Source and Reliability of Informant:
Most information from the patient and additional information from the relatives
Past Use of Health Care System and Health Seeking Behaviors:
Patient has been coming to the hospital frequently due to his condition, Asthma.
Present Health or History of Present Illness:
Patient came to the hospital with complains of chest tightness, shortness of breath, wheezing sound on breathing and coughing especially in the morning or at night.
Past Health History
General Health: (Patient’s own words)
Patient complains about rapid respiration and episodes of shortness of breath.
Allergies: (include food and medication allergies)
There is no known allergy to any food.
The patient is allergic to Sulphur (drugs with Sulphur)
Aminophylin tabs 100mg BD
Salbutamol 4mg TDS
Last Exam Date:
All childhood immunizations received.
Serious or Chronic Illnesses: Asthma
Past Health Screening (see “”Well Young Adult Behavior Health Assessment History Screening”” below) Tuberculosis screening
Past Accidents or Injuries:
Not had any.
Been admitted for many times, uncountable,since childhood.
No surgery ever done to the patient
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): Non-alcoholic
Allergies: Sulphur (mother)
Blood Disorders: None
Cerebral Vascular Accident (Stroke): None
Heart Disease: None
High Blood Pressure: None
Immunological Disorders: None
Kidney Disease: None
Mental Illness: Cousin
Neurological Disorder: None
Seizure Disorder: None
Obstetric History (if applicable) Not applicable
Review of Systems
(Include both past and current health problems. Comment on all present issues.)
General Health State (present weight – gain or loss, reason for gain or loss, amount of time for gain or loss; fatigue, malaise, weakness, sweats, night sweats, chills ):
Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritis, excessive bruising, rash or lesion):
No history of all the above
Health Promotion (Sun exposure? Skin care products?):
Hair (recent loss or change in texture): No
Health Promotion (method of self-care, products used for care):
Nails (change in color, shape, brittleness):No
Health Promotion (method of self-care, products used for care):
Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo): No
Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts): No
Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection):
Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo): No
Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears):
Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell): Seasonal allergies,nasal obstruction and frequent colds are a common symptom.
Health Promotion (methods for cleaning nose):
By use of a clean handkerchief and the patient should do it gently so as not to cause trauma, nosebleeding
Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, alteration in taste): None
Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.):
Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter):
Neurologic System (history of seizure disorder, syncopal episodes, CVA, motor function or coordination disorders/abnormalities, paresthesia, mood change, depression, memory disorder, history of mental health disorders):
Health Promotion (activities to stimulate thinking, exam related to mood changes/depression):
Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold):
Health Promotion (last blood glucose test and result, diet):
Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery):
Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products):
Respiratory System (History of lung disease, smoking, chest pain with breathing, wheezing, shortness of breath, cough – productive or nonproductive. Sputum – color and amount. Hemoptysis, toxin or pollution exposure.): Patient has had history of chest pain with breathing, wheezing, shortness of breath, productive cough, with clear sputum.
Health Promotion (last chest x-ray, smoking cessation):
Medication: patient on bronchodilators
Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):
Health Promotion (last cardiac exam):
Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet, varicose veins, intermittent claudication, thrombophlebitis or ulcers):
Health Promotion (avoid crossing legs, avoid sitting/standing for long lengths of time, promote wearing of support hose):
Hematologic System (bleeding tendency of skin or mucous membranes, excessive bruising, swelling of lymph nodes, blood transfusion and any reactions, exposure to toxic agents or radiation):
Health Promotion (use of standard precautions when exposed to blood/body fluids):
Gastrointestinal System (appetite, food intolerance, dysphagia, heartburn, indigestion, pain [with eating or other], pyrosis, nausea, vomiting, history of abdominal disease, gastric ulcers, flatulence, bowel movement frequency, change in stool [color, consistency], diarrhea, constipation, hemorrhoids, rectal bleeding):
Patient has had a history of diarrhoea once
Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives):
Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness):
Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion):
Urinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence; history of urinary disease; pain in flank, groin, suprapubic region or low back)
Health Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegel exercises):
Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia):
Health Promotion (performs testicular self-exam):
Female Genital System (menstrual history, age of first menses, last menstrual cycle, frequency of cycles, premenstrual pain, vaginal itching, discharge, premenopausal symptoms, age at menopause, postmenopausal bleeding):
Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products):
Sexual Health (presently involved in relationship involving intercourse or other sexual activity, aspects of sex satisfactory, use of contraceptive, is relationship monogamous, history of STD):
Patient has been married for three years now, the couple has a normal sexual life with all satisfactory aspects.
The relationship is monogamous.
Health Promotion (safe-sex practices):
Faithfulness to each other as partners.
Based on this health history and health screening, the following diagnoses were made;
The actual nursing diagnosis made was Ineffectile breathing pattern related to airway blockage by tenacious mucous secretions as manifested by patient’s irregular rapid breathing pattern (Nettina, MSN, & Nettina, 2013).
Readiness for enhanced management of therapeutic regimen is the wellness diagnosis made.
Risk diagnosis made is the risk for activity tolerance related to decreased xygenation (Holloway & Galvin, 2016).
Holloway, I., & Galvin, K. (2016). Qualitative research in nursing and healthcare. John Wiley & Sons.
Nettina, S. M., MSN, A. B., & Nettina, S. M. (2013). Lippincott manual of nursing practice. Lippincott Williams & Wilkins.
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