Nursing History And Assessment

I. Client Profile
Patients name is Mary Gene Rose Tan Salimbangon, 50 years old, married. She work as a
pharmacist. She lived at San Antonio, Tubod, Lanao Del Norte. She was admitted on February 2, 2014 at
3:34pm. Her chief complaint is Nephrolithiasis. Her admitting physician is Dr. Tenazas.
II. Clients Brief Personal History
The patient has no any history of food allergies, she have an allergy of antibiotic drug. Patient is
asthmatic, non-alcoholic beverage drinker, non-smoker.
III. Past Medical History
a. Immunization Record
The patient is complete with the required immunizations at birth and beyond.
b. Previous Hospitalization
The patient was hospitalized last January to remove her mass in the breast.
c. Past Illness
She never had any illness in the past.
IV. History of Present illness
Before the admission, patient MS had annual check-up when UTZ was done, she have
nephrolithiasis as a result of her UTZ at right kidney. She was advised for surgery by the doctor.

V. Environmental History
The patient lived at their own house and lot, one storey with mixed materials. Three rooms and
six people living in the house. They have flushed-type of toilet, motor collection of garbage with closed
drainage system, MCWD water system, VECO as their electricity source. They have four dog in their
house.
VI. Developmental History(Erik Erikson)
Patient is a 50 years old. Generativity vs. Stagnation, according to Erik Eriksons stage of
psychosocial development. The adult stage of generativity has broad application to family ,
relationships, work and society. Help growing and grown children to be responsible adults.


VII. Gordons Functional Health Pattern
1. Health Perception/ Health Management
The patient is or strong enough, she is not weak or gets sick easily. She just eat a lot and
take a rest.
2. Nutritional-Metabolic
Before the admission the patient loved to eat salty foods and eating junk foods even
without eating a meal. During the admission, the patient is on NPO.

3. Elimination
Before the admission, Mrs. Salimbangon urinate many times a day, no pain and have a
regular defecation. During the admission she have Fully Bag Catheter attached and have a
irregular bowel movement.

4. Activity-Exercise
Mrs. Salimbangon have no regular exercise, mag tan.aw rako ug TV basta wa koy
trabahuon as verbalized by the patient.

5. Sleep-Rest
Before the admission the patient sleeps at 10:00pm and woke up early at 6:00am in the
morning. During the admission she has no problem in sleeping-Rest cycle.

6. Cognitive Perceptual
The patient was able to answer the questions properly, can hear, approachable and she
can speak properly.

7. Sexuality Reproductive
Her first menstrual period, when she was in grade 6 . A mother of 4 children.
8. Self-Perceptual / Self- Concept
Silent-type man ko, ganahan ko maghilom pero kung naa koy problema ishare pod nku
sa akong bana ug family as verbalized by the patient.
9. Role- Relationship
The patient is the third to the eldest among the four siblings. She is a good mother of
four children, two girls and two boys. She work as a pharmacist.





GENOGRAM:










10. Coping & stress Tolerance
kung kapuyon ko mag tan.aw ra jud kog TV. as verbalized by the patient

11. Values & Belief
Patient is a Roman Catholic. They attended mass every Sunday with her family.




Prepared by:

MUTIA, RHEA MAE B.
BSN-3