UNIVERSITY OF THE PHILIPPINES MANILA

The Health Sciences Center

COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
CHED Center for Excellence Sotejo
Hall, Pedro Gil Street, Manila

NURSING HEALTH HISTORY

Name of the Student: INFANTE, Hene Shane L.
Date of Health History Taking: May 8, 2017

A. Biographic Data

Name: ILOG, Juanita

Address: 55 Doctor C., Bauza Street, Navotas City, Manila
Age: 84 Birthday: August 10,
1979
Sex: Female Race:
Filipino
Marital Status: Widow Occupation: ----
Educational Attainment: Grade 3
Religious Orientation: Roman Catholic
Source of Healthcare Financing: PhilHealth

B. Chief Complaint or Reason for Visit

The clients reason for admission was because of complaints of general weakness and not being able to stand
up after patient accidentally slipped 1-2 months ago.
C. History of Present Illness
Since March to April 2017, the client started to feel aches on her body especially on her upper dorsal region. The
guardian stated that the patient periodically experienced pain in that area. The guardian reported that the patients
condition was caused by her accidental slipping. The guardian also reported that the patient mainly managed the
symptoms by simply having the affected areas massaged by the patients children. The patient had never been brought to
any hospital or received any checkup after the accident. It was on April 26, 2017 when the patient was first admitted to the
charity ward in PGH. The patient had undergone complete blood count, blood chemistry, serum lipid profile, and gram
stain test. On the first week of May 2017, she was advised that she could go home but was held back because the
doctors found out that the patient had pneumonia.

D. Past History
The client had mumps, measles, pneumonia, diarrhea, and worm infestation as a child on ages she cannot recall
any longer. All of these diseases are already treated. The patient stated that she only received one vaccine as a child but
was unsure of what she had received. She also stated that she does not have any allergies. The patient reported that she
was hospitalized last 2003 or 2004 due to surgery of her left eye which was affected by cataracts.

E. Family History of Illness

The client stated that her mother and father have expired. She reported that her father and mother have already
expired but was not sure of what the cause of death was. Moreover, the patients guardian mentioned that the patients
father suffered from a skin disorder, like hers, which they think was eczema. The patient also stated that she has 6 other
siblings, although 3 of them have also expired 3 of her brothers. 2 of her deceased brothers died from lung
complications due to unhealthy lifestyle such as excessive smoking. She mentioned that she was not sure what her other
deceased brothers cause of death was, although she did mention that the same brother also suffered from the same
skin disorder she has. Other than that, all of her siblings are free of the above mentioned conditions. Lastly, her father
and one of her deceased brothers also had the same skin disorder as hers.

F. Functional Health Pattern

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 1. Health Perception and Health Management Pattern

The patient stated that she thinks that she is not that healthy anymore given that she is already old. The patients guardian
stated that the last time the patient got sick was last year and had coughs. She reported that the coughs lasted for almost 1-2
weeks, thus they brought her to a doctor for a checkup. The guardian also stated that the patient does not have any method of
keeping or maintaining her health. She added that the patient, her mother, has never tried smoking or drinking before. Moreover,
the patient does not perform regular self-breast exam for she does not know how to properly do it. The guardian added that the
patient is able to follow the doctors and nurses advice and prescription well. The guardian also stated that she thinks that her
mother is in that condition due to her accidental slipping. However, the only methods they have done to alleviate the pain felt by the
patient is through massaging the affected areas only.

2. Nutritional and Metabolic Pattern

Her usual fluid intake is 4 glasses of water a day. The guardian reported that her mother has severely lost weight after
the accident, but was not sure with the specifics. The guardian stated that the patient has a poor appetite. She stated that before
being hospitalized, the patient usually only drank water and refused to eat any solid food. Currently, the patient can only be fed
every 4 hours. The guardian reported that the patient easily recovers from sickness as long as she takes her meds appropriately. It
was observed that the patient was suffering also from dryness of the skin. The guardian reported occasional neck and shoulder
pains of the client and treated it by massaging the affected area.

3. Elimination Pattern

His usual bowel movement is thrice a day. She described her stool as similar to a mashed avocado which is a bit soft and
greenish in color with no significant odor. She reported no difficulty in eliminating. On the other hand, she reported to void as
frequent as 9 times a day with a clear color and no distinct odor. She has no problem in voiding. She has no problem in his body
odor.

4. Activity-Exercise Pattern

As of now, the client states that she does not have sufficient energy to finish her work. She does not get any exercise as
she cannot stand up and has been lying on the bed ever since she was admitted in the ward. She spends his time at the hospital
by chatting with his significant others and sleeping.

Level of Care
Feeding 4
Bathing 4
Toileting 4
Dressing 4
Grooming 4
General mobility 4
Home maintenance 4
Shopping 4
Cooking 4

Level 0: Full self-care

Level 1: Requires use of equipment or device

Level 2: requires assistance/ supervision (person)

Level 3: Requires Assistance/supervision (person & Device)

Level 4: Dependent; does not participate

5. Sleep-Rest Pattern
The guarding reported that the patient is regularly asleep ever since she was admitted in the ward. During her stay in
the hospital, the guardian stated that her sleeping pattern was disturbed. Although, the guardian reported that the patient does not

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have any difficulties in falling asleep. The patient has her morning and afternoon naps as she is regularly asleep. The patients form
of relaxation is through sleeping.

