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Nursing Health Assessment

I.

Admission/ Final diagnosis


Hypertension, Superimposed Preeclampsia,
Gestational Diabetes Mellitus
G4 P2 20120
II. Health history and Physical Examination
A. Demographic (biographical data)
1. Clients initials: GGG
2. Gender: female
3. Age, birthdate, and birthplace: 40 yrs old, 6-31976, Sariaya, Quezon
4. Marital (civil) status: married
5. Nationality: Filipino
6. Religion: catholic
7. Address and telephone number: 70, Salitran, city
of Dasmarinas, Cavite
8. Educational background: college graduate
9. Occupation: none
10.
Usual source of medical care: DLSUMC
11.
Date of admission: September 13, 2016
B. Source and reliability of information
The patient was competent to provide information. She
was able to speak clearly; conscious and coherent;
oriented to time, place person. The patients chart was
also included as a secondary source of information.
C. Reasons for seeking care or chief complaints
Complained that she felt dizzy and felt nausea
D.History of present illness
Increased blood pressure
1. Started 3 days ago
2. Occurred only at home
3. She felt really dizzy
4. She felt a little light headed
5. She was watching a TV at noon time
6. She felt dizzy and hot headed.

7. The heat aggravated it and the cold compress she


puts on her neck and nape. And also took her
medications.
8. Shes not too bothered by her illness because she
already had that signs and symptoms before.
E. Past medical history or past health
a.) NA
b.) She had a mild stroke last 2010, when she was 34
years old
c.) She had an inflammation in the gallbladder last
2014, she was 38 years old at this time
d.) Her age of menarche, started when she was 12
years old. Her period is 28 days per cycle, duration
lasts for 5 days. Her last menstruation period was
on January 20, 2016. Her OB scoring: G4 P2 20120
e.) Immunization: not recalled
f.)Allergies: no known allergy
g.) She takes methyldopa 250 mg 2 caps per day for
lowering her blood pressure, Nifedipine 30 mg for
relaxing her muscles to also lower her blood
pressure, Aspirin 80 mg used to alleviate her pain
since she has a pain located in her right gluteal
area due to magnesium sulphate shot,
multivitamins for maintenance of vitamins for her
and her baby, ferrous sulphate as a prenatal
vitamin, Onima Caloma, Iberet used to treat or
prevent vitamin deficiency, and lastly is Caltrate for
maintenance of Calcium
F. Family history

My patients father has both hypertension and


diabetes mellitus. Apart from her and her father, all
members of the family are healthy. She has two
daughters, one is 16 years of age, and the other one is
18 years of age.
G.
Family member/
relationship to
patient
Mark genova
(husband)
Anne Genova
Hannah Genova

Occupation/
source of income

Monthly income

Electrician

Not disclosed

None (student)
None (student)

H.Psychosocial Assessment
Patients age: 40 years old
Developmental stage: adulthood
Developmental task: generativity vs. stagnation
During middle adulthood (ages 40 to 65 yrs), we establish
our careers, settle down within a relationship, begin our own
families and develop a sense of being a part of the bigger picture.
We give back to society through raising our children, being
productive at work, and becoming involved in community
activities and organizations. By failing to achieve these objectives,
we become stagnant and feel unproductive. Success in this stage
will lead to the virtue of care.
Patient was able to achieve this stage. Before she got pregnant
she had a job in the government. She has good relationship with
her daughter. She develops the virtue of care as she establishes it
to her daughters. Although shes having problems with her
spouse, shes able to cope up for her children.

I. Functional assessment
1. Health- perception-health management
pattern
Patient is worried about her health condition but
mostly the future condition of her baby. She takes
her medications for her hypertension because that
is her main concern. She is also aware that her
father had a history of hypertension and diabetes
mellitus.
2. Nutritional-Metabolic pattern
She eats fruits and vegetables every day. Especially
fruits rich in potassium since she have potassium
deficiency.
3. Elimination pattern
She defecates at least twice a day. But she
experiences increased in frequency in urination. She
voids up to 10 times a day due to her medications
and also to her pregnancy.
4. Activity-exercise pattern
Patient is hypertensive and also has potassium
deficiency so thats why she doesnt engage in any
exercise activities. Although she spends her leisure
time with watching shows in televisions and
listening to music. She also spends time with her
baby as she let him hear music.
5. Sleep-rest pattern
Person has sleep pattern disturbance r/t
environmental stimuli. She said shes not used to
noisy environment. And she falls asleep at home
with the help of her television. Person looks relaxed.
6. Cognitive- perceptual pattern
Patient doesnt have any sensory deficit. She was
able to express herself clearly and logically. She is
well educated.
7. Self-perception-self-concept pattern

Patient is well-groomed. She is comfortable with her


appearance
8. Role relationship pattern
Patient do her best and show it to her daughters
thats she is a good role model. Shes hard working
and brave. Because even though shes having a
hard time keeping a good relationship with her
husband. Shes still being courageous for her
children
9. Sexuality-reproduction pattern
She is not satisfied with her relationship with her
spouse due to another woman. She claimed that her
baby right now was not planned
10. Coping- stress tolerance pattern
Patient claimed that she just listens to music or
watch and spend time with her children to be able to
cope up with stress. And this helps her relieve stress
11. Value-belief pattern
Shes a catholic so she loves to go to the mass
every Sunday with her family. She do her best in
practicing morality at home or anywhere and also
she teachers her children good manners and right
conduct
J. Review of systems and physical examination
System
1. general

2. integument

R.O.S
her wt. is
maintained. She
experience
fatigue and
weakness
No history of skin
disease, recent
hair loss, and no
changes in shape

P.E
Patients wt: 165 lbs

(+)
hyperpigmentation in
the axilla area and
nape

of the nails
3. head
Experiences
frequent dizziness
4. eyes
Uses glasses only
when reading
5. ears
No presence of
problems
6. nose and sinuses Experiences nasal
stuffiness and
congestion
7. mouth and throat No presence of
any problems
8. neck
No presence of
any problems
9. breast and axilla Experiences
breast tenderness
due to lactation
10.
respiratory No presence of
any problems
11.
cardiac
hypertensive
12.
Gastrointestinal
13.
Urinary

14.

genitalia

No presence of
any problems
Experiences
frequent urination
due to
medications
No presence of
any problems

Bp: 130/70
prehypertensive

(+) positive pain on


the sinuses

Can feel pain near


the nipple areas of
both boobs

Previous bp upon
admission is 140/90