MINDANAO STATE UNIVERSITY Iligan Institute of Technology College of Nursing NURSING HEALTH ASSESSMENT I

Student Name: ________________________ Date of Care: __________ Score: ____________ Area of Assignment: _____________________ Clinical Instructor: _______________________ DEMOGRAPHIC DATA Name: Address: Patient X Age:_ 63 yrs. Old . Sex: Male . Status: Married Mabulo , Cebu City Religion: Roman Catholic Occupation: none

HEALTH HISTORY A. Chief complaint/s: Left Hip Pain with discharges B. Impression/Admitting Diagnosis: Chronic Osteomyelitis , Left Hip to r/o septic arthritis sec to ORIF DHS Left C. History of Present Illness: (Location, onset, character, intensity, duration, aggravation and alleviation, associated symptoms, previous treatment and result, social and vocational responsibilities). At dawn of February 22 , 2013 pt. experiences severe pain while sleeping at his left upper part of the thigh on which he has had his surgery before due to fracture that occurs when he slip off from the floor of their C.R. He experiences severe pain; pain was associated with white discharges. The epichondyle of the femoral bone was dislocated and was protruding in the skin. Thus prompted to hospital for consultation and was advised for admission.

D. History of Past Illness/es: (Previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illness, allergies, medication, habits, birth and development ofhistory, nutrition for pedia) Patient has had previous history of hospitalization at the same institution (August , 2008), ORIF DHS Left was ruled out due to fracture at his Left upper hip., No history of infectious diseases, No allergy to food and medication

E. Heath Habits Kind 1. Tobacco 2. Alcohol 3. OTC drugs Frequency Every day Once a week Once a day (centrum) Amount 13 sticks 1 bottle (Grande) 1 tablet Period From middle adulthood up to present From middle adulthood up to present 60 yrs. Old up to present

F. Family History with Genogram History of Heredo-familial diseases: __x__ Cancer __x__ Diabetes ____ Asthma Legend: ____ Hypertension ____ Cardiac Disease ____ Mental disorder ____ Others: ______________ G. Patients Perception Cancer

Genogram (up to 3 generation) DM

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Stroke

Present Illness: ok ra man ko dong medyo sakit siya pero gamay ra kayo nga sakit unya operhan man daw ko pero dili nako ganahn adtong tag 100,000 kay wa nakoi kwrta, ang ako lang ma tang tang ning naka ingon ani sa ako ok na ko bahalag di ko kabalik ug lakaw naa anad na bitaw ko nga lima ka tuig naa rako sa balay. As verbalized by the patient Hospital Environment: : ahw dri sa hospital ok ra man, dili ra kaayo banha dili pud baho, igang lang jud. As verbalized by the patient. H. Summary of Interaction The student nurse patient interaction went well, the patient is coherent and cooperative during the interview, expresses feelings regarding present condition, maintain good eye to eye contact, the patient perceives that The interview is a normal conversation.

SUMMARY OF MEDICATION MEDICATION Tramadol Ofloxacin DOSAGE 500 mg. 400 mg. ROUTE Oral Oral FREQUENCY prn Twice a day REMARKS Given and tolerated Given and tolerated

SUMMARY OF INTRAVENOUS FLUID DATE IV FLUID & VOLUME DROP RATE TIME STARTED TIME ENDED INDICATION