Spinal Cord Injury Case Study (Nursing History)

Chapter II
NURSING HEALTH HISTORY
A. BIOGRAPHIC DATA
Client A.A, a 37 years old male, who currently resides at Gonzales, tubao,
La union. He was born a Filipina on September 18, 1979. His religious affiliation
is Roman Catholic. Works as a farmer. The patient was admitted at Ilocos
Training & Regional Medical Center with a chief complaint of Immobility of both
upper and lower extremities, last February 11 2017 @ 7:15PM
B. REASONS FOR SEEKING HEALTH CARE
Client A.A seek medical attention with the following Chief Complaints:
immobilty of extremites. His wife brought him to the hospital.The initial diagnosis upon
admission was; actute spinal cord ijury C4 level.
C. PRESENT HEALTH HISTORY
Patient A.A chief complaint was limitation of movement at extremities. 1 week
prior to admission, pt. was apparently well when he was rigging in his farm until he
accidentally fell. Pt hit back on floor causing a little loss of consciousness, after that he
already experience minimal movement of extremities. Pt. tolerated the condition with no
consultation done and no medication taken persistence of the condition, he then visited
the Nazareno hospital in Agoo when the pain was no loger tolerable and was refered to
illocos taining and regional medical center to have a CT scan and after which he was
admitted at ITRMC because of chief complaints immobilty of extremites.
D. PAST HEALTH HISTORY
Patient A.A experienced measles, mumps, as a child. He also experienced
cough, colds. He has completed all her immunizations and including two shots of tetanus
toxoid. He has no known allergies. He also took OTC drugs such as paracetamol for
fever, biogesic for headache and neozep for colds. He has no allergy to foods, drugs &
animals. And He had never undergone any major/minor operation and he had no history
of fracture. He has never been hospitalized before. This was the first-time patient A.A
was admitted in the hospital. Patient A.A plays basketball daily in the evening after
returning from the farm as his means of exercise.
E. FAMILY HEALTH HISTORY
Grandmother Grandfather Grandmother Grandfather
Mother
Father
Legend:

Hypertension
Patient
Died of old
age
Pneumonia
Both the grandparents from the mothers side died from old age. From the
fathers side, the grandmother died from Hypertension and the father died from
Pneumonia. The mother is not experiencing any health problems but the father has
hypertension and asthma.
F. LIFESTYLE & HEALTH PRACTICES
1. Description of a Typical Day
Patient A.A wakes up at 5:00 am; at times, he eats his usual breakfast like fruit
and vegetables and a small amount of rice.
2. Nutrition and Elimination
Patient A.A eats at least 3 times a day and has a snack. Patient A.A has a
regular bowel movement.
3. Activity level and Exercise
Patient A.A plays basketball daily, and also cleans the hosue surronding every
evening after his basketball game.
4. Sleep and Rest
Patient A.A sleeps at least 6-7 hours every night. He sleeps at 10pm and wakes
up 5am.
5. Medications and Substance Use
Patient A.A takes paracetamol, when having fever. And he sometimes takes pain
reliever gotten from the counter.

6. Environment
The family lives in a bungalow type house made of semi-concrete material.
They buy mineral water as their drinking water. Their garbage is being collected by a
dump truck that goes around in their area.
DEVELPMENTAL TASK
A. Erik Eriksons Stages of Psychosocial Development Theory
Erikson describes eight developmental stages through which healthily developing human
should pass from infancy to late adulthood. In each stage the person confronts, and
hopefully masters, new challenges. Each stage builds on the successful completion of
earlier stages. The challenges of stages not successfully completed may be expected to
reappear as problems in the future. Each of Erikson's stages of psychosocial
development are marked by a conflict, for which successful resolution will result in a
favorable outcome and by an important event that this conflict resolves itself around.
B. Sigmund Freuds Psychosexual Development Theory
According to Freud, people enter the world as unbridled pleasure-seekers. Specifically,
people seek pleasure through from a series of erogenous zones. These erogenous
zones are only part of the story, as the social relations learned when focused on each of
the zones are also important. Freud's theory of development has 2 primary ideas: One,
everything you become is determined by your first few years - indeed, the adult is
exclusively determined by the child's experiences, because whatever actions occur in
adulthood are based on a blueprint laid down in the earliest years of life (childhood
solutions to problems are perpetuated) Two, the story of development is the story of how
to handle anti-social impulses in socially acceptable ways. My patient belongs to the

genital stage which begins at puberty involves the development of the genitals, and
libido begins to be used in its sexual role. However, those feelings for the opposite sex
are a source of anxiety, because they are reminders of the feelings for the parents and
the trauma that resulted from all that.

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What is the patient's chief complaint?

What is the patient's chief complaint?

What is the patient's past medical history?

What is the patient's past medical history?

Chapter II

NURSING HEALTH HISTORY

is Roman Catholic. Works as a farmer. The patient was admitted at Ilocos

upper and lower extremities, last February 11 2017 @ 7:15PM

B. REASONS FOR SEEKING HEALTH CARE

admission was; actute spinal cord ijury C4 level.

C. PRESENT HEALTH HISTORY

Patient A.A chief complaint was limitation of movement at extremities. 1 week

admitted at ITRMC because of chief complaints immobilty of extremites.

D. PAST HEALTH HISTORY

Patient A.A experienced measles, mumps, as a child. He also experienced

returning from the farm as his means of exercise.

E. FAMILY HEALTH HISTORY

Grandmother Grandfather Grandmother Grandfather

hypertension and asthma.

F. LIFESTYLE & HEALTH PRACTICES

1. Description of a Typical Day

and vegetables and a small amount of rice.

2. Nutrition and Elimination

regular bowel movement.

3. Activity level and Exercise

evening after his basketball game.

4. Sleep and Rest

5. Medications and Substance Use

reliever gotten from the counter.

The family lives in a bungalow type house made of semi-concrete material.

dump truck that goes around in their area.

A. Erik Eriksons Stages of Psychosocial Development Theory

reappear as problems in the future. Each of Erikson's stages of psychosocial

B. Sigmund Freuds Psychosexual Development Theory

According to Freud, people enter the world as unbridled pleasure-seekers. Specifically,

exclusively determined by the child's experiences, because whatever actions occur in

to handle anti-social impulses in socially acceptable ways. My patient belongs to the

the trauma that resulted from all that.

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