NURSING HEALTH HISTORY

1. Biographic data
a. Name : Ny. A
b. Age : 20 years
c. Sex : Female
d. Race : Banjar
e. Work : Student
f. Marital Status : single
g. Religious orientation : Islam
h. Health Care Financing : insurance
i. Usual search of medical care : health center
j. Address : Banjar Baru City

2. Chief Complain or Reason for Visit

Nurse ask to the client what is troubling you, and the client said fever and headache.

3. History of Present illness

Nurse ask to the client when she feel fever and headache. The client said since two
day ago before treated at Hospital then nurse ask to the client what do you mean by terrible
or good. The client said such as terrible. The client said complaint fever and headache
since two day ago before treated at hospital. Headache and fever had the quality up and
down. The onset symptoms are suddenly. The complaint felt on the head and body.
Character of the complaint is intensity of pain nothing. The size discharge of a lesion
mucus is little. Activity in which the client was involved when the problem occurred is
anorexia and insomnia. Phenomena or symptoms associated with the chief complaint is
always headache, fever, and limb. Factor that aggravate or alleviate the problem is many
activities and blurred vision.
 The client said that the family of his father had suffered from the same illness and
that no family member at no family member at home suffered from the same illness as
the current illness. The client disability is long stand, can eating by herself and
compressed by others.

4. Past History
a. Childhood illness
The client not have childhood illness because she was first affected by a fever.
b. Childhood immunization.
The client said childhood immunization is measles immunization.
c. Allergies
The client not have allergies.
d. Accidents and injuries.
The client said she had ever fallen from a motorcycle.
e. Hospitalization for serious illness
The client has never been hospitalization because of a serious illness.
f. Medications
The client just take paracetamol

5. Family History of Illness

Nurse ask the client about the risk factors for certain disease and the client said that
her uncle has suffered from the same illness as himself. Her uncle hit same illness
when he was 17 years old. The client does not have hereditary disease.

6. Life Style
a. Personal habits
The client never use tobacco and alcohol. But, the client Consumptions of coffee
every day 3 times a day and the client never use of illicit.
b. Diet
The client’s diet is always eats junk food. The food she likes is in the form of pizza,
burgers, and others. The makes the client less likely to eat nutritious and healthy foods.
The client chooses to buy junk food because she parents are busy working. Ethnic client
diet is like to eat salty food. The client always forget hand wash before eating.

c. Sleep/rest patterns
The client always stayed up late and sleep above midnight. The clients has many
college tasks and that’s why she always consume coffee. The solution is the client have
to finish her tasks earlier when she have a free time.

d. Activity of daily living

The activity is assisted by parents. Before entering hospital, the client feels no
appetite, feels fever and headache. When at hospital, the client feels more appetite, and
feels safe because the pain decreases.

e. Recreation/hobbies
The client always open social media in her hand phone. When free time the client
like watching television.

7. Social Data
a. Family relationship/ friendship
The relationship between the client and his family is very good. Patient interaction
with doctors and nurses is good because patients are friendly people. the client lived
with parents. The client’s parent helps her when she in need. The contact when the client
is in an emergency is her parents. She feels close with her mother. Her parents and her
friends were worry when she in illness. Her parents are healthy.

b. Ethnic Affiliation
The client and family are Indonesian. The client not identify with his ethnic group.
The client often eat junk food.
c. Educational history
The client’s have a history educational namely senior high school and now she
continues study in university.

d. Occupational History
The client not work because he is college student.
e. Economic status
The client economic status is sufficient.
f. Home and neighborhood conditions
The mental of client is very important in nurse discussions about home security
measures and adjustments in physical facilities that maybe needed to help clients
manage physical disability intolerance to activities and activities of daily living.
According the client about the avaibility of neighborhood and community services to
meet the client’s need is good.

8. Psychologic data
a. Major stressor
Major stressor because of many tasks. So that the client feels burdened and worried
about not completing her campus assignments.
b. Usual coping patterns
The client always vent to his parents to find a solution.
c. Communication style
The client’s verbal communication style is the ability to express emotions is
appropriate. And non verbal communication is eye movements, use of touch, and
posture, as well as client interactions express anxiety, suspicion, withdrawal, and anger.
d. Self concept
The client self concept is close with other people except to her parent.
e. Mood
The client’s mood looks flat. She has sleeping trouble. She feels the situation is too
bad to deal with it. And she has no desire to commit suicide.

9. Patterns of Health Care

The family patterns of health care is health center. The client considers the
treatment provided is adequate.