APPENDIX A

INFORMED WRITTEN CONSENT

I, ______________________________, have received the discussion of the study entitled
THE EFFECTIVENESS OF TWICE A DAY INTAKE OF LEMON GRASS
(ANDROPOGON CITRATUS) DECOCTION AMONG HYPERTENSIVE
INDIVIDUALS OF BARANGAY STA. LUCIA, PAGADIAN CITY,
ZAMBOANGA DEL SUR.


The study has been fully explained to me by the researcher to my understanding and I am
affixing my signature to signify my willingness to include myself as a respondent.


________________________________________________________________________


_______________________________
Respondent
Signature over printed name





_______________________________
Witness
Signature over printed name


_______________________________
Researcher
Signature over printed name




APPENDIX B


RESEARCH INSTRUMENT

NAME:______________________________ AGE:_______________
ADDRESS:___________________________ GENDER:___________
PHASE:_____________________________ WEEK:_____________
(if under lemon grass phase checked according to concentrations)
( )50% ( )100%

BP Mon Tue Wed Thu Fri Sat Sun Avg
(MAP)
AM
PM

HR Mon Tue Wed Thu Fri Sat Sun Avg
AM
PM


Symptoms Mon Tue Wed Thu Fri Sat Sun Avg
M.headache
S. headache
Nape pain
F. urination
L. O. C.
Dizziness
B. O. V.
Chest pain
Palpitation
D. O. B.
Weakness
Numbness
Edema
Tremors
Flank pain
No urine
output

Fever
Others.
APPENDIX D


Josefina Cerilles State College
Pagadian City Campus

Bachelor of Science in Nursing

April 3, 2012


To: Dr. Arnel Lerias
Public Health Doctor
Pagadian City

Good Day!

The GROUP 2 of third year BSN students of JH Cerilles State College would
like to ask your permission to conduct a study of the hypertensive clients in Barangay
Sta. Lucia Health Center. This is in accordance to our requirements in the subject of
Nursing Research. The study is entitled THE EFFECTIVENESS OF TWICE-A-DAY
INTAKE OF LEMON GRASS (Andropogon citratus) DECOCTION AMONG
HYPERTENSIVE INDIVIDUALS IN BARANGAY STA. LUCIA, PAGADIAN
CITY, ZAMBOANGA DEL SUR.

Please indicate your approval of this permission by signing the letter which is
indicated below.

Thank you very much.

Sincerely, Noted by:
______________________ ____________________________
JANE LOU BACLAYON JOY C. BONGABONG RN, MN
BSN-3 Group 2 Leader JHCSC BSN Program Coordinator
_________________________________
EDMARIE P. TABACULDE, RN, MN, BS Bio
Nursing Research Instructor

PERMISSION GRANTED FOR THE USE REQUESTED ABOVE:
( please sign above the signature line)
-----------------------------
Dr. Arnel Lerias
Public Health Doctor
Pagadian City
APPENDIX E

RESPONDENTS PROFILE

Part I. DEMOGRAPHIC PROFILE

Name:___________________________ Address:________________________
Age:____________________________ Occupation:_____________________
Gender:__________________________ Income per month:________________
Height :_________________________
Weight:_________________________

Vital Signs:
Temperature:_______________
Respiratory Rate:____________
Pulse Rate:_________________
Blood Pressure:_____________


Part II. HEALTH HABITS

A. Diet
Legend: A Always - does the activity daily
B Often - does the activity every other day
C Sometimes - does the activity three times a week
D Rarely - does the activity once or twice a week
E None at all - does not perform the activity

Food/ Beverages
A B C D E
Rice (humay)
Rice (mais)
Dried fish
Ginamos
Itlog
Sardines and other
canned goods

Noodles/ pancit
canton

Pork


B. Vices
Type Frequency Amount Period
a. Tobacco
(sigarilyo)

b. Alcohol




















Food/
Beverages
A B C D E
Alcohol
Coffee
Tuyo
Uyap
Asin
Beef
Chicken
Fried fish
Soft Drinks
C.Activities
Legend: A Always - does the activity daily
B Often - does the activity every other day
C Sometimes - does the activity three times a week
D Rarely - does the activity once or twice a week
E None at all - does not perform the activity
































Activities A B C D E

Watching T.V


Sleep/ Rest at late hours


Exercise

Activities A B C D E

Fetch water


Drinking alcohol


Cigarette Smoking

APPENDIX F

LEMON GRASS DECOCTION AND PLACEBO


LEMON GRASS DECOCTION

Materials

50% concentration: leaves including its roots of lemon grass about 1 foot long
100% concentration: leaves including its roots of lemon grass about 1 foot long
1 basin
1 liter of water
1 steel pot
1 strainer
1 pitcher
15 pieces of 250 ml plastic bottles

Procedure

1. Thoroughly wash the lemon grass with water
2. Soak the leaves and its roots for about 10 to 15 minutes
3. Boil leaves of lemon grass and its roots in liter for 20 minutes
4. Allow the decoction to cool down by natural processing
5. Strain and pour the decoction into a 250 ml plastic bottle

PLACEBO

Materials

1 bottle of commercially prepared lemon flavoured artificial food color
1 liter of water
1 stirring rod
1 pitcher
15 pieces of 250 ml plastic bottles

Procedure
1. Mix about 6 to 8 teaspoons of commercially prepared lemon flavoured artificial
food color in 1 liter of water
2. Mix and pour the placebo into a 250 ml plastic bottle