with 300cc @60cc/hr, 2nd unit on
Marh 15,2017 at 2 am, completed at 7:20 am with 320 cc @60cc/hr, 3rd unit on March 16,2017
at 3:15 am, completed at 9 am with 300cc @50cc/hr
The surgical procedure surgical procedure started at 11:34 AM and ended at 11: 47 AM with
the following vital signs; T: 35, BP: 100/65, RR:18, PR: 75, oxygen saturation of 100 and
oxygen administration via nasal cannula @ 3L/min; IVF hooked of PNSS @ 30 gtts/min, @ left
metacarpal vein
Past Health History
Mrs. Mariga delivered via normal spontaneous vaginal delivery at their home in the year
1989. She had experienced a chicken pox when she was 10 years old. She does not usully get
cough and cold but experience fever at times due to weather conditions. She cannot recall her
immunization status.
She was admitted last 2010 at Marawi City due to profuse vaginal bleeding and was treated
with medroxyprogesterone with poor compliance. She was diagnosed with anemia.
Family Health History (Genogram only)
Note: Your genogram is Figure 1 to be included in your List of Figures

GENOGRAM DIAGRAM

Figure 1. Genogram Showing the Family History of Client X (bold)

Physical Examination and Review of Systems (PEROS)
Table 1
Physical Examination and Review of Systems of Mrs. Mariga
Areas Examined Subjective Objective Findings Problems

Findings Identified

1. General Health Survey

a. Physical development and o Weighs 5.7 kg

body build o Height 5’2

b. Gender and sexual o Sexual

development development is

appropriate for

gender and age

c. Apparent age as compared “Bente syete o Client appears

to reported age na ko ron..” to be her stated

chronological

age

d. Skin condition and color o Pale Fatigue related

o Moist and to anemia

flushed skin

o Good skin

turgor

e. Dress and hygiene o Well pleasant

appearance
 o No foul odor

f. Posture and gait o Normal posture

and comfortable

for age

o Ambulatory

without

assistance

g. Level of consciousness o Conscious

o Coherent

h. Behaviors, body o Fatigue

movements and affect o Slight irritable

i. Facial expression o Grimace

j. Speech o Clear

o Moderately

paced

k. Vital signs o T: Range of

36.2-36.5

o PR: 85-90

o RR: 16-22

o BP: 100/70-

130/80
2. Integumentary System o Moist and

flushed skin

o Pale skin

o Good skin

turgor

3. HEENT

a. Head and face o No deformities

noted

o No pain upon

palpation

b. Eyes o Pale conjunctiva Fatigue related

o Anicteric to anemia

Sclerae

o Sunken eyeballs

o Farsightedness

c. Ears o No hearing

problem

o No pain upon

palpation

o No ringing or

cracking in ears

o Normal sounds
 is audible

d. Nose o No nasal

discharge

o Nasal flaring

was not noted

e. Oral cavity o Pale and dry lips Risk for fluid

o Moist oral deficit related

mucosa to blood loss

4. Neck o No pain upon

palpation

o Without bulging

of masses

o Supple

5. Respiratory System o RR: Range of

16-22

o Equal chest

expansion

o No retractions

o No abnormal

sounds
6. Cardiovascular System o BP: Range of

100/70- 130/80

o PR: Range of

85-90

o No murmurs

o Regular rhythm

7. Breast and Axilla o Color brown

areola and

nipple

o Light

symmetrical

breast

o No tenderness

8. Gastrointestinal System and o No scars noted

Abdomen o Bowel sounds

are present

o Flaccid

abdomen

9. Genitourinary/Reproductive o No offensive
 Tract odor

o Minimal

vaginal

discharges

brownish in

color

o Total urine

output of

1750cc

10. Musculoskeletal System o Can extend arms

without

difficulty

o No edema

o IV hooked 1

5DLR L @ 20

gtts/min @ right

metacarpal vein

11. Neurologic System o Conscious

o Coherent

12. Lymphatic/Hematologic o RBC: 248 Activity

System (4.6X10 12\L) intolerance

o Hematocrit related to

0.21 (0.37-0.47 decrease

 o Hemoglobin hemoglobin

56.0( 110-180

g\L)