6. Cognitive-Perceptual Pattern

The guardian states that the patient does not have any problems in hearing and learning. However, the client stated that
she cannot see anything from her right as it is affected by cataracts. The patient also thinks that nothing has changed with regards
to her memory. For her, the best way to learn is when the material is taught or demonstrated to her.

7. Selfperception and Self-Concept Pattern

The client sees herself as sickly as she is already old. She also described her family as simple and quiet. The patient and
the guardian thinks that their main problem that would be hard to resolve is money. However, the guardian stated that they are able
to get by with the help they receive from her other siblings. The client cries and gets annoyed, and sad easily. She sometimes cries
because she has a tendency to feel down whenever she remembers her current condition. She also easily gets annoyed whenever
it is too noisy for her. Whenever she feels these emotions she stated that not minding the causative factors helps her calm down.
Consequently, she does not get nervous or afraid easily.

8. Role-Relationship Pattern

The patient lives with her 2 daughters and her grandchild in their house. She described her family as a quiet and simple
family that helps one another in times of trouble and crisis. Before she was in that current condition, she used to help in doing the
household chores. The current problem of their family is her condition. Because of this, her family is faced with financial crisis
because of her medications. They resolve this problem with the help of her children.

When his family discovered that she is sick, they were surprised and sad. They, too, did not expect it to come along.
Soon, the family accepted the situation and helps in cheering up the clients feeling.

9. Sexuality-Reproductive Pattern

The client stated that before she got into the accident, she did not have any sexual relationships for several as she is
already widowed.

10. Coping-Stress Tolerance Pattern

The patient does not feel tense or nervous. She usually talks to her daughter when she is in need of help or support.
The biggest change in his life is her current condition and hospitalization. Due to this, she has been very dependent on
her daughter. She thinks that her current situation could be improved by praying and asking guidance from the Lord.

11. Value-Belief Pattern

Her family is the most important thing for her. Her dream is to help her family ascend in life. Although, she does not think
that it would be easily achieved as two of her daughters who stay with her does not have work currently. She says that religion is
very important for her and said that she prays every night. As a matter of fact, her sickness made her closer to God and
strengthened her faith. She does not consider his hospitalization as a hindrance to her religious beliefs.

SIGNIFICANT FINDINGS
The patient was assessed for having general weakness, skin disorder, pedal edema, and pneumonia. The patient
perceives her overall health condition as bad as she is already old. The guardian said that the patients medication helped her a lot.
The guardian also added that the patient frequently experiences coughs. The guardian reported that the patient does not have any
methods in maintaining her health. The patient has never consumed or have tried smoking or drinking before. The patient does not
examine her breasts as she does not know how. The guardian also stated that the patient was able to carry out the orders and
advices of the doctors and/or nurses. The guardian thinks that the patients accidental slipping is the reason why the patient is in
that condition. Her usual fluid intake is 4 glasses of water a day. The guardian reported that the patient has experienced sudden
loss in weight but was not sure of the specifics. The guardian stated that the patient has very poor appetite. She also reported that
the patient easily recovers from sickness. It was observed that the patient is suffering from dryness of the skin. Her usual bowel
movement is thrice a day with no difficulty in eliminating. Her stool is a bit soft and greenish and has no distinct color. On the other
hand, she reported to void as frequent as 9 times a day with a clear color and no distinct odor. She has no problem in voiding. As of
now, the patient states that she does not sufficient energy to finish any work. She spends her time at the hospital by chatting with
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her significant others and sleeping. She observed total dependency in feeding, bathing, toileting, dressing, grooming, general
mobility, home maintenance, shopping, and cooking. The guardian reported that the patient is usually asleep. During their stay in
the hospital, she stated that the patients sleeping pattern was disturbed but has no difficulty in getting asleep. The client states that
he does not have any problems in hearing and learning. However, she claimed that she cannot see from her right eye due to
cataracts. For her, the best way to learn is by explaining or demonstrating the material to her. The client sees herself as sickly
because of old age. The patient currently easily cries, gets annoyed, irritated, and sad. She cries easily because she has a
tendency to feel down when remembering her current condition. Whenever she feels these emotions she stated that not minding
them helped calm her. Consequently, she does not get afraid or nervous easily.
The patient lives with her 2 daughters and 1 grandchild in their house. She described her family as a quiet and simple
family that helps one another in times of trouble and crisis. The current problem of their family is her condition and money. Because
of this, her family is faced with financial crisis because of her medications. They resolve this problem with the help of her children.
When her family discovered that she is sick, they were sad. Soon, the family accepted the situation and helps in cheering up the
patients feeling. The patient does not feel tense or nervous. She usually talks to her daughter when she needs help or support.
The biggest change in her life is her current condition and hospitalization. Due to this, she has been very dependent on her family.

Her family is the most important thing for her. Her dream is to help her family ascend in life. She says that religion is very
important for her. As a matter of fact, her sickness made her closer to God and strengthened her faith. She does not consider her
hospitalization as a hindrance to her religious beliefs.

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