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Nursing Health History for Nursing Students

by Anna Katharina on June 17, 2011

It is the aim of the new nursing curiculum (CHED CMO # 14 s 2009) to develop competencies utilizing the nursing process in varying health situations.

The first step in the nursing process is assessment and four closely related activities are collection of data, organizing data, validating data and documenting data. Two types of data have to be collected, subjective, and objective data. Part of the subjective data is the nursing health history.

The nursing health history components are

A. Personal or Biographic Data

Ex: Charan Sagar, 34 y/o male, married, accountant, Christian, Indian National, living at Project 7 Quezon City, was admitted for the first time at Century General Hospital.

B. Chief Complaint

“What’s troubling you?” or What brought you to the hospital or clinic?, it should be recorded in the client’s own words
Ex: ” masakit ang tiyan ko ” or ” epigastric pain”

C. History of the present Illness

Clear, chronological narrative account of the problems for which the client is seeking care.
It should include the onset of the problem, the setting in which it developed, its manifestations, treatments, its impact upon the patients life, and its meaning to the patient .
The principal symptoms should be describe in terms of their location , quality, quantity or severity, timing, onset of duration and frequency, setting, factors that have aggravated or relieved these symptoms, associated manifestations.

Example:

The client states that he has been experiencing on and off epigastric pain one month prior to confinement. He claimed that the epigastric pain was accompanied by nausea and heartburn. When these symptoms are present, they wake him up at nigh..It is cramping , and radiates to the umbilical area. Antacids usually alleviate the symptoms

D. Past Health History

Childhood illnesses
Immunizations
Adult illnesses/ Injuries
Psychiatric illness
Previous Operations Hospitalizations
Current medications( frequency and dose)
Allergies to (both food and medication

D. Family History of Illness

The age and health or age and cause of death of each immediate family member
The occurrence within the family of any of the following conditions ( diabetes, TB. Heart disease, high blood pressure, stroke, kidney disease, cancer arthritis’ Anemia, mental patient

E. Lifestyle

Personal habits, diet, sleep/rest pattern, activities of daily living, recreation/ hobbies

F. Social Data

Quality of family relationships/friendships
Ethnic affiliation
Health customs and beliefs, cultural practices that may affect health care
Educational background
Occupational history
Economic status
information how the client is paying for medical care and hospitalization, whether the clients illness presents financial concerns
Home and neighborhood conditions
home safety measures, and adjustments in physical facilities
activity intolerance and activities of daily living
availability of neighborhood and community services

G. Psychological Data

These are major stressors experienced by the client and their perception of them
how they cope up with these stressors
communication to relay appropriate emotion

H. Patterns of Health Care

Includes all the health care resources that the client is currently using and has used in the past.

The nursing health history will provide a baseline data of your client, be sure you know how to phrase the right questions and in a language your client is comfortable with. Use your knowledge of communication techniques and know how to establish client rapport.

Be cordial and respect your client. Use the proper terms or words that your client can understand. When subjective data are incomplete these will create gaps in client’s data, thereby affecting your nursing diagnosis selection.

Be patient, you will learn doing your NCP the right way. Keep reading this blog to guide you in making your NCP the easy and proper way.

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Philippine Spring Cleaning Day

by Anna Katharina on May 2, 2011

in Blogging,Community,Health Concerns,Product Promo,Safety

“I clean. I save,” the Philippine Spring Cleaning Day

In the Philippines, eight out of 10 top causes of morbidity are infectious in nature. These diseases like measles, chicken pox and pneumonia are transmitted by sneezing, coughing, spitting, talking and by air currents. On the other hand, diarrhea can be acquired by contaminated water, food, milk and blood.

The infection process is like a circle of links, its a cycle that goes on and on in a sequential manner. To prevent infection is to break the links in the chain of infection. The links are: infectious agent, reservoir, portal of exit from the reservoir, mode of transmission, and portal of entry into a susceptible host.

To break the link of the chain of infection , there are several ways and methods that can be practiced and thus prevent infection. Prevention of infections should start at home!

• Foremost is hand hygiene, either you use soap and water or the available hand sanitizer. Once I enter our home, the first thing that I do is hand washing.

• Anything that is moist is a breeding ground for microorganism thus a source of infection.

1. In the kitchen, clean and disinfect countertops especially crevices, it will prevent bacteria from hiding there.
2. Replace sponges and wash cloths often.
3. Air or sun dry wash cloths, bath, face towels every day, they can be breeding ground for fungus.
4. Spray the inside of shoes with disinfectant to kill off fungus spores. Never keep shoes in cabinets, air dry them.
5. Clean and disinfect the floor, vinyl tile, and walls inside an air conditioned room every now and then.

• For your children especially if they are toddlers, select play toys that can easily be cleaned and disinfected, stay away from stuffed furry toys if these will be shared with other children.
• Do away with the hanky, it’s unhygienic. Use tissue to Cover mouth/nose when sneezing, and then dispose properly.

If you have more tips on how to maintain cleanliness at home , Join the Philippine Spring Cleaning Day Contest

Give us your best tip on how to clean your home.

1. Put your best tip in Philippine Spring Cleaning Day in commitment/tips page.
2. You also have to email your tip to philippinespringcleaningday@gmail.com with your name and contact number.

Best 20 tips will receive gift packs from Lysol.
Winners will be announced thru Phil. Spring Cleaning FB Fan page – (http://www.facebook.com/philippinespringcleaningday) on May 10, Tuesday.