13. Endocrine System o Irregular Altered

menses sexuality

o Weakness patterns related

to the

condition
Gordon’s Functional Health Patterns Assessment

Table 2
Gordon’s Functional Health Patterns Assessment of Mrs.Mariga
Health Patterns Before Hospitalization During Hospitalization

1. Health Perception and  Mrs. Mariga was  Coherent and

Health Management admitted due to profuse conscious

Pattern vaginal bleeding and  Concerns for her

body weakness health condition

 She understand that the  Willing to accept and

treatment and admission listen to health teachings

were necessary for  Shows interest to

further management recover easily

 She was expecting that

the hospital will give

right treatment and

management for her

recovery

 She was admitted due to

profuse vaginal bleeding

last 2010

2. Nutrition and  Miss Sundae eats fish  NPO status for D&C
 She continues her
Metabolism Pattern and vegetables most of
nutrional meal after she
 the time pass out flatus, 3 pm in
the afternoon
 She does not have any
 DAT
food allergies.
 She takes ferrous  Intake output total of
gluconate(Sangobion) OD
3970 cc
 She go to fastfood
restaurant rarely
 She was anorectic prior o

admission because of the

condition

 Miss France drinks at

least 6 glasses of water

per day

3. Elimination Pattern  Miss Sundae  No pain and burning

defecates daily with brown sensation during urination

formed stool  No bowel movement

 She urinates 12-15 since admission

times a day  Urine output of 120cc

 She has no skin

problems

4. Activity and Exercise  Her daily routine is going  Confine to bed

Pattern to school as her daily

exercise

 She is a professor in
 MSU Main teaching

computer engineering

 No vices at all

 She experienced dyspnea

prior to admission

 She has blurring vision

5. Cognition and  She was diagnosed with Confine to bed

Perception Pattern astigmatism last Dec.

2016

 Does wear eye glasses

 Farsightedness

 Blurring of vision started

when she starts working

 No hearing problem

6. Sleep and Rest Pattern  Miss Sundae usually  Able to rest and sleep

wakes up a 5 am in the sufficiently

morning and sleep at 12

midnight

 Inadequate rest and sleep

 She experienced imsoni

once a week

7. Self-Perception and  Mrs.Mariga believed that  Felt anxiety when

Self-Concept Pattern admission will be helpful advised to undergo D&C

 to assist in her needs and

overcome the condition  Agreed to be admitted

she has and treated

 Hopeful to be treated

8. Roles and  Living with spouse and  Always pray to Allah

Relationships Pattern parents

 Extended type of family

 Turns for help to her

spouse

9. Sexuality and  Unsatisfied with sexual  Minimal menstrual

Reproduction Pattern relationship because of bleeding

her condition

 She started her menarche

when she was 13 years

old

 Had profuse vaginal

bleeding last 2010

10. Coping and Stress  Anxious when advised to  Anxious as the

Tolerance Pattern undergo D&C condtion may worsen

 Her works was the caus

 of her stress because of

physical requirements

 She deals with her

tension and stress by

sharing it to her husband

11. Values and Belief  Family is the important  Family is the important

Patternto things in life things in life

 Her plan for the future is  Her plan for the future is

to take care of her family to take care of her family

and herself and herself

 She has strong beliefs  She has strong beliefs

 Her conditions does not Her conditions does not affect

affect her beliefs to god her beliefs to god

Developmental Level
Psychosocial Development (Erik Erikson): (Pilliteri. 2014)

Developmental Task Nursing Implications

Intimacy Vs. Isolation

o Directs and participates in her own care o Negotiate learning outcomes with the

o Complies with hospital regulations patient

o Demonstrates continued interest in o Use patient-centered nursing care

personal role o Provide for immediate application of

o Shows concerns about her condition learning

o Let the patient test own ideas