Adreanah M.

Rańises
BSN 2 BLOCK 2

HEALTH HISTORY
ASSESSMENT OF FUNCTIONAL HEALTH PATTERNS

A. Patient J.G , is a 12 yr .old female child who lives in Banilad ,Cebu City Phils.

I. Client’s Profile

• The client was born on November 11,1998. A member of the Church of

Christ . The eldest daughter in the family with a single female sibling.

Reason for seeking health care:

• The patient experience a fever of 38oC for the [ast two days , with evident
rashes on the skin.

Treatments/Medications:

• Upon assessment , the client takes biogesic (paracetamol) PRN per orem .

Parenteral Fluid:

• During December 9, 2010, the client’s IV is D5. IMB at 180 cc/hr. While on
December 10, 2010, the client’s IV is still D5.IMB and was decreased into 120
cc/hr .

Past Illnesses/Hospitalizations:

• The patient has no history of past illnesses and also not undergone
hospitalizations.

Allergies:

• The patient has no allergies.

II. Developmental History:

Subjective Data
 • The patient verbalized that she has no physical difficulties pertaining to
bodily functions. Moreover , she is a healthy child and have not experience
pertinent illness only common colds and seasonal flu when she was little . Also
the patient is an outstanding student and continuously belongs to the top
students in her class upon entering her elementary years. She dreams to be an
architect someday . And according to her the present illness she is experiencing
does not interfere with her life goals only it’s a reason for her to be a bit left
behind with her lessons.

Objective Data:

• The patient does not have development lags and her condition does not
interfere with the ability to accomplish the necessary developmental, physical,
psychosocial, or cognitive development.

III. Health Perception-Health Management Pattern:

Subjective Data

• The patient perceives health as a “condition when you are able to

accomplish things daily without feeling unwell” . While her idea about illness , “ is
somewhat a body weakness when one is no longer capable of doing the things
he/usually does .”

• She loves to eat vegetables and poultry . Her parents as she said
immediately attends to her if ever she is sick or there are certain medications or
means that should be done or brought whenever she is sick.

IV. Nutritional-Metabolic Pattern:

Subjective Data

• The patient loves to drink juices such as orange and apple juice at about 4-
5 glasses per day during mealtime and snack time. She doesn’t like to drink much
with soft drinks .

• The patient’s skin has red spots (petechae) and warm.

• Her eating habits are soundly well .

Objective Data

• The patient’s vital signs; temperature is 36.9 degree Celsius, respiratory rate is 18,
heart rate is 80.
V. Elimination Pattern:

Subjective Data

• The patient’s bowel movement is fine and is regular accordingly ( once a

day) as she said ( in the morning )

• Since she is drinking to much juice lately she usually urinates at least 4-5
times in a shift .

Objective Data

• The patient’s abdominal skin is intact with no lesions. Umbilicus is inverted

and is in the midline. Abdomen is symmetrical bilaterally and there is no
abdominal distension.

VI. Activity-Exercise Pattern

Subjective Data

• The patient’s daily activity is going to school and attending her chorale
classes. She spends her leisure time in playing badminton or volleyball also she
considers this as an exercise routine for the day.

Objective Data

• The patient’s thoracic is normal, lung has no abnormal sounds and there is
a positive pulsations at the apex.

VII. Sexually-Reproduction Pattern

Subjective Data

• The patient’s first menstrual period was on Dec.29, 2009 when she was 11

VIII. Sleep-Rest Pattern

Subjective Data

• The patient verbalizes that she usually sleeps at 10 pm and wakes up at

6am .

Objective Data

• The patient is with in her normal mood. Not irritable and very cooperative
to every thrown question .
IX. Sensory-Perceptual Pattern

Subjective Data

• The patients discloses that she doesn’t have any difficulty in her senses and
claims that they are functioning perfectly.

• The patient identifies pain , perceives it as has a good pain threshold.

Objective Data

• Match to his age and his sensory is active.

X. Cognitive Pattern

Subjective Data

• The patient has an excellent understanding and communication skills as

evidenced by the way she answers my questions as well as her academic
accomplishments which proves her intellectual ability

Objective Data

• The patient has unquestionable mental skills , she gain normal results when
ask with the time orientation , memory recall and other mental status
assessments

XI. Role-Relationship Pattern

Subjective Data

• The patient perceives that as an eldest daughter in the family she should be
act as a model to her younger sister.

XIII. Coping –Stress Tolerance Pattern

Subjective Data

• The patient claims that whenever she has difficulties in school or in terms
of dealing with her friends she immediately tries to figure out some ways to solve
the situation .

• She usually seeks help to her mother in advises with regards to either
academic and social matters.
XIV. Value-Belief Pattern

Subjective Data

• The patient was baptized as a member of the INC (Inglesia ni Cristo) .

Objective Data

• The patient all together with her family goes to the church during
Thursdays and Tuesdays .

Physical Assessment

Physical Examination:

• Integumentary System

The patient has evenly colored skin tones without unusual or

prominent discoloration. Skin is intact but some red spots can be
noted (petechae), skin is smooth and even. Skin surface is fairly
moist. Skin pinches easily and immediately returns to its original
position. The patient’s hair color is black. Evenly distributed and fine.
Free from parasites. Scalp is clean and dry. Hair is smooth and firm,
somewhat elastic. The clients nail is light in color. Nails are at 160
degrees angle, smooth and firm, nail plate firmly attached to nail bed
and convex, upon doing the capillary refill testing; pink tone returns
immediately to blanched nail bed when pressure is released.

