West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City
LEVEL IV AACCUP Accredited
Division of Clinical Nursing

I. VITAL INFORMATION

Name: J.S.E. Date of Interview:

Age: 46 years old Informant:

Sex: Female Relationship to Patient:

Address: Alfelor St. , Passi City, Iloilo

Civil Status: Married

Date and Time Admitted: January 6, 2017; 3:15 PM

Chief Complaint: Nadisgrasya ako. ,as verbalized by the patient.

Ward: Orthopedic Service Ward

Bed No.: 9

Allergies: Patient claimed that she is allergic to the scent of mosquito

coil and dust.

Religious Affiliation: Born Again

Physicians Initial: Dr. P

Impression/Diagnosis: Open Book Injury APC II Secondary to MVA

Pre-op Diagnosis (optional): N/A

Post-op Diagnosis (optional): N/A

Surgical Operation Performed (optional): N/A

Days Post-op (optional): N/A

II. CLINICAL ASSESSMENT

II. A.: NURSING HISTORY

1. History of Present Illness

a. Usual Health Status

J.S.E. usually wakes up at around 5:00-6:00 in the morning to make

breakfast for her family and clean the house. She was a former field worker
in a money lending business and goes around towns to collect and lend
 West Visayas State University
COLLEGE OF NURSING
La Paz, Iloilo City
LEVEL IV AACCUP Accredited
Division of Clinical Nursing

money. She doesnt usually get sick except for the usual common cold, fever,
flu and asthma attack. During these moments, she would just take sufficient
rest and drink plenty of fluids. She doesnt take medications if its not really
needed because she believes that it would damage her liver. She usually
seeks medical supervison at Aleosan District Hospital which is 64 km away
from their house. She doesnt believe in doctor kwak. She considers brisk
walking as her form of exercise. She claimed that she does not smoke nor
drink any alcoholic beverages. She is not taking any maintenance
medications.

b. Chronologic Story

3 hours PTC, patient was riding a motorcycle with her husband going to
Pototan when they encountered a Montero in Punong Passi which suddenly turned
without warning. Her husband tried to dodge the vehicle which resulted to them
going out of balance. She cannot recall who fell off the motorcycle first but she was
conscious after the accident. She felt stabbing pain in her leg so she stayed fro
where she fell and waited until a help came and brought them to the WVSU-MC,
thus this admission.

c. Relevant Family History

Patients father was also involved in a motor vehicular accident years

ago as the patient claimed.

d. Disability Assessment

Patient claimed that her current condition has impeded her ability of
performing activities of daily living.

2. Past Health Problems/Status

a. Childhood Illness

(+) mumps
(+) measles
(+) chicken pox

b. Immunization

Patient can no longer recall the immunizations that she received.

c. Allergies

Patient claimed that she is allergic to the scent of mosquito coil and
dust.

d. Accidents and Injuries

None as claimed by the patient.

e. Hospitalization for serious illnesses

 West Visayas State University
COLLEGE OF NURSING
La Paz, Iloilo City
LEVEL IV AACCUP Accredited
Division of Clinical Nursing

Patient claimed that she was hospitalized twice last 2010. Both
were due to pneumonia. On her first hospitalization, she can no longer
recall the month she was hospitalized but she stayed in Aleosan
District Hospital for a week. She undergone x-ray examination. Her
second hospitalization was on July 2010, she stayed in the same
hospital for 3 days and also undergone the same medical procedures.

f. Medications

She was prescribed some antibiotics which she can no longer

recall and salbutamol. Doses and frequency can no longer be
recalled by the patient. She was also prescribed to take steroidal
drug for maintenance for asthma but she didnt complied.

3. Family History of Illness

Heart disease (-) Jaundice (-)

Cancer (-) Bleeding (-)
Diabetes (+)Paternal and maternal Ulcers (-)
Hypertension (+) Paternal Migraine (+) Maternal
Obesity (-) Alcoholism (+) Paternal
Allergy (+) Paternal and maternal Mental Illness (-)
Arthritis (+) Paternal and maternal Hematuria (-)
Tuberculosis (+) Paternal and maternalAsthma (+) Paternal and
maternal

4. Patients Expectations

a. What does he/she expect to occur during this hospitalization?

Ma ayo as verbalized by the patient.

b. What does he/she expect regarding nursing care?

Buligan ko nila. Mayo man sila as verbalized by the

patient.

5. Patterns of Functioning

a. Breathing Patterns

Respiratory Problems: None as claimed by the patient.

Usual Remedy: Not Applicable

Manner of Breathing: Effortless and even

 West Visayas State University
COLLEGE OF NURSING
La Paz, Iloilo City
LEVEL IV AACCUP Accredited
Division of Clinical Nursing

b. Circulation

Usual Blood Pressure: 120/90 mmHg

Any history of chest pain, palpitations, coldness of

extremities, etc: None as claimed by the patient.

c. Sleep Patterns

Usual bedtime: 10:00PM-11:00PM

Number of pillows: 3 approximately 14x19x3 in size; two

pillows are usually placed under her head and one pillow is placed
on her leg.

Bedtime Rituals: Pray

Problems regarding sleep: None as claimed by the patient.

Usual Remedy: Not Applicable

d. Drinking Patterns:

Kinds of Fluid in 24 hours/Amount in mL or Number of

Bottles:

KIND OF FLUID AMOUNT

Water 2000-2500ml
Coke 300ml
Coffee 240ml
TOTAL 2540ml - 3,040 ml

e. Eating Patterns

MEAL USUAL FOOD TAKEN TIME

Breakfast Patient doesnt eat

anything for breakfast.

2-3 cups of steamed rice,

Lunch 1 bowl of sinigang 11:00AM-12:00NN
bangus
2-3 cups of steamed rice,
Dinner 1 bowl of tinolang manok 7:00PM-8:00PM

Snacks Patient doesnt take any

snacks.
 West Visayas State University
COLLEGE OF NURSING
La Paz, Iloilo City
LEVEL IV AACCUP Accredited
Division of Clinical Nursing

Food likes: Tinolang manok

Food dislikes: None as claimed by the patient.

f. Elimination Patterns

1. Bowel Movement

Frequency: Twice a day

Problems or Difficulties: None as claimed by the

patient.

Usual Remedy: Not Applicable

2. Urination

Frequency: 3-4 times a day

Problems: None as claimed by the patient.

Usual Remedy: Not Applicable

g. Exercise: Patient considers brisk walking as a form of exercise.

h. Personal Hygiene

1. Bath

Type: Full bath and Half bath

Frequency: 1-2 times a day

Time of Day: 6:00AM-7:00AM and 8:00PM-9:00PM

2. Oral Care

Frequency: Twice a day

Care of Dentures: Patient doesnt have

dentures.

3. Shaving

Frequency: Patient claimed that she does not

shave.

4. Use of Cosmetics: Shampoo, lotion, soap, toothpaste,

lipstick, perfume, hair conditioner

i. Recreation
 West Visayas State University
COLLEGE OF NURSING
La Paz, Iloilo City
LEVEL IV AACCUP Accredited
Division of Clinical Nursing

Patient usually watches television on her free time or go help

in their church.

j. Health Supervision

Patient seek health supervision at Aleosan District Hospital

and West Visayas State University-Medical Center. She doesnt
believe in doctor kwak.

II.B.: CLINICAL INSPECTION

Date and Time taken: January

9, 2017; 8AM

II.B.1. Vital Signs:

T = 36.9 C PR = 86 beats per minute

BP = 120/80 mmHg RR = 27 breaths per

minute

spO2= 85%

II.B.2. Height:161 cm

II.B.3. Weight:64 kg