New Era University

College of Nursing
No. 9 Central Avenue New Era Quezon City

NURSING HEALTH HISTORY

A. Biographical Data

Name: Ms. BX
Address: Bagumbayan Darangan, Binangonan, Rizal
Age: 6 yrs old
Sex: Female
Race: Filipino
Marital Status: Single
Occupation: None
Religious Orientation: Roman Catholic
Health Care Financing and Usual Source of Medical Care: None

B. Chief Complaint or Reason for Visit

The patient was brought to the hospital due to fever, vomiting and lost of appetite.

C. History of Present Illness

As narrated by the client’s mother, four days prior to admition the patient was already
experiencing vomiting with accompanying fever. They brought her to the hospital for further
medication and management last morning of August 14, 2009. She was then diagnosed with UTI; the
physician prescribed her with catrimoxazole TID and was sent home for observation. The night after
the checkup the patient was returned to the hospital due to lack of appetite and inability to take her
medication. Upon consult she was diagnosed with Dengue Fever Syndrome and hence admitted. Her
medication was changed to Cefuroxime together with paracetamol.

D. Past history

Upon interview, her mother told the student nurses that Ms. BX does have a complete
immunization. She has also no other diseases from past except from some fevers. She also had a
convulsion during her fever when she was one year old. She has no known allergies. Prior to admition
she was taking vitamin C as her dietary supplement.

E. Family History of Illness

The patient’s grandmother has history of UTI, her great grand mother died from DM2. One of
her cousin from her mother’s side has tuberculosis.
F. Functional Health Pattern

1. Health Perception and Health Management Pattern

As stated by the client’s mother as part of their health maintenance she is always giving her
child with supplements such as vitamin C and giving her appropriate foods for her growth. She also
brings her children immediately to hospital if she notices some health problems from them. The only
family member in their house who’s using tobacco is the client’s father.

2. Nutritional and Metabolic Pattern

Prior to hospitalization Ms. BX’s usual food intake along with rice are fried fish, pork and
chicken, she’s also fond of eating candies, drinking zesto and other juice products. At the hospital she
was given with soft diet under DAT to dark colored foods. She is currently having an IV infusion of
D5 0.3 NaCl 500cc for 6 hours. She had gone blood transfusion last August 16, 2009. Her skin
problem was only rashes in her lower extremities which are due to the disease process. She also has
some dental carries due to the type of foods she eats.

3. Activity-Exercise Pattern

According to the mother, PTA the client is taking her daily exercise in school every morning
during flag ceremonies. She’s also fond of playing “habulan” and other physical types of games. In the
hospital the client is unable to move freely due to her health condition and her IV infusion. Because of
her young age and her condition she requires assistance and supervision from her parents in all her
daily activities.

4. Elimination Pattern

The client’s bowel movement was 2-3 times a day, with normal feces. She micturates 4-5 times
a day. The client has no excess perspiration and no odor problems.

5. Sleep-Rest Pattern

The client sleeps approximately about 9-10 hours during night time. She has no problem in
sleeping. She doesn’t take naps during morning and afternoon.

6. Self-perception and Self-control pattern

According to the client’s mother the client is usually shy to people whom she doesn’t know.
She always cries if she is being shouted by her parents.