A Case Study on NURSING HEALTH HISTORY

Jun 18th, 2015
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Alabama State University
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Nursing health history is the first part of the client’s health status, it is systematic collection of subjective data provided by the patient’s/significant other’s verbalizations and supplemental by objective data gathered during physical assessment. It is needed for solving and determining a patient’s problem and for the nurse to know what interventions to be applied and what may be the cause of the illness. Since our patient cannot really express much of herself due to her condition, we chose to gather information from her mother whom is very close to her.

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NURSING HEALTH HISTORYNursing health history is the first part of the clients health status, it is systematiccollection of subjective data provided by the patients/significant others verbalizationsand supplemental by objective data gathered during physical assessment. It is neededfor solving and determining a patients problem and for the nurse to know whatinterventions to be applied and what may be the cause of the illness.Since our patient cannot really express much of herself due to her condition, wechose to gather information from her mother whom is very close to her.It was on December 28, 2008, Friday, when we chose a case for our individualcase study. During my first encounter with the patient, she was lying on DR table with#1 IVF of D5LR @ 30 gtts/min. hooked at the left cephalic vein.For the patients trust, privacy, dignity and respect we gave herm we decided tohide her name and called her Patient B.Patient B is an 18-year-old female, who is pregnant for more than 42 weeks,married, and a mother of one. She is a Muslim, with fair complexion. Stands 153centimeters and weighs about 83 kilograms. Her AOG is 43 weeks, LMP was lastFebruary 3, 2008, and her EDC would be on November 10, 2008. She was born on May15, 1990 through normal spontaneous delivery at Agusan del Norte Provinvial Hospital(ADNPH). She was the 3rd eldest among the 5 siblings.Patient B grew up at Purok 10, Ong Yiu, Butuan City with her family, and hasbeen used to the Musli

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