NURSING HEALTH HISTORY

The Nursing Health History is a systematic collection of subjective and objective data
with the step by step process inculcating detailed Information which provides a conceptual
baseline data utilized in developing nursing diagnosis, subsequent plans for individualized care
and to assemble all the information that will help us understand the Patients life experience.

Nov. 16, 2009 when the level II Nursing affiliates of section 23 had their first exposure in
Butuan Special Education Center. Nov. 23, 2009 at 8 in the morning in section Violet, visually
impaired section, we were assigned to observe and we met our client. Our group decided to
choose Client Y as the subject of our study.

This morning we are going to discuss the Nursing Health History of our client, all the
gathered information was based on Clients significant others, Clients laboratory results, Clients
record noted during the treatment which was given to us by the Patient’s Mother . The Data were
gathered when we had our first interview to the Client’s mother on Nov. 23, 2009 and when we
had our home visit last Dec. 19, 2009.

For the Privacy and dignity of our client, we decided to call him Client Y. Client Y is an
8 yr. old male who stands 130cm or 4ft and 3 inches and weight 41 kilograms or 90.39 pounds
with the body mass index of 24.3 kilograms/m2 which classified as overweight. A Roman
Catholic by faith and is basically residing with his family at Purok 7 Barangay Lumbukan,
Butuan City Agusan del Norte, Philippines.

INFORMANTS:

Name: Mrs.Y
Relation to the Patient: Mother
Apparent understanding
of the Present situation of the Patient:
“Sa Sugod di jud ko musugot nga kuhaon ang mata sa ako anak, pero ang ingon
sa doctor kinahanglan jud, mao to nagsugot nalang ko. Luoy man jud pero la naman me
mabuhat ana.”
Other characteristics and attitude Of the informants: The Informant was responsive and willing
to answer all questions and elaborate on them.

Name: Ms. X, Ms. A and Ms. B

Relation to the Patient: Sisters
Apparent understanding of the Present situation of the Patient:
“Naluoy rami sa iya kay kuhaan man siya ug mata, Ingon daw sa Doctor mao man
pod daw maka-ayo sa iya. Mag-guide nalang
me sa iya. Makahilak nalang me.

Other Characteristics and attitude: The Informant was responsive and willing to answer all
Questions and elaborate on them.

FATHER’S PROFILE:

Client Y’s Father is currently working in an international cruise ship as a cook. He is

currently away with his family to earn money. He was there for almost 10 years. When asked
about the condition of the child, the mother verbalizes what her husband felt. “Sa una la pa
namo gisultian nga ing-ana ang sitwasyon ni patient Y kay naa baya siya sa barko, basin maunsa
siya digto ba. But tong amo na gidala si Client Y sa Cebu, digto na namo gipahibalo sa
sitwasyon. Wala jud niya nadawat kay bata pa jud lage si patient Y. Nagwild siya digto ug ako
iya gi-sisi sa nahitabo ako anak. Nagniwang jud siya.” But because of the incident done by Mr.
Y, He was demoted.
When asked if there is any history of illness or diseases on the eyes on paternal lineage;
Mrs. Y replied, Ang lolo ni Client Y sauna nasakit ug namatay kay nagdaku ang mata, gibarang
lang to siya kay kada mag-high tide magdaku pud iya mata nga hangtod nibuta, Mao to iya
gikamatay.”

MOTHER”S PROFILE:

Mrs. Y is with her 4 children living with the mother of her husband in purok 7 barangay
Lumbukan Butuan city. As a teenager, she was not in any vices and during her pregnancy she
was very careful with her child.

SIBLINGS:

Client Y has 3 siblings. His older sister, Ms X aged 13 yr. old and is currently studying at
Lumbukan National High School. When asked about her reaction when he knows the condition
of her little brother, she only said “naghilak ko kay naluoy man ko sa iya.” Her older sister is 5
yrs older than Client Y. The Second sister of Client Y is Ms. A, 12 year old and studying at
Lumbukan Elemtary School and was also asked and simply replied “mao ra gihapon, naluoy ko
kay bata pajud siya. Siya amo baby ato na mawala pajud mata.” The Third sister is the closest
sister of Client Y; Ms. B age is 10 year old. She is also studying in Lumbukan Elementary
School. When asked about her reaction about the condition of client Y, She verbalized “Sa sugod
luoy jud ug nanghilak me, pero karun dawat na namo kay ok naman si client Y.”

