Nursing Health History

Nursing health history is the first part and one of the most significant aspects in case

studies. It is a systematic collection of subjective and objective data, ordering and a step-

by-step process inculcating detailed information in determining client’s history, health

status, functional status and coping pattern. These vital informations provide a conceptual

baseline data utilized in developing nursing diagnosis, subsequent plans for individualized

care and for the nursing process application as a whole.

In keeping the private life of my patient and in maintaining confidentiality, let me

hide for with the pseudonym of Patient P.

Patient P was born on December 19, 1992. She was born to parents from Surigao

Del Norte, but she didn’t actually live with them. She was technically abandoned to the

relatives, but those people could not essentially foster her. She stayed at the Department of

Welfare and Social Development or DSWD and spent her 15 years of existence. Her

education was funded mainly by volunteers and charitable foundations. At the same time,

she compensated for it by means of helping in chores and accomplishing tasks in the said

foundation.
 She grew up with other abandoned children with questions in her mind. But to that,

she never completely disclosed herself. Patient P is a victim of sexual abuse. She was raped

and was unable to resist because of her innocence. She doesn’t talk that much. Often

times, she paces back and forth inside the ward, sits silently on her bed and sometimes

quietly stares outside the window. When tried to ask about what she knows of her family,

she could only turn silent, and somehow implies to ask the next question to her. But when

chance punched, I grasped it and coiled directly to my point. Unfortunately, hesitancy was

felt from the kind of thing that was wanted to be discussed. The issue was not forced until

her watcher, which has no relation to her, revealed the reason behind her pregnancy.

According to Patient P’s watcher, it was on a cold night in September 2007, when

Patient P came home from school: Upon nearing the center, a man, which she identified as

a newcomer to the center, blocked and harassed her brutally. She struggled to let go from

the ruthless hands of the unaccustomed man. Patient P was threatened that if she’d make

any noise, she’d get killed. Ill-fatedly, she was held powerless to the man, and the crime

had happened. Fortunate enough that she wasn’t killed, she thanked the Lord for sparing

her life. Although alive, she felt very much unfair about her situation. She could only tell,

“Kabata pa kaayo nako nahimong inahan, nganong nahitabo man pud ni..” . Patient P

conceived the baby and bore it for 9 months. For the first trimester, she couldn’t believe

and accept her fate, and sometimes thought of slight curses to the person who did the

crime. But somehow, she felt a jot of excitement of a having a baby unexpectedly. She

even verbalized, “Wa naman koy mabuhat. Nahitabo nato. Basin makasala pa kog ipalaglag

nako ang bata.. Wala man siya’y sala.”