• Head and Neck

The patient’s head is symmetrical, round, erect and in midline. No

lesions are visible. The face is symmetric with a round, oval,
elongated. No abnormal movements noted. CN7 is intact. Neck is
symmetric with headis centered and without bulging masses. Thyroid
cartilage, cricoid cartilage and thyroid gland moves upward
symmetrically as the clients swallows. Trachea is placed midline.
Thyroid is not visible. No bruits are auscultated. Upon palpation, lymph
nodes is present, size is 1cm, mobile, superficial and soft but not
tender. Jungular veins is also palpable.

• Eyes

The upper and lower lids close easily and meet completely when
closed. Lower eyelids are upright with no inward or outward turning.
Eyelashes are evenly distributed and curved outward along the lid
 margins. Skin on both eyelids is free from redness, swelling lesions.
Eyeballs are symmetrically aligned in sockets. No swelling or redness
over one as of the lacrimal gland. Has normal distant visual activity at
20/20. Has also normal findings upon performing confrontation test to
assist visual fields. Eye movement should be smooth and symmetric
through out all six directions. CN 3,4 and 6 are all active and intact.

• Ears

Are equal in size by bilaterally the auricle aligns with the corner of
each eye and within a ten degree angle of the vertical position. The skin is
smooth with no lesion, lamp or modules. Color is consistent with facial color.
The auricle, tragus and mastoid process are not tender. Canal walls are pink
and smooth without modules. Small amount of odorless cerumen is the only
discharge hearing acuity is normal and the CN 8 is active.

• Nose and Sinuses

Upon assessing the external nose; color is same as the rest of the
face. The nasal structure is smooth and symmetric; The client reports no
tenderness. Upon assessing the internal nose; the nasal mucosa is dark pink
moist. The nasal septum is intact and free of perforation or ulcers.

• Mouth and Oropharynx

Lips are pink and consistently good, Buccal mucosa is pink in color and
also consistent. Gums are pink, moist and firm with tight margins to the tooth.
Teeth is 16 at the lower part, 16 upper 32 teeth in all, had 32 pearly whitish teeth
with smooth surface and edges.

Tongue offers strong resistance. CN 5, 9 and 10 are all intact and active.

• Thorax and Lungs

Upon inspection the anterior and posterior thorax the skin and sub-
cutaneus tissue are free from lesions or redness. No intercostal reaction
notice. Chest expansion is equal, respiration is 38. Sternum is medially
positioned as well as the trachea. Upon palpation no tenderness noted.
Fremitus is symmetrical and easily identified in the upper regions. Upon
percussion posterior ICS resonance to T10 – T12, anterior ICS resonance to
 2nd and 4th space, lateral ICS resonance to 8. Upon auscultation, in breath
sounds bronchophony and egophony are all muffled while whispered
pectroliloquy is low pitch.

• Inspection (Cardiac assessment)

Intercostal spaces, midsternal line, midclavicular line and anterior

auxially line are all symmetrical upon palpation aortic area had positive pulsation,
pulmonic area, erbs point, tricupid area and mitral area had also positive
pulsations. Upon precussion to defince cardiac borders and auscultation. BP: N/A,
pulse rate: 80, heart rate: 83, site: Apex, rate:83, strength: fair, temporal: 78
carotid:80, apical:81, brachial:79, radial:80, popliteal:80, dorsalis pedis: 80,
posterior tibialis:80, femoral/inguinal: data not available.

• Breast ( Not Able to Assess)

• Abdomen

Upon inspection, skin color is uniform, the skin integrity is fair, umbilicus is
at the midline and symmetrical. Upon percussion, dullness sound at the right
hypochondriac, and tympanic sound in the right lumbar, right iliac, epigastric
region, umbilical region, left hypochondriac, left lumbar, and left iliac. Upon
palpation, there is soft tenderness, and non-tender in the right upper quadrant, left
upper quadrant, right lower quadrant, and left lower quadrant.

• Genitourinary-Reproductive System ( Not able to Assess)

• Musculoskeletal System

The patient’s gait is good, symmetrical, good strength, and his ROM upper
and lower extremities are both active. And also the CN XI is active.

• Laboratory Findings and Diagnostic Procedures

The client’s hemoglobin is 13.4 mg/d/, hematocrit 40.3, RBC 4.8, WBC 1.51,
lymphocytes is 50, monocytes is 13,. Platelet count is 78,000 /cc.mm. The client’s
urinalysis is color yellow, appearance is cloudy, specific gravity is 1.025, ph is 6.0,
a (+) protein and glucose negative.

D. Summary of Significant Findings

• Functional health pattern

• The patient’s health pattern so far manifests remarkable

results. Therefore there aren’t difficulties or problems in terms
of the patients’ functional well being .

• Physical Assessment

• Upon assessment . There no particular unusualities . Moreover

there where no noted physical misplacements only red spots on
the patients skin . Which also denotes capillary damages .
• Laboratory and Diagnostic Tests

• The patient’s platelet count 78,000 / cc.mm is low compared to

the normal platelet count which is 140,000 -440 ,000 cc.mm .
Therefore nursing diagnosis can be formulated as risk for
hemorrhage as evidenced by low platelet count ( coagulating
factor ) . Nursing interventions and priorities as such be
implemented.

 Tooth brushing strokes may be limited to avoid bleeding

of gums

 Movements are to be controlled or monitored as well to

avoid the risk of injuries or bruises

 Monitoring of any unusual signs of bleeding such as blood

present in urine stool should be reported immediately