PRENATAL:

Mrs. Y found out about her Pregnancy during the 3rd month. When she was pregnant with
her fourth child, she was glad hoping that it was a baby boy. At that time, Mrs. Y had a Urinary
Tract Infection and was taking a medicine, we tried to ask what drug she was taking, but
unfortunately, she can’t remember the drug she was taking. When she found out that she’s
pregnant she discontinued the use of the drug. She took the vitamins given by Dr. Jumapao.
During her pregnancy, during the first trimester, Mrs. Y lost her apetite, “Sa first trimester murag
nawala man ang ako gana sa kaon, nagbalik lang ako gana pagka 5 months.”
During Mrs. Y’s previous pregnancies, she already had taken Tetanus Toxoid 1, Tetanus
Toxoid 2, tetanus toxoid 3, tetanus toxoid 4 and Tetanus toxoid5. She verbalized that “Fully
immunized naman ko adeser nag-abot si client Y.”

BIRTH:

Client Y was born on September 23, 2001 through Normal Spontaneous Vaginal delivery
at their house in Purok 7 barangay Lumbukan. During the Delivery of Patient Y, the Quack
doctor had a difficulty on the delivery of the child. Mrs. Y verbalized “Naglisod man ko
pagpananak kay dako man kayo ang bata, dili siya mugawas kay nasangit siya sa akong buna-
buna.”

INFANCY:

When Client Y was 1 year old, He was able to manifest developmental milestones that
the normal children usually experience at his age.
 Mrs. Y testified that she breastfed Client Y up to 3 days of age and proceeded to bottle
feeding. When asked about the immunization of Patient Y, Mrs. Y said “Kumpleto naman na
siya ug pa-immunized. Fully immunized na siya sa santos hospital me nagapa-immunize adtong
mga last nah nga immunization niya sa barangay clinic nalang kay layu-an name kung sa santos
pa.”

CHILDHOOD:

Client Y had a normal experience of childhood. As a child, Client Y is very jolly and fun
to be with. He loves being with people he knows. He also loves to play and watch cartoons.

When he was 1 year and 11 months old, he started showing signs of blindness, At first
Mrs. Y was just observing his son’s actions. “Sa sugod, mabantayan nako nga magluha-luha iya
mata ug mutan-aw siya ug tv duol na kaau ug murag maglibat-libat kung mutan-aw.” As testified
by Mrs. Y. This Observation made Mrs. Y decided to have her child checked with the specialist.

COURSE OF TREATMENT:

When Mrs. Y noticed that client Y kept on banging when he walked and when he
positioned himself very near in watching television, She decided to have him checked. They
visited the clinic of Dr. Rey Villanueva in Villanueva’s Eye Clinic; On September 11, 2003.
After the Eye Examination, Dr. Rey Villanueva referred Mrs. Y to go to Cagayan de Oro City to
Dr. Miguel de Leon. When they arrived in Cagayan de Oro on September 15, 2003, client Y
undergone into different test, The Computerized tomography scan (CT scan) and ultrasound
reports diagnosed client Y’s condition as Retinoblastoma, Bilateral. After the results Dr. De
Leon advised them to go back to Dr. Villanueva when they arrived to explain more about client
Y’s condition. Mrs. Y then went to Dr. Villanueva when they arrived at Butuan City. Dr.
Villanueva explained the details about the condition of patient Y and advised Mrs. Y to have
Client Y’s operation to remove the eyes of Client Y because of the malignant cells that might
spread which is more dangerous. “Ingon ni Dr. Villanueva nga dalion jud daw para maoperahan
daun si Client Y kay magtakod-takod ang mga tumor ug pas-pas unya delikado daw na. “ As
testified by Mrs. Y, But Mrs. Y refused to believe it all, “Ingon man to amo silingan nga
magpasecond opinion daw me kay di daw maayo mga doctor dire sa Butuan ug Cagayan, Sa
Cebu radaw me paycheck-up” So Mrs. Y decided to go to Cebu together with Client Y and
Client Y’s grandmother. They did Computerized tomography scan (CT scan), Ultrasound and
many more test but the result was the same. When they arrived home from Cebu city, Mrs. Y just
noticed that Client Y can’t see completely. Mrs. Y say’s “Tong padulong pami Cebu, makakita
paman siya pero hanap-hanap pa lang, pero sa ka-busy nako pag-abot namo sa balay sa
lumbukan adeser nko nabantayan nga di najud siya kakita, gitistingan nako ug flashlight iya mata
wala man siya reaction ug la daw siya nakita, ngit-ngit lang daw.” The next day, Mrs. Decided to
go back to Dr. Villanueva. They were arranging to refer Client Y to Philippine General Hospital.

