Baliuag University

College of Nursing
Baliuag, Bulacan

I. BIOGRAPHIC DATA

Name: Kimberly Tiu

Address: #415 Gil Carlos St., Baliuag, Bulacan
Contract No. : 09154148295
Birthdate: January 21, 1992
Birthplace: Plaridel, Bulacan
Age: 17 y/o
Occupation: N/A
Sex: Female
Civil Status: Single
Religion: Roman Catholic
Nationality: Filipino
Educational Attainment: College Freshman
Ordinal Position in the Family: 2nd among 4
Name of Spouse: N/A
Number of Children: N/A
Date of Admission: April 18, 2009
Attending Physician: Dra. Lourdes Cruz
Chief Complaint: flank pain for 3 days
Diagnosis: Urinary Tract Infection

II. REACTIONS AND EXPECTATIONS TO ILLNESS, HOSPITALIZATION, DIAGNOSTIC STUDY

AND PERSONNEL

A. HISTORY OF PRESENT ILLNESS

She was admitted last April 18, 2009 at 3:45 in the afternoon as she was
complaining of flank pain three days prior to admission. According to her, the pain
becomes worse and she has felt pelvic discomfort more frequently. It started from a
scale of 4 to 8, based on the pain assessment scale, where 1 is the least painful and 10 is
considered as very painful. Since yesterday, she has felt pain in the flank area early in the
morning and has recurred several times throughout the day. She has also felt hot since
yesterday afternoon. She also experienced difficulty in urinating for 2 days now. She has
taken Paracetamol (Biogesic) every 6 hours since she had fever and has increased her
fluid intake since yesterday.
She was seen and examined by Dra. Cruz and was advised to have her urine
tested. Urinalysis reveals a WBC count of 20-25, her temperature was taken as 38˚ C /
axilla and was subsequently admitted. She was given DSLR 1 liter for hydration and
Cefuroxime 750 mg every 8 hours for her antibiotics. Her vital signs were monitored
continuously. She was then transferred to Room 308.

B. HISTORY OF PAST ILLNESS

1. Childhood Illness

She had chicken pox when she was 4 y/o, measles at 5 y/o, and mumps at 5 y/o.
She also experienced coughs, colds and fever.
 2. Allergies

She stated that she is allergic to legumes like nuts and beans. She is also allergic
to penicillin and penicillin based antibiotics.

3. Accidents/Injuries

She didn’t experience any major accidents and injuries aside from minor
abrasions and cuts acquired in her early childhood while playing.

4. Hospitalization

She stated that she was previously hospitalized for a week at Castro Maternity
and General Hospital (CMGH) last April 1996 due to her measles. She visits CMGH
regularly for her regular check up.

5. Medications, Immunizations

She is not fond of taking over the counter medications and dietary supplements.
She is currently taking Cecon (Vitamin C), once a day as her vitamin supplement. She is
not fully immunized. She received a shot of BCG, 2 doses of DPT and OPV and a dose of
Hepatitis B vaccine. She has not received the Measles vaccine.

C. FAMILY HEALTH HISTORY

1. Father Side

Her father frequently smokes tobacco and is a habitual drinker. At present, she
doesn’t know of any genetically predisposed illness in her paternal side. She stated that
her great grandfather had lung cancer and all of her paternal uncles smoke, either
cigarette or tobacco.

2. Mother Side

Her mother died when she was still 7 years old due to cervical cancer. My client
stated that Diabetes Mellitus and Hypertension is present in her mother’s family that
two of her mother’s sisters have Diabetes and her Grandfather and uncle are
hypertensive. No other member of the family has history of cancer.

3. Siblings

Her siblings are generally healthy although her youngest brother sometimes
experience difficulty of breathing usually after playing ball games and contact sports.
Her eldest sister was previously hospitalized last May 2008 at Castro maternity and
General Hospital of Urinary Tract Infection.

III. ACTIVITES OF DAILY LIVING

A. CIRCULATION

Her blood pressure is 100/70 mmHg. Her pulse rate is 75 beats/min in regular
rhythm. She is weak in appearance. Her conjunctiva is pale but there is no palmar pallor.
nail beds are pink in color.
B. RESPIRATION

Her respiratory rate is 18 breaths per minute. Quiet, rhythmic and effortless
respiration is noted. She does not have cough and has not experienced shortness of
breath during activities.

