Nursing Health History 3rd Yr

Nursing Health History Name: Huang Yi Fei Sex::Female Age: 2 years old Address: sta. Cruz Date of birth: October 23, 2006 Place of birth: Hongkong Religion: Buddhist Nationality: Chinese Marital status: C Chief Complaint: Fever Room no: 510 AMD: Dra. Castro, Cereus Diagnosis: Herpetic Gingivostomatitis Present Health History

The patient started to have an intermittent fever since Thursday and presently on her normal temperature. She experiences a gradual loss of appetite because of mouth discomfort and difficulty in eating and drinking. The patient was brought to the Metropolitan Medical Center one day (June 27, 2009) prior to admission. There are different laboratory test that was done such as Culture and smear test to identify the cause of infection. When vital sign’s taking the patient is still sleeping because of her complain on her mouth. There is an IV fluid of D5IMB 500cc at 80cc level regulated at 40 gtts/min and located at her lower left side of the arm. She was instructed to have a soft diet. Vital signs were check every 4 hours. When the patient was assessed the patient gets tired and irritated easily than other normal child. There was a blister like on the sides of the gums and some sores. The patient’s mother refuses to continue the IV fluid replacement and requested for discharge due to what the doctor said to her last night.

Past Health History The patient was born via normal spontaneous vaginal delivery. The patient is on its first time hospitalization. According to the client’s mother she doesn’t still experience any chickenpox, mumps, &

German measles. Ms. Fei has completed the immunization vaccines according to what the mother recalled—BCG, DPT, OPV, Hepa-B, Measles, were noted. She did not have any minor and major operations. When it comes to childhood eating habits, Ms. Fei prefers to drink milk than to eat. She has no known allergies. .

Family Health History The Family has no known history of hypertension and diabetes. Social History The patient is always inside the house because her parents are afraid for their child to acquire some disease. She was always visited by her grandmother and play with her cousin. The members of the family are open to share when there is a problem within the family or personal problems. They are very close to each other.

Lifestyle The patient loves to watch television and play inside their house. She prefers to drink her milk than eating solid foods. Psychological data The patient is always crying when her mother is not near with her. When she can’t get what she wants she cry and stamp her feet. She shows a little scared when we try to talk to her and take her vital sign’s but as the assessment took longer she feels alright.

Review of the Systems

Urinary System “wala naman siyang masakit na sinasabi pag umihi”as verbalized by the mother Digestive system “Tapos ayaw pa kumain....Parang singaw tapos mapula.” As verbalized by the mother Musculoskeletal system “wala naman siyang ginagawang iba kundi manuod ng t.v at maglaro sa loob ng bahay.” as verbalized by the mother Integumentary System “Wala naman..kahit anong allergies wala.…” as verbalized by the mother Respiratory system “Hindi naman siya hirap huminga..normal lang” as verbalized by the mother