CHAPTER II

NURSING HEALTH HISTORY

A. Biographical Data

Patient C.N.C., a 35 year old male patient is residing in Darigayos, Luna, La

Union. He was born on February 10 1984. He is married and he is living in with her

partner. Affiliated to Roman Catholic and he is a Filipino citizen. Patient C.N.C is a

vocational graduate and he is working as a welder.

B. Reasons for seeking healthcare

Patient C.N.C. was seeking for healthcare for complaints of pain at the right

lower quadrant.

C. History of Present Illness

Last September 9, 2019, around 9pm patient C.N.C was done eating their

dinner after 5-10 minutes patient suddenly feel pain at the upper abdomen, patient

thinking just the food they ate, patient tolerating the pain but a few more minutes the

pain became sharp/severe. Around 9:30pm patient relatives rush him immediately at

Balaoan District Hospital, at the time patient arrived patient was admitted and

diagnosed appendicitis, because of the lack of equipment at the BDH the patient

was transferred in ITRMC (Ilocos Training Regional Medical Center) around 11pm,

when the patient arrived, the NOD reffered the patient for OR was associated with

(+) fever, no vomiting, no dizziness. The operation performed was “Emergency

Appendectomy”, operation start at 12:34 am (September 10, 2019) and end at 2:48

am.
 D. Past Health History

Negative Diabetes Millitus, Negative Asthma, Negative Cancer, Negative

Hypertension.

E. Family Health History

For the patient’s mother health history is Hypertension and for the father’s health

history is Diabetes Millitus.

F. Lifestyle and Health Practices

1. Description of a Typical Day

Patient C.N.C. usually wakes up around 6AM to help her partner in preparing

breakfast before going to his work. After his work, before he go home patient will go

first at the market to buy food for dinner and breakfast, at around 7:30 to 8 pm they

will eat their dinner by 9 to 10 they will do to sleep. But if the patirnt doesn’t have

work he love to play basketball or go out with her partner.

2. Nutrition and Weight Management

Patient C.N.C. diet is usually composed of rice, red meat, white meat and

vegetables, at 10am he usually eat snacks composed of soda/juice and bread.

He defecates twice in a day usually in the morning when she wakes up and after

dinner, He urinates when he feels the urge, but sometimes he is controlling his urine

according to her he urinates 2 to 3 days a day.

3. Activity Level and Exercise

Patient C.N.C play basketball twice a week.

4. Sleep and Rest

Patient C.N.C. goes to sleep at 10PM and wakes up at 6AM. So she has almost

8 hours of sleep in a day. Sometimes he take a nap after her work.

5. Environmental and Living Condition

Patient C.N.C is living with her partner in Darigayos Luna, La Union. Their

house is bungalow type located just 20-25 minutes away from the town proper but

there house is along the highway. Their source of water is from water pump. And

their garbage is being collected every Wednesday and Saturday.

6. Medication and Substance use

According to the patient , they don’t take over the counter drugs. First they

will have a check up when they feel ill or sick, they immediately go to the hospital.

They don’t use herbal medicines.

7. Self concept and Self-care responsibility

Patient C.N.C. is a hardworking person, he works for her partner and family

because of his hardworking sometimes he forget to take good care of his self,

sometimes he skip a meal just to finish his work.

8. Social Activities

Patient C.N.C. is a friendly person he gets along with her family, friends and

neighbors. He has a harmonious and healthy relationship with them.

9. Belief System and Values

He doesn’t believe in superstitious belief like “when you see a black cat you

should not go any where” and “when something was broken there is a bad things will

happen”. She doesn’t believe in herbal medicine can cure certain illnesses.

10. Education and Work

Patient C.N.C is a vocational graduate, he works as a welder, but not all

the time he haves work.

G. Developmental Level: Generativity vs. Stagnation

Generativity refers to "making your mark" on the world by caring for others as

well as creating and accomplishing things that make the world a better place.

Stagnation refers to the failure to find a way to contribute. These individuals may

feel disconnected or uninvolved with their community and with society as a whole.

Those who are successful during this phase will feel that they are contributing to

the world by being active in their home and community. Those who fail to attain this

skill will feel unproductive and uninvolved in the world.