C. FOOD/FLUID

She eats three meals daily with snacks in the afternoon. She takes her breakfast
and diner at home and it is usually prepared by her father. She takes her lunch at the
school canteen. Her usual viand is pork and chicken. She consumes 1 cup of rice every
meal. She seldom eats vegetables. She is fond of eating hamburgers and chips during
snacks. She also eats vanilla ice cream two times a week. She does not skip her meals. As
for her fluid intake, she drinks 2-3 glasses of cold water a day, and 3-4 bottles of Coke or
Sprite. She takes a cup of dark coffee in the morning as part of her breakfast.

2 days prior to admission, she experienced sudden loss of appetite, but she has
increased her fluid intake to 5 glasses of water since yesterday. She is on DAT – Diet as
Tolerated, but is advised to avoid salty and spicy foods, especially junk foods and to also
avoid carbonated drinks. She was also advised to take 6-8 glasses of water or more,
everyday.

D. ELIMINATION

She defecates once every morning. Its usual color is brown and is soft in
consistency. She urinates 4-5 times a day. Its usual color is dark yellow. She has not
experienced difficulty or pain on voiding or defecating.

During her illness, she experienced flank pain and pelvic discomfort. She also
stated that she has difficulty voiding for 2 days now. Its color is dark yellow, small in
amount, concentrated, usually 6-7 times a day. There is no significant change in her
defecation pattern.

E. PERSONAL HYGIENE

Her shoulder-length hair is usually tied up with a ponytail. He wears light

make-up, cheeks blushed, and pink lipstick. She takes a bath once every morning and
washes her face and feet before she goes to sleep. She uses a deodorant, a perfume
and a scented lotion. She carries a pressed powder with her when she goes to school.
She brushes her teeth twice a day.
During hospitalization, she still does her daily self care regimen except for going
to the bathroom on her own because of the intravenous fluid inserted on her left
hand. While she is in the hospital, she washes her face and extremities frequently and
has not yet taken a complete bath.

F. EXERCISE

She does not have a regular exercise program but she plays volleyball with her
friends during vacation.
G. USUAL PAIN OR DISCOMFORT

She seldom experience pain or discomfort. She experiences headache only after
a very tiring and hectic schedule, relieved by a sound sleep.
During her illness, she was able to manage pain by taking an analgesic. Since she
has not been feeling well for 3 days now, she went to the hospital (Bulacan Medical
Center) as she was accompanied by her elder sister, to seek for medical advice, and
was subsequently admitted.

IV. COMPETENCIES
a. Physical

She is ambulatory. She is able to move, sit, stand and walk without assistance.
She is able to perform her activities of daily living without any difficulty. She helps to
do the household chores and goes to school everyday.

b. Emotional

She is living harmoniously with the rest of the family members. She has lots of
friends both in school and in the community and is able to relate with them well.
When she has problems, she always asks help either from the family members or her
friends.

c. Mental

She is a first year Nursing student and an achiever in school. She can sing, dance
and play the piano. As I talked to her, she can answer my questions well and able to
relate past situations to the present. She is able to recall past experiences and share
about the questions asked appropriately. She is able to maintain a good eye contact
and is very cooperative.

d. Spiritual

She is a Roman Catholic. She attends the Sunday Mass every week. She serves as
a choir in their chapel in their community. Before going to sleep one of her rituals is
praying to thank God for the blessings that she has received for the day.

e. Social
She mingles and makes friends both in school and in the community. Every week,
she tries to go out with her friends after a tedious work at school. She also spends
time with her siblings, watching movies, eating, and going out of town. She is the
P.R.O of their class and is active in co-curricular activities.

f. Environmental
She maintains cleanliness and orderliness in the house. According to her, she
cannot work with a dirty and messy environment. Few blocks away from their house
is a Rural Health Unit for consultation, a dental clinic and a water station. It would
take a 5 minute tricycle ride to be able to go to the market, church, cemetery, and
grocery store. The house is free from rodents, pest, mosquitoes, and cockroaches.
They have a garden with herbal plants grown and maintained by her father.

Prepared by: Nurse Betty