October 15, 2003. Client Y was admitted at Philippine General hospital under the
supervision of Dr. Agahan/Leal/Selia, M.D. Client Y underwent Computerized tomography scan
(CT scan). After the result the Doctors in Philippine General hospital advised Mrs. Y to have
Patient Y an Enucleation on both eyes. But Mrs. Y refused the operation because she worries
about the future of her child and because of financial matter. The Doctors explained the risk if
Client Y can’t have the operation. Doctors tried to convince Mrs. Y they even called one staff
nurse from Mindanao who also speaks visaya well. The Doctors ask the nurse to convince Mrs.
Y in vernacular language but still she wasn’t convinced. The Doctors even showed the ward for
Eye diseases to Mrs. Y and explaining the things might happen to Client Y if the procedure will
not be performed. “Gidala ko sa isa ka-Doctor sa ward para sa mga patiente na nay sakit sa mata,
clase-clase nga mga sakit sa mata naa digto. Ug naa siya mga gitudlo nga patiente nga
nanglugwa na mata, naay magbitay ang mata ug naay magtulo-tulo sa mata. Ingon ni doc, maing-
ana daw akong anak kong di maoperahan.” As verbalized by Mrs. Y.

After seeing the patients in that ward, Mrs. Y then decided to have Client Y a Surgical
operation. The Enucleation was scheduled on October 17, 2003. Before the operation,
Computerized tomography scan (CT scan) and G-scan was done and different test to determine
the child’s readiness for the operation. The Operation started at 11:00am to 8:00pm. After the
operation Client Y was transferred to Intensive Care Unit. When Mrs. Y entered the ICU, She
saw Client Y sleeping; Hours later, Client Y was awake but he was in tantrums that was said to
be the patient’s reaction to the wearing off of the general anesthesia. Mrs. Y tried to calm Client
Y and Mrs. Y gives a bottle of milk to the Patient. One of the Doctors advised Mrs. Y to have his
child a special education. “Ingon sa Doctor nga di lang daw ko maguol kay naay mga school nga
para sa ila.” As verbalized by Mrs. Y.

October 18, 2003 the dressing was removed. Mrs. Y was emotional seeing her child with
no eyes.

The Doctors then advised Mrs. Y to have her child Chemotherapy. The
Chemotherapy of Client Y started on November 6, 2003 and supposed to be ended on July 2004
but because of the complication during the treatment on its 7th cycle, its completion was delayed.
On May 22, 2004, Client Y’s was having pneumonia, fever and parotitis. So the doctors decided
to reschedule the 7th cycle of chemotherapy on June 15, 2004. On August 13, 2004, the 8th cycle
of chemotherapy ended.

On September 28, 2004 they went back to PGH to undergo CT scan for any
detection of re-occurring of the tumor. The CT scan reports show that Client Y is free from any
new tumor growth. Mrs. Y also testified that “Ingon sa Doctor Cancer free nadaw si Client Y
karun, E-continue lang daw namo mga giresita nga tambal.”

