Nursing Health History

1. NURSING HEALTH HISTORY
History taking is an essential component of patient assessment that allows high-quality care
(Fawcett & Rhynas, 2012). Understanding the complexities and processes involved in taking
health history helps nurses better understand their patient's problems. Priorities in care can be
identified, and the most appropriate interventions can be implemented to improve patient
outcomes.
The purpose of obtaining a health history is to gather subjective data from the patient or
the patient’s family so that the health care team and the patient can collaboratively create a plan
that will promote health, address acute health problems, and minimize chronic health conditions.
(Doyle et al., 2015)
I. Patient’s Profile
Patient F is a 39-year-old African-American man who has sickle cell disease (SCD),
sometimes called sickle cell anemia marked by frequent episodes of severe pain. He is married
and has two children. Patient F weighs 89 kilograms and has a height of 5’9, equating to a BMI of
29.2 which falls on the category of overweight.
II. Past Health History
Patient F’s sickle cell anemia has been managed with multiple transfusions. He started
showing signs of chronic renal failure 6 months ago.
III. Onset of Illness
Last Wednesday morning (December 1), while in the hematology clinic, Patient F’s
hemoglobin measured 6.7g/dL. He received 2 units packed RBCs over 3 hours and then went
home. He developed dyspnea and shortness of breath approximately 1 to 11⁄2 hours later, and his
wife called 911. The emergency medical system crew-initiated oxygen and transported Patient F
to the emergency department (ED). Laboratory test were done and medical treatment were
provided. Upon discharge, the patient was prescribed with Folic acid, Ceftriaxone, Droxia, and
Lasix.
GORDON’S 11 FUNCTIONAL PATTERN
I. Health Perception – Health Management Pattern
Patient F, in terms of illness, purchases over-the-counter drugs to aid his condition.
However, he visits his healthcare provider with symptoms that already lasted for a couple of days.
He easily adheres to the prescribed medication regimen and is not hesitant to comply if health
modifications are needed. Patient F hasn't smoked his entire life as well as the rest of the family
members. He doesn't drink nor use recreational drugs. He perceives himself as someone who is
health-conscious and seeks medical advice whenever needed. With regards to his treatment,

2. Patient F verbalized that one of his biggest fears is that he’ll come in the hospital with a crisis and
that his pain won’t be treated aggressively enough. The patient is afraid to be labeled as a drug
seeker or an emergency room abuser because of his medications for recurrent pain.
II. Nutritional Metabolic Pattern
Patient F has no diet restrictions. He eats thrice a day and consumes more protein and
vegetables. His appetite is mostly affected when Patient F experiences pain and eats less when
about to undergo transfusions. He has no problems with swallowing and has a moderate intake of
fluids with 4-6 glasses a day. Patient F isn't fond of drinking soft drinks and opts to drink water
most of the time. When asked about any allergies present, he responded with: “None. I have no
allergies.”
III. Elimination Pattern
Patient F has no problems with voiding and defecating. When asked about how frequent
he voids in a day, he responded with: “About 8 – 10 times in a 24 hour period.” Patient F doesn’t
use any laxatives to assist defecation.
IV. Activity – Exercise Pattern
Patient F spends most of his time reading books and newspapers. When asked about his
exercise pattern, Patient F verbalized that he feels tired most of the time and only does simple
stretches every weekdays and engages to light sport during the weekends. In terms of his daily
activities, Patient F can independently perform ADLs. However, he reported that he often
experiences a recurring pain at the right side of his back.
V. Sleep and Rest Pattern
Patient F wakes up around 9 or 10 in the morning. When asked about what time he sleeps
at night, he responded with: “Earliest is around 1 AM.” When asked about what causes him to
sleep late at night, patient responded with: “It’s my typical sleeping schedule. I’m not used to
sleeping early around 9 or 10 pm.”
VI. Cognitive – Perceptual Pattern
Patient F stated that he has no hearing problems. In terms of his vision, patient responded
with: “Sometimes my vision gets blurry, but not all the time.” When asked about his last visit to
his ophthalmologist, patient responded that he never had a check-up with an ophthalmologist.
Aside from this, he reported that he has no problems with cognition and perception.
Regarding his diagnosis, Patient F understand the nature and causes of it. Whenever he
experiences sickle pain at home, aside from medications, he applies non-pharmacologic methods
to relieve pain like drinking more fluids and the use of heating pads.

3. VII. Self-perception / Self-concept Pattern
Patient F has no issues at the early stage of his condition; this is not until the disease
progressed and had caused frequent painful crises after having undergone multiple transfusions.
He reported that there are times where he blames himself for the pain he has been going through.
Despite this, Patient F manages to relieve himself by taking a pause and surround himself with the
company of his loved ones.
VIII. Role – Relationship Pattern
Patient F is living along with his family with two children, one living with them while the
other one is living with his in-law. Being diagnosed with SCD, patient reports that his family is
very supportive and understanding especially when he experiences pain attacks. In terms of his
wife, he is thankful to have been given a partner who is very supportive since the day he was
diagnosed with the disease.
When asked about any experience of being discriminated due to his condition, Patient F
responded with: “So far, not yet. I haven’t ever been discriminated due to my condition.”
IX. Sexuality and Reproduction Pattern
When asked about the frequency of sexual intercourse, Patient F responded: “We aren’t
that active.” The couple has two children, and both are satisfied with the number of children.
Furthermore, Patient F reported that his wife has already undergone tubal ligation.
X. Coping – Stress Tolerance Pattern
Patient F doesn’t always think about his diagnosis to prevent stressing himself out in terms
of coping with the condition. He treats every day of his life as a blessing and seizes it with his
family, especially his children. He said that he could surpass the challenges especially knowing he
got his family right by his side.
XI. Value and Belief Pattern
Patient F is a Roman Catholic by faith and attends masses every Sunday. Being in a
Christian life and believing in Jesus Christ helps him be strong, and along with his family's support,
it gives him a positive view of life. He believes that being happy and enjoying his life to the fullest
with his family matters most.

4. DEVELOPMENTAL STAGE
Erik Erikson’s Psychosocial Theory discusses that during childhood, adolescence, and
maturity, people go through stages and face new decisions and turning points. Two conflicting
psychological inclinations – one positive and the other negative – define each stage. An ego
virtue/strength or maldevelopment emerges as a result of this. When virtue is practiced, it can aid
in the resolution of a present decision or dispute. It will also help later stages of development and
contribute to establishing a solid foundation for crucial belief systems regarding the self and the
outside environment. With the adoption of the underdeveloped quality, the opposite occurs.
Intimacy vs. Isolation
Intimacy versus isolation is the sixth stage of Erik Erikson's theory of psychosocial
development, which happens after the fifth stage of identity vs. role confusion. This stage takes
place during young adulthood between the ages of approximately 19 and 40. The primary source
of conflict at this period of life is building close, loving relationships with others. At this level,
success leads to satisfying relationships. On the other side, struggling at this period might lead to
feelings of loneliness and isolation.
Patient F has been living happily with his family for the past years. As he has reflected, it
isn't easy to be diagnosed with Sickle Cell Disease. It took a lot of adjustments and acceptance,
which is indeed hard at first to process. Through time, he learned to grasp his present condition
and adapt to the inevitable changes it may bring. According to him, SCD couldn't stop him from
enjoying and fulfilling his purpose in life. He stands and sees himself as an inspiration for others,
especially those at the edge of losing hope and the willingness to live. He further emphasized the
importance of his family as his support system. Surrounded by these people, it encouraged him to
fight and keep up with the pace of life. Thus, Patient F is under intimacy and is not experiencing
isolation.