I.

CLINICAL SUMMARY
A. GENERAL DATA PROFILE

NAME: Patient EA
ADDRESS: Dalahican Lucena,City
BIRTHDAY: December 18, 1952
BIRTH PLACE: Infanta, Quezon
SPOUSE NAME: Eriberto M. Azores
NATIONALITY: FILIPINO
RELIGION: Roman Catholic
OCCUPATIONS: House Wife
DATE OF ADMISSION:
ADMITTING DIAGNOSIS:
ADMITTING PHYSICIAN:

B. CHIEF COMPLAINT:
Prior to admission the patient always felt tired and experienced high blood pressure.
After she took a shower