Nursing Health History

The Nursing Health History is the data collected about the clients level of wellness (present and past), family history and change in life patterns, socio-cultural history, spiritual health and mental and emotional reactions to illness. The nursing health history is obtained through an interview and it is a major component in conducting an assessment. The objective data is used to identify patterns of health problems, deviations from normal and available resources for adaptation. We the level IV nursing affiliates of Butuan Doctors College had our clinical exposure at Philippine Orthopedic Center from November 11, 2013 to November 22, 2013. It was on the third day of duty that we had chosen the client for our Patient Analytical Research Presentation. We were not able to have an interview on her mother because whenever we have our duty, her mother is at work and she has no with significant others. We assessed only the patient and interview her. In accordance to ethical guidelines for conducting a nursing research on our patient based on the principle of ethical conduct of confidentiality which pertains to the duty to respect privileged information, we therefore withhold the real name of the subject. Thus, we shall address the patient as Patient H, a 13 years old female, Filipino citizen, Roman Catholic by faith. We shall address her admitting physicians as Physician 1, 2, 3 and 4. Past History On April 20, 2000, Patient H was born via Normal Spontaneous Vaginal Delivery at their home, assisted by a manhihilot or a Dr. Kwak at Dasma, Cavite. She is the eldest among 4 siblings. She has two brothers and one sister. Her father used to work as a taxi driver while her mother is only a housewife. They transferred in Manila when she was 3 years old. When patient H was 5 years old, her parents got separated. Her father took her 2 brothers. She said sabi nila ibebenta lang daw ni papa yung kalabaw namin noon tapos dina siya bumalik. Dinala niya mga kapatid ko. Sabi nila sa Davao daw. It has been 8 years that they have no communication. Her sister is currently now living at her grandmothers house in Bohol. Childhood (Illness, Injury/ies,Immunization) Patient H has some known illnesses during childhood, she stated, tapos na po akong mag bulutong at tigdas. Minsan nilalagnat ako, ubo at sipon. Health Practices Patient Hs parents often used herbal plants when she was a child such as yerba buena and kalabo in relieving mild aches or common ailments such as cough and fever. She learned self-medication to relieve mild aches and fever like taking paracetamol for fever and OTC antibiotics like cotrimoxazole and amoxicillin for treating cough. Family History of Illness

On her family, they have no history of Hypertension. She stated yung side sa mama ko po, tita ko may Potts Disease rin. At saka tatlo po na tita ko may TB. Ang isa TB sa balat. She also stated that Lifestyle According to patient H, she doesnt smoke and drink alcoholic beverages. She helps her mother in doing household choirs. Diet Patient Hs diet includes eating only few of rice. She loves to eat vegetables such as Okra, Ampalaya, Kalabasa, Malungay and sitaw. She seldom eats meat. Activities of Daily Living Patient H usually sleeps around 10pm and wake up in the morning around 6am. She goes to school at 8am. She eats her breakfast first before going to school.

Social Data Family relationships and economic status

Educational History Patient H is now currently 2nd year high school student of Antonio A. Maseda Integrated High School at Sampaloc, Manila. She was able to go to school on the first 3 months and stopped because of her condition.

Psychosocial Data Theory. History of Present Illness Febuary, 2013 when patient H was cleaning their house, she lifted the cabinet then suddenly heard a click sound at her back. She cant breathe and got so weak. Her mother brought her to a manhihilot only..It took 3 months before they went to the hospital for a checkup. June 18, 2013 when she had her first checkup at Philippine Orthopedic Center. She said pinabrace lang po ako at may binigay na reseta. Nakalimotan ko kung ano yun. Her mother decided to admit her on the hospital when she frequently complains of shortness of breath, difficulty in walking, she cant breathe when standing and pain on her back. She was admitted on the

hospital on October 33, 2013. Her admitting diagnosis was Sci Spinal Level T7-T8 secondary to Potts Disease.