NURSING HEALTH HISTORY

A. Biographical Data Name: Charlie Position to the Family: Youngest son (2 nd child) Religion: Roman Catholic Sex: Male Health Care Financing: n/a

Address: Brgy. Bagumbayan, Bulakan, Bulacan Birthdate: Dec. 11, 2009 Birthplace: Malolos City, Bulacan Occupation: n/a

B. Chief Complaint Yung anak ko ay may amoebiasis. As verbalized by the mother. This is one of the major concern of the mother for her sons health condition. The condition that he is experiencing recently show symptoms such as diarrhea, stomach cramps, evidences of frequent watery stool with greenish color, foul odor, and presence of mucus. The child began to felt those sign and symptoms last 2 weeks until now ( Nov 30, 2010). Her mother noticed that her child feels uncomfortable especially when the child feels pain in his abdominal part. C. History of Present Illness The mother stated that her son experiencing recently, is he showing some evidences of frequent watery stool with greenish color, foul odor, and presence of mucus giving rise to a certain health condition commonly called as amoebiasis or dysentery. It can be acquired by ingesting food-borne microorganisms orally from contaminated food or water which gives result to an infection in the intestinal tract of the human. D. History of Past Illness According to the mother, last year, after the full term delivery of the child, the physician gave an order that her child should be confined in the hospital. The main reason for it is the child showed symptoms of difficulty in breathing, cyanosis, and chest pain.The physician diagnosed the child having an infant pneumonia due to accumulation of infectious pathogenic strain in the respiratory tract of the child. The disease had been inhibited and cured by following the doctors prescription properly and by taking antibiotic drugs to interfere the action of pathogens that causes infectious disease.

E. Family History of Illness

Mostly, the clients relatives have a stable health condition. Base on the genogram, there are no deceased person indicated in the familial health status. There are no incidence of genetic diseases such as Diabetes Mellitus and even mental illnesses. The childs grandmother is experiencing an enlargement of the hearts tissue or cardiomegaly. The mother of the client suffered in amoebiasis when she is in the age of 20.

GORDONS FUNCTIONAL HEALTH PATTERN

A. Health Perception and Health Management Pattern Sa tingin ko, ok naman ang health niya.. yun nga lang, madalas naman siyang magkasakit. As verbalized by the mother. She perceived that her son is vulnerable in some certain diseases. Even though her son had taken complete vaccination, she is still not comfortable for the because she thinks that her sons resistance against illnesses is not stable enough to prevent acquiring diseases again. As for that assertion, she needed to have an immediate action for it by having her child medical check-up for at least 6 times a month as needed. She also did not skip days without her son taking his vitamins and supplement. Her son is experiencing amoebiasis recently and she believes that it was acquired by his trough licking and sucking things that are being contaminated such as toys. She had her childs medical check-up last 2 weeks. She never ignored nor refuted the doctors prescription because she believes that it serves as an important key to cure an illness.

B. Nutritional and Metabolic Pattern

Dec. 13 Breakfast 200 ml of bottled milk 3 pcs. of Marie biscuit 250 ml bottled milk cup rice piece of lakatan banana 180 ml of water French fries 250 ml bottled milk

Dec. 14 250 ml bottled milk

Lunch Merienda / Snack Dinner

Usuall, the child takes about 3-4 times of bottled milk per day. Her mother felt that her son is gaining weight by lifting his son as an indication. She doesnt know the exact measurement of the weight of her child. Charlie has no problem in his appetite. It is just that he chooses food that he wants to eat. Hindi siya kumakain ng gulay lalo na pag hindi masarap ang lasa gaya ng okra at ampalaya. Uttered by the mother. It is because he doesnt like its taste.

C. Elimination Pattern

Frequency

Amount

Characteristic Clear appearance Light yellow color Aromatic odor Greenish in color Foul odor Soft and watery stool

Urine

6x a day

Approx. 1500 ml per day

Stool

3-4x a day

Base on the mothers observation, her second child sweats excessively especially when the weather is hot during noon time and summer season.

D. Activity and Exercise Pattern Playing outside the house, playing with toys and friends, walking, and running outdoors are the activities that her child typically do everyday. The mother considered those activities can be a form of her sons exercise and it can give contribution to growth and development of her son. Watching TV, playing, and even going to malls are activities that they spend their quality time together when the family has a time for leisure

E. Sleeping and Rest The client normally get enough of sleep everyday. As a child, he doesnt experience any form of sleep deprivation that usually occurs in adult. He usually fall asleep during 8 o clock in the evening and awakes in about 5-6 oclock in the morning. He takes a one hour nap after meal.

F. Cognitive- Perceptual pattern The mother said that her child has no impairment in his sensory functions. He doesnt have difficulties in visualizing his surrounding. He easily learn, discover, and remember things that captured and caught his interest and attention. During the interview process, the child reacted and responded well. G. Self- Perception and Self Concept Pattern As being asked, the mother described his son as one of the important persons in her life. Her child made her life worth living. She felt that she reached the state of fulfillment as a mother and a woman after she gave birth to her children. She consider her son as a blessing given by God. She is hoping that her son may someday become a loving person to the family. H. Role Relationship Our client belongs to a extended family. He with his immediate family lives in his grandmothers house. His mother is a plain housewife while her father works as an technician abroad in Taipei, Taiwan. Hindi talaga maiiwasan ang pagkakaroon ng problema. stated by the mother. One of the major family problems regarding family regulation and finances is meeting the familys basic needs. She herself manages the expenditures properly by budgeting their monthly finances. She owned a sari-sari store in front of their house which gives an additional budget to their finances. I. Coping Stress Tolerance

Mother said that her son is sensitive in noise especially when the noise is loud and distorted that can make him feel irritated and cry. Her mother make him comfortable by giving her child bottled milk and singing him a lullaby. Her son also gets irritated when his things such as toys are using by other without any permission. Her mother make ways to prevent it by placing her childs toys in a proper place. J. Value belief Pattern Religion and family are things that the mother considered important to her life and her family as well. The family faithfully believe in a thought that with god beside them, nothing is impossible to happen. Her family is a wonderful bless given by God and she shows her gratitude to Him by devoting her time and effort in giving love and care to the family.