Chapter II

NURSING HEALTH HISTORY

A. BIOGRAPHIC DATA
Client C.N.L, a 22 years old housewife and first time mother, who
currently resides at Lettac Norte, santol, La union with her husband Mr. Costales.
She was born a Filipina on November 9, 1993. Her religious affiliation is Roman
Catholic. The patient was admitted at Ilocos Training & Regional Medical Center
with a chief complaint of abdominal pain, headache and blurring vision, last
March 8, 2016 at around 5:10 p.m.
B. REASONS FOR SEEKING HEALTH CARE
Client C.N.L. seek medical attention with the following Chief Complaints:
headache,blurred vision,dizzness. Her husband brought her to the hospital.The initial
diagnosis upon admission/imression: G1P0 Pu 381/7 wks, CIL; pre-eclampsia with
severe features.
C. PRESENT HEALTH HISTORY
Patient C.N.L was brought to Lorma Medical Center because of chief complaints
headache, blurred vision, dizzness, and abdorminal pain.
D. PAST HEALTH HISTORY
Patient C.N.L experienced measles, mumps, and chickenpox as a child. She
also experienced diarrhea, fever, cough, colds and self-medicates with over the counter
medications like paracetamol and cough medications before she became pregnant. She
has completed all her immunizations and including two shots of tetanus toxoid during her
prenatal visits. She has no known allergies. She has never been hospitalized before.
This was the first time patient C.N.L was admitted in the hospital.

E. FAMILY HEALTH HISTORY

Grandmother

Grandfather

Grandmother

Mother

Grandfather

Father

Patient

Legend:

Hypertension

Died of old age

Pneumonia

asthma
Deceased

Both the grandparents from the mothers side died from old age. From the
fathers side, the grandmother died from Hypertension and the father died from
Pneumonia. The mother is not experiencing any health problems but the father has
hypertension and asthma. The patient, upon admission has elevated blood pressure and
is suffering from aggravating factors like anxiety, nervousness and fear.
F. LIFESTYLE & HEALTH PRACTICES
1. Description of a Typical Day
Patient C.N.L wakes up at 5:00 am; at times she eats her usual breakfast like
Fruit and vegetables and a small amount of rice.
2. Nutrition and Elimination
Patient C.N.L eats at least 3 times a day and has a snack. Also eats snack and
junks from Jollibee most of the times. Patient C.N.L has a regular bowel movement.
3. Activity level and Exercise
Patient C.N.L does moring excersise when she feels like, she does jogg around
the house and and sweeps around the house.
4. Sleep and Rest
Patient C.N.L sleeps at least 6-7 hours every night. She sleeps at 10pm and
wakes up 5am.
5. Medications and Substance Use

Patient C.N.L. takes paracetamol, when having fever. And she sometimes take
pain reliever gotten from the counter.

6. Environment
The family lives in a bungalow type house made of semi-concrete material.
They buy mineral water as their drinking water. Their garbage is being collected by a
dump truck that goes around in their area.
G. SOCIO-ECONOMIC AND CULTURAL FACTORS
Patient C.N.L. is plain housewife and her husband is an extra laborer on a
construction site. She graduated at a Public High School. And she didnt continue
her college level due to financial problem. Patient C.N.L. was raised as a Roman
Catholic, were she learned about religious values but she still believes in super
natural forces and superstitious beliefs. When it comes in health matters, she
seeks the help of an albularyo and uses herbal medicines to treat any member of
the family who has an ailment. But when serious matters arise she still refers to
medical professionals for help.