BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

NURSING HEALTH HISTORY

A. Biographic Data
1. Name: M.L.L
2. Address: Purok 3, San Pablo, Malolos City. Bulacan
3. Age: 39
4. Sex:  Male Female
5. Nationality: Filipino
6. Marital Status Single Married Separated Widow
7. Occupation Housewife
8. Religious Orientation Roman Catholic
9. Healthcare Financing and usual source of medical care: Rural Health Unit (RHU)

B. Current Pregnancy
1. LMP: April 7, 2019
2. AOG: 28 Weeks and 1/7 days
3. EDC: January 14, 2020
4. Ask if she experience the following since LMP: Spotting Bleeding  Abdominal Cramping
5. Ask her opinion about the time of conception and when is the infant due?
“Excited na ako lalo na ngayon pitong buwan na akong buntis di pa rin talaga nawala ung excitement kaya nagsisimula na ulit kaming bumili
ng mga gamit ni baby” as verbalized by the patient
6. Attitude towards pregnancy Planned  Unplanned Wanted Unwanted
7. Pregnancy Test result  Positive Negative Not done
8. Discomforts since LMP  Nausea Vomiting Fatigue  Urinary Frequency
 Breast Tenderness

C. Past Pregnancies
1. Number of Pregnancies: 5_________________________________________
2. Number of Abortion: 0_________________________________________
3. Number of Living Children: 4_________________________________________
4. History of Previous Pregnancies

First Name Age Length of Length of Type of Birth Birth Weight Type of Feeding
Pregnancy Labor
1
2
3
4
5

5. GP TPAL Score: ___G5P4 (T4P0A0L4)__________________________________

D. Gynecologic History

1. Date of Last Pap Smear: Normal

__*Forgotten by the patient______ Abnormal Not done
2. Previous Infections: Vaginal Cervical Tubal Sexually Transmitted None
3. Previous Surgeries: None_________________________________________
_________________________________________
_________________________________________
_________________________________________

4. Age at Menarche 14 years old

5. Use of Contraceptives
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 Type of Still Describe experience while using the contraceptive
Contraceptive using?
(Y/N)
1

E. Chief Complaint or Reason for Clinic Visit

1. “What is troubling you?”
“Madalas ako makaramdam ng hilo at palaging namumutla” as verbalized by the client

F. History of Present Illness

1. Ask what is the chronological sequence of events in reference to the client’s chief complaint:
o When symptoms started?
The symptoms started a year ago
o How often? Are the symptoms always present or on and off?
“Nararamdaman koi to tuwing napupuyat ako” as verbalized by the client__
o Describe location, intensity and quality of each symptom?
“Minsan talaga namumutla ako ng sobra pero pinagpapahinga ko naman magiiging ok na rin after ilang oras” as verbalized
by the patient
o What are the precipitating and/or aggravating factors?
“Mabilis akong mainis kahit sa maliit na bagay lalo na tuwing maingay” as verbalized by the patient___
o What kinds of activity are doing to when problem occurred?
“Tinutulugan ko nalang para hindi lumala ang galit ko at maiwasan ang tension sa loob ng bahay” as verbalized by the
patient
2. Was help or any medical consultations sought? Yes No
3. What home remedies or medications were taken to relieve these symptoms?
“Noong hindi pa ako nagbubuntis umiinom lang ako ng paracetamol, ngayton tubig at pahinga nalang” as verbalized by the
patient
4. How did the health problem and its symptoms interfere with daily life?
“Hindi ko naaasikaso ang mga anak kong pumapasok at hindi makagawa ng mga gawaing bahay” as verbalized by the patient

G. History of Past Illnesses

1. Childhood diseases  Fever Cough Colds  Ear Infection
 Diarrhea  Measles  Mumps
2. Immunizations  BCG  Hepa B  OPV  DPT
Toxoid Others: ___________________________________________
3. Allergies: NONE__________________________________________________
__________________________________________________
4. Accident and Injuries: NONE__________________________________________________
5. Hospitalizations Year: ________ Diagnosis: ________________________________
Year: ________ Diagnosis: ________________________________
Year: ________ Diagnosis: ________________________________

