It involves the collection of data about the patient and her family’s health which forms the identification of patient’s problems. It is the systematic collection of client data pertaining to the individual’s health status, abilities and preferences for care and treatment.
This chapter will discuss among others; patient’s particulars, family medical and socioeconomic history, patient’s developmental history, patient’s lifestyle and hobbies, past and present medical history, admission of the patient, patient’s concept of her illness, literature review and validation of the data coted. This information is gathered from client, family members, literature review and diagnostic investigations.
Madam R A is a 59-year-old woman who was born on 20th of July, 1960. She is married with 6 children. Madam R.A comes from Adaklu Waya but is currently staying with her daughter in Ho, near the Central Market.
Madam R.A is a farmer and has never stepped foot in the classroom. She is dark in complexion, 150cm tall and weighs 58kg. She has no physical impairments. She speaks only Ewe. She is a Christian and worships with the Apostolic Church of Ghana. Her next of kin is Miss O.A, who is her daughter.
During my interaction with Madam R.A, she mentioned that there is no known hereditary diseases such as hypertension, sickle cell, heart diseases, diabetes and epilepsy in her family. They sometimes suffer minor sicknesses like abdominal pains, fever and headache which they report and seek medical attention.
Madam R.A is not allergic to any drug or food and she also said she has never been hospitalised; thus, this was her first time of being hospitalised in the hospital.
Socioeconomically, her family falls into the middle-income class and is able to settle hospital bills with the National Health Insurance Scheme (NHIS). Her husband is also a farmer and they get their source of income from the sale of the produce from their farm. They also get some money from their children. Madam R.A is very friendly with people and she easily make friends wherever she finds herself according to her daughter. The members of the family are all Christians and therefore respect the Christian norms and values.
Developmental history refers to the information obtained from the parents of a specific client regarding potential significant historical milestones and events that might have a bearing on the client’s current difficulties.
Madam A.R was born at Adaklu Waya in the Volta region of Ghana on 20th July, 1960. Information she gathered from her mother revealed that she was delivered spontaneously through the vagina as a full-term baby without any complications by a Traditional Birth Attendant (TBA).
She was not immunized against any of childhood diseases as there were no such thing at that time, according to her mother. Madam R.A couldn’t give a detailed account of her developmental milestone. She passed through the normal developmental milestone, at 6 months she could sit, started to crawl at 7 months and by 12months she could walk without assistance. She also said she started showing signs of maturity at the age of 13 years with the enlargement of breast, growing of pubic hair, menstruation and the others. She said never stepped foot into the classroom before and she always helped her parents on the farm. She got married at the age of 21 years and left her parents to live with her husband.
Madam R.A has had 7 pregnancies which she carried to term; they were spontaneous deliveries with no complications but along the line she lost one child. Currently she has six children. According to her, she had no menstrual disorder and the flow was normal. She is now in her menopause. She has never used any of the contraceptive methods.
With reference to Erik Erikson’s theory of psychosocial development, Madam R.A is at the seventh stage that is Generativity Versus Stagnation/Absorption. According to Erik Erikson, generativity involves finding your life’s work and contributing to the development of others through activities such volunteering, mentoring and raising children. During this stage, middle aged adults begin contributing to the next generation often through childbirth and caring for others; they also engage in meaningful and productive work which contribute positively to society. Those who do not master this task experience stagnation and feel as though they are not leaving a mark on the world in a meaningful way; they may have little connection with others and little interest productivity and self-improvement. Madam R.A is at the generativity stage, that is, she is focused on contributing to society as she has children who she raised into responsible adults, she takes part in voluntary activities like sweeping the church and she works as a farmer to feed society.