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Battered Wife and Domestic Violence, Are you at Risk?

by Anna Katharina on May 1, 2011

in Community,Family,Love and Emotions,Nurse Quad,Safety

“Anti-Violence Against Women and Children Law or Republic Act 9262 of 2004″

“ RA 9262 penalizes the commission of violence against women their children (VAWC) in the context of domestic violence or violence in intimate relationships. It defines VAWC as any act or a series of acts committed by any person against a woman who is his wife, former wife, or with whom the person has or had a sexual or dating relationship, or with whom he has a common child, or against her child whether legitimate or illegitimate, within or without the family abode, which results in or is likely to result in physical, sexual, psychological harm or suffering, or economic abuse including threats of such acts, battery, assault, coercion, harassment or arbitrary deprivation of liberty.

Furthermore, the Law recognizes “Battered Woman Syndrome” which refers to a scientifically defined pattern of psychological or behavioral symptoms found in women living in battering relationships as a result of cumulative abuse, as an acceptable defense for actions committed by the victim as a result of battering.”

Who is at risk for domestic violence?

Here 2 tools used by doctors and professionals to help determine your risk for domestic violence.
They are the Lethality Checklist and the Physical Abuse Ranking Scale. These two can determine what you should watch out for in a relationship.

Lethality Checklist:
Count the items that apply to your current relationship. The higher the number of items from this list, the greater your danger potential.

Objectifies you (calls you names, body parts, animals): (Tinatawag ka lang ng kung anu-anung pangalan .
Blames you for injuries (Sinisisi ka sa mga pinsalang nangyari sa inyong katawan o kapaligiran)
Is unwilling to turn you lose ( Ayaw kang pakawalan o mawala)
Is obsessed with you ( nahuhumaling siya sa iyo na itituring ka na niyang isang pag aari na parang kalakal)
Is hostile, angry, or furious ( palagi kang sinasalungat, nanlalaban, o galit nagalit)
Appears distraught (Mukhang palaging nababahala o balisa)
Is extremely jealous, blaming you for all types of promiscuous behavior (sobrang magselos, at sinisisi kang madalas sa immoral o mahalay na paguugali)
Has been involved in previous incidents of significant violence (Nasangkot na siya dati sa ibang karahasan)
Has killed pets (nakapatay na ng mga alaganag hayop)

10. Has made threats (mayroon na siyang ginawang pagbabanta)]
11. Has made previous suicide attempts (mayroon ng ginawang pagtatangka magpakamatay sa sarili niyang buhay)
12. Is threatening suicide (nagbabantang magpapakamatay)
13. Has access to guns (pwedeng makakauha o mayroon baril)
14. Uses alcohol (umiinom ng alak)
15. Uses amphetamines, cocaine, or other drugs ( gumagamit ng mga pinagbabawal na gamot)
16. Has thoughts of hurting you (may saloobin o nag plaplano na sasaktan ka.
17. Has no desire to stop violent or controlling behavior ( walang pagnanais na huminto o pigilin ang sarili sa marahas na pag uugali
18. Has a relationship with you that is extremely tense and volatile ( ang relasyon siyo ay maigting o sumpungin)

Physical Abuse Ranking Scale:

The scale depicts increasing risk with increasing number (’1′ representing low risk and ’9′ highest risk).
Any violent act greater than 5 on this scale indicates a high danger potential.

Throwing things, punching the wall
Pushing, shoving, grabbing, throwing things at you
Slapping with an open hand
Kicking, bitinga
Hitting with closed fists
Attempted strangulation
Beating up, pinning to the wall or floor, repeated kicks and punches
Threatening with a weapon
Assault with a weapon

Reference:

http://www.emedicinehealth.com/domestic_violence/page7_em.htm

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SMACC 53rd Commencement Exercises

by Anna Katharina on March 27, 2011

in Community,Events,Family,School,Traditions

St Mary’s Academy of Caloocan City 53^rd Commencement Exercises

The St Mary’s Academy of Caloocan City celebrated their 53^rd Commencement Exercises on March 26, 2011 at the SMACC Audi –Gym with the theme “ The Ignacian-Marian Graduates: Responding to the call of Christian Charity and Stewardship”.

There were more than 200 graduates as presented by Mrs. Ma. Dolores B. Agoncillo , High School Principal and declared as graduates by Sis Ma. Andes Yee, School Directress.

The SMACC 53^rd Commencement Exercises, was highlighted by Thanksgiving Mass officiated by Fr Allan V. Lopez, OP , followed by the graduation ceremony. There was also awarding of medals to the outstanding graduates of Batch 2011. The Academic General Excellence medals were given to John Arden S. Romanillos, Valedictorian; Mary Rose D. Mercado, Salutatorian; Ma. Liane Claudette C. Bote , First Honorable Mention; Ma. Isabela C. Villacorta, Second Honorable Mention; Ma. Christine F. Tadique, Third Honorable Mention.

The parents and families of awardees of graduating seniors were requested to go to the stage when the grad’s name was called to pin the medals of the awardees. Also there was a slide show of SMACC Batch 2011 graduation pictures.

John Arden S. Romanillos, Class Valedictorian, delivered the Address of Gratitude. He expressed in behalf of SMACC Batch 2011 their sincere appreciation and gratitude to their teachers, school officials and parents whose presence and guidance help ingrained in them the values of faith, love and charity.

Finally the SMACC Batch 2011 gathered on stage to sing The Alma Mater Song and St Mary’s Hymn. Their graduation song was “My Life Begins Today” by Bruno Mars.

The Recessional completed the ceremony and graduates share handshakes, hugs, smiles, and tears with their well-wishers.

Congratulations to the SMACC High School Batch 2011!

Congratulations too to my daughter Roxanne Marie G .Pena , loyalty awardee and a member of SMACC High School Batch 2011. She is my youngest daughter and she’s awesome. I was teary eyed as she gave me her loyalty medal. It will be 6 years more before her next graduation. Hugs and kisses for you my sweet girl!