Chapter II

NURSING HEALTH HISTORY

A. BIOGRAPHIC DATA

Client A.A, a 37 years old male, who currently resides at Gonzales, tubao,

La union. He was born a Filipina on September 18, 1979. His religious affiliation

is Roman Catholic. Works as a farmer. The patient was admitted at Ilocos

Training & Regional Medical Center with a chief complaint of Immobility of both

upper and lower extremities, last February 11 2017 @ 7:15PM

B. REASONS FOR SEEKING HEALTH CARE

Client A.A seek medical attention with the following Chief Complaints:

immobilty of extremites. His wife brought him to the hospital.The initial diagnosis upon

admission was; actute spinal cord ijury C4 level.

C. PRESENT HEALTH HISTORY

Patient A.A chief complaint was limitation of movement at extremities. 1 week

prior to admission, pt. was apparently well when he was rigging in his farm until he

accidentally fell. Pt hit back on floor causing a little loss of consciousness, after that he

already experience minimal movement of extremities. Pt. tolerated the condition with no

consultation done and no medication taken persistence of the condition, he then visited

the Nazareno hospital in Agoo when the pain was no loger tolerable and was refered to

illocos taining and regional medical center to have a CT scan and after which he was

admitted at ITRMC because of chief complaints immobilty of extremites.

D. PAST HEALTH HISTORY

Patient A.A experienced measles, mumps, as a child. He also experienced

cough, colds. He has completed all her immunizations and including two shots of tetanus

toxoid. He has no known allergies. He also took OTC drugs such as paracetamol for
fever, biogesic for headache and neozep for colds. He has no allergy to foods, drugs &

animals. And He had never undergone any major/minor operation and he had no history

of fracture. He has never been hospitalized before. This was the first-time patient A.A

was admitted in the hospital. Patient A.A plays basketball daily in the evening after

returning from the farm as his means of exercise.

E. FAMILY HEALTH HISTORY

Grandmother Grandfather Grandmother Grandfather

Mother
Father

Legend:

Hypertension

Patient
Died of old
age

Pneumonia
 Both the grandparents from the mothers side died from old age. From the

fathers side, the grandmother died from Hypertension and the father died from

Pneumonia. The mother is not experiencing any health problems but the father has

hypertension and asthma.

F. LIFESTYLE & HEALTH PRACTICES

1. Description of a Typical Day

Patient A.A wakes up at 5:00 am; at times, he eats his usual breakfast like fruit

and vegetables and a small amount of rice.

2. Nutrition and Elimination

Patient A.A eats at least 3 times a day and has a snack. Patient A.A has a

regular bowel movement.

3. Activity level and Exercise

Patient A.A plays basketball daily, and also cleans the hosue surronding every

evening after his basketball game.

4. Sleep and Rest

Patient A.A sleeps at least 6-7 hours every night. He sleeps at 10pm and wakes

up 5am.

5. Medications and Substance Use

Patient A.A takes paracetamol, when having fever. And he sometimes takes pain

reliever gotten from the counter.

6. Environment

The family lives in a bungalow type house made of semi-concrete material.

They buy mineral water as their drinking water. Their garbage is being collected by a

dump truck that goes around in their area.

DEVELPMENTAL TASK

A. Erik Eriksons Stages of Psychosocial Development Theory

Erikson describes eight developmental stages through which healthily developing human

should pass from infancy to late adulthood. In each stage the person confronts, and

hopefully masters, new challenges. Each stage builds on the successful completion of

earlier stages. The challenges of stages not successfully completed may be expected to

reappear as problems in the future. Each of Erikson's stages of psychosocial

development are marked by a conflict, for which successful resolution will result in a

favorable outcome and by an important event that this conflict resolves itself around.

B. Sigmund Freuds Psychosexual Development Theory

According to Freud, people enter the world as unbridled pleasure-seekers. Specifically,

people seek pleasure through from a series of erogenous zones. These erogenous

zones are only part of the story, as the social relations learned when focused on each of

the zones are also important. Freud's theory of development has 2 primary ideas: One,

everything you become is determined by your first few years - indeed, the adult is

exclusively determined by the child's experiences, because whatever actions occur in

adulthood are based on a blueprint laid down in the earliest years of life (childhood

solutions to problems are perpetuated) Two, the story of development is the story of how

to handle anti-social impulses in socially acceptable ways. My patient belongs to the

genital stage which begins at puberty involves the development of the genitals, and

libido begins to be used in its sexual role. However, those feelings for the opposite sex

are a source of anxiety, because they are reminders of the feelings for the parents and

the trauma that resulted from all that.