6. Medications (Ask medications the patient have been prescribed oftentimes and/or any OTC drugs commonly taken for illnesses)
The patient did not take any medications since she knows that she is pregnant

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H. Family History of Illnesses
(Draw genogram here)

Narrative:
The patient is married; they have 4 children- 3 son and 1 daughter. She is currently pregnant now for 7 months. She had 1 brother. The
patient’s mother has 1 brother and also her father. Both of her grandfather and grandmother are already deceased
I. Functional Health Pattern

a) Health Perception and Health Management Pattern

1. How has the general health been for the patient?
“Kinakaya ko naman araw-araw, awa ng Diyos wala pa nangyayare sakin na malubha” as verbalized by the patient
2. Are there important health practices he/she always abides to stay healthy? (This depicts any folk/traditional/home remedies for
illnesses; e.g. cold remedy)
“Nilalayo naming sa kwarto yung mga may sakit para di kami magkahawaan” as verbalized by the patient_________
3. Use of: Alcohol  No Yes Bottle/day: ______________
Cigarette  No Yes Sticks/day: ______________
Prohibited Drugs  No Yes Amount/day: _____________

4. In the past, has it been easy to comply with doctors’ prescription and nurses’ advices? If any difficulties experienced, specify and explain.
Yes it is easy
5. If patient had hospitalizations or clinic visits in the past, are there important issues, suggestions and reminders the patient would
like to raise to improve healthcare delivery? How can nurses be more helpful to patients?
Yes she would like to improve the service and have more alternative medication given by the medical personnel. Such as herbal
medicine or natural medicines
6. Traditional concepts of health and illness, beliefs and practice
She used herbal oil to lessen her dizziness (Katinko)
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 b) Nutritional and Metabolic Pattern
1. 72-hr Diet Recall:

Day 1 (Date) Day 2 (Date) Day 3 (Date)

Breakfast
Lunch
Dinner

2. Ask how the patient describes his/her appetite.

The toleration of her diet is good but there is also some change in her appetite
3. Ask if patient experiences eating discomfort or is currently on specific diet restrictions. (E.g. dental problems, low fat diet)
There are no eating discomforts felt by the patient.
4. Know if patient has wound healing issues.
None.__

c) Elimination Pattern
1. Urinary/Bowel Elimination Pattern

Urine Stool
Frequency 5 Times a day 2 Times a day
Color Bright yellow Brown
Discomfort None Hemorrhoids
Characteristics Cloudy hard

d) Activity – Exercise Pattern

1. Discuss and describe the Patient’s Activities of Daily Living (ADL)

“Tuwing umaga pinaghahanda ko ng makakain ang mga anak ko para nakakain bago pumasok sa scholl at naglilinis lang ng
bahay kapag tapos” as verbalized by the patient
2. Is energy sufficient to sustain daily activities?
“Madali na ako mapagod, hindi ko na rin masyado nagagawa yung mga dating nagagawa ko tulad ng ibang gawaing bahay,
lalo na yung paglalaba” As verbalized by the patient
3. Leisure activities and child-play activities, if appropriate
“Madalas nanunuod lang ako ng TV at kung walang pasok ang mga anak ko tinuturuan ko sila magbasa” as verbalized by the
client
4. Perceived Ability to Perform ADL (Graded by Level):

__1__ General Mobility __0__ Feeding __0__ Bathing _0___ Toileting

__1__ Bed Mobility _0___ Dressing __0__ Grooming __1__ Cooking
___1_ Home Maintenance __1__ Outdoor Activities (E.g. Shopping)

Suggested Functional Level Classification:

Level 0 – Full Self Care or Completely Independent
Level I – Requires use of equipment or device
Level II – Requires help from another person for assistance, supervision, or teaching
Level III – Requires help from another person and equipment device
Level IV – Dependent, does not participate in activity

e) Sleep – Rest Pattern

1. Approximate hours of sleep at night _____6-8 hours___________
2. Sleep characteristics (if continuous or not; if with sleeping difficulty)
The sleep pattern of the client is not continuous because of her younger daughter who is 5 years old
3. Is there a need for sleep-inducing medications?
None.

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 4. Does the patient feel rested after waking?
“Pakiramdam ko naman hindi kulang tulong ko, hindi naman ako nakakaramdam ng kakaiba kapag gising” as verbalized by
the patient
5. Is the patient taking naps in the afternoon? If yes, how long?
The client takes naps at least 2 hours after her son/daughter goes to school
6. Relaxation habits (watch movie, reading books, dancing, shopping, etc.)
The client used to watch movie/teleserye until she get asleep

f) Cognitive – Perceptual Pattern

1. Sensory alteration
Visual  No Yes Specify: ______________
Auditory  No Yes Specify: ______________
Olfactory  No Yes Specify: ______________
Gustatory  No Yes Specify: ______________
Balance  No Yes Specify: ______________
Muscle coordination  No Yes Specify: ______________
2. Use of eyeglass and previous checkups: None
3. Use of hearing aids and previous checkups None
4. Memory status (memory losses, if one has) None
5. Learning Strategies (Easiest way to learn things? if the patient understands things better by reading, listening, or in other ways of
learning)
The client uses listening skills as her Learning Strategy
6. Any discomfort/pain, how do you manage it?
Contraction, tolerable as interpreted by the client

g) Self- Perception and Self-Concept Pattern

1. “How do you describe yourself? Do you feel good about yourself?”
The client is well-kept, and she likes to wear make-up

2. How the patient see the physical changes in his/her body and changes on activities he/she usually does. (physiologic changes
occurring in
The client is aware that she’s gaining weight because of her pregnancy and she takes it as normal changes pregnancy)
The client is aware that she’s gaining weight because of her pregnancy and she takes it as normal changes
3. What are the things or situations that easily make the patient angry, annoyed, fearful, anxious or depressed? What helps him/her to
cope with these?
“Naiirita ako pag maingay” as verbalized by the patient “At minsan nagkukulong ako sa kwarto” the way the clined copes the
problem

h) Role – Relationship Pattern

1. Is the patient living alone? If living with his/her family, describe their family structure and availability of support system.
She is living with her family, her husband and her 4 children
2. Common family problems and how these were handled
The common family problems that they usually face are financial problem. They handled it by budgeting their weekly
allowance.
3. Issues with dependent member in the family and how these get managed, if applicable.
None.
4. If appropriate, how do significant others feel about the illness and/or hospitalization?
“Lagi silang nagaalala sa akin syempre medyo may edad narin kasi ako” as verbalized by the patient
5. Problems encountered within social groups, close friends, workplace.
None

i) Sexuality – Reproductive Pattern

1. Discuss any changes or problems in sexual relations
None.
2. Inquire about use of contraceptives and family planning.
None.
3. Include menarche, LMP, menstrual problems, and pregnancy-related concerns.
The client’s family is always worried about her pregnancy because of her age.

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 j) Coping – Stress Tolerance Pattern
1. Tense a lot of time? What helps? Use of any medicine, drugs or alcohol?
No.
2. Who’s most helpful in overcoming life stresses? Are they available at all times?
The most helpful in overcoming her life stresses are her children. Yes, they are always available to be with her because they
are living in the same house
3. Any big changes which put an impact to your life in the last year or two?
None.
4. How do you handle life stressors? Is your coping mechanism found to be effective?
The client always makes time to her family because they are the one who makes her happy.

k) Value – Belief Pattern

1. It discusses things or relations patient value the most.
The client value her family especially her children
2. Religion and religious practices.
The client is Catholic, and she goes to church with her family every sunday
3. It discusses how the patient sees his/her spiritual being and how one’s belief help or interfere in any health-related matters.
When the client prayed she feel calm, stress free, and feels like God got her back so it brings positivity in her daily basis

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