After the 8th cycle of chemotherapy they went back to Butuan City to consult to
Dr. Villanueva for some check-ups. Dr. Villanueva gives a drug for Client Y every time Client
Y’s eye has discharges. The current drug Client Y is taking is Tobramycin, an ointment for client
Y’s eye. To cope up with Client Y’s condition, Mrs. Y decided to enroll Client Y to Butuan
Special Education Center when he reaches 4-5 years age. “Gi-advisan pod ko ni Doctor nga
makatabang jud daw ng special education para ila ug kami pud nga mga parents naa training para
mucare sa ila.” As verbalized by Mrs. Y.

Daily Routine and Present Condition:

Client Y usually wakes up 6 in the morning to get ready for school. He can also walk in
their house without anyone’s assistance but when He bathed his mother is present to assist. He
even dresses up, He uses his hands to “see” his things; sometimes he mistakenly wears the
clothes of his sisters so he asked his mother if he is wearing his clothes. “Tong una mamali jud
na siya, mao gilahe na naki iya mga sinina. Karun mangutana nalang na siya kung nabali ba iya
gisuot kay usahay mabali man.” As verbalized by Mrs. Y. Client Y goes to school with his
mother who always guides him when his on an unfamiliar places. They traveled from Lumbukan
to Butuan SPED center. In their school, Client Y uses cane to guide when his walking and when
crossing the streets. He also read and writes on stylus of the Braille system, specialized for
visually impaired people. But if the weather is not good, Mrs. Y and Client Y don’t go to school
at all because of the bad weather. But as a pupil, client Y is good and in fact, Last 2009 he was
awarded as the most outstanding pupil of section Violet. Client Y also participated in school
activities like singing, dancing and sometimes they even joined some activities outside the school
like the MILO marathon 5k which is held last 2008 with the assistance of their adviser. They
even joined some training in different places for visually impaired programs implemented by the
government. “Kadto lang mga November 2009, nagtraining baya me sa cagayan, mao tong
nawala me dire kadali.” As verbalized by Mrs. Y.

During weekends, Client Y cleans the house, He can sweep and scrubs the floor and He
gets mad if his sisters keep on messing the area. “Masuko jud na siya pagtamakan namo iya
nascruban miskan maghinay-hinay me ug lakaw para di masayran, masakpan gihapon me.” As
verbalized by Ms. X, his eldest sister. But most of the time Client Y plays with his sister. He
likes to play “tagu-taguan”, “ habul-habulan”, water-sili and Chinese garter with his sisters.
“Matingala jud ko, mag apil-apil jud siya, naniid ko sa ila, bisan wala niya ang iyang igsoon
kung asa nitago, isinggit niya nag nakita niya, kung kinsa moreact maabal jud kay makadungog
naman, masakpan nuon”. As verbalized by Mrs. Y. As a child, Client Y loves to play in the
seashore because it’s only meters from their house. He usually plays with his sisters. After
playing, they went home and watch TV, Client Y loves watching wowowee and sings with
Willie Revillame, Client Y also memorized the songs and advertised in the TV like “Bro, ikaw
ang star ng Pasko”. At night He slept with his mother around 8pm-9pm.

DIET:

Client Y eats three meals a day. He eats a lot of food, especially when he likes the food.
In the morning client Y loves to eat noodles and canned food like beef loaf. “Ganahan man jud
ko ug noodles ug beef loaf”. As verbalized by Client Y. And during their snacks in school, Client
Y eats biscuits, candies and chips.

Theories of development:

According to Erickson’s psychosocial theory Client Y belongs to school age, “industry

vs. inferiority” developmental task, and in psychosexual theory he belongs in Latent stage. In
Kohlberg’s moral development theory, Client Y belongs to Conventional level, stage III and
according to Piaget’s cognitive theory Client Y belongs to concrete thought.

During our initial and succeeding interaction and on the home visit the following nursing
problems were identified and addressed. November 23, 2009, we observed that Client Y brings
his packed food prepared by her mother; He eats rice with beef loaf. After eating the packed food
Client Y ate biscuits and other sweet foods they bought. Every time he walks outside the room,
he uses cane to guide when walking. And on Dec. 19, 2009 another problem was identified.
During our Physical assessment, we noticed wounds in his left arm and because of his condition;
Client Y is more prone to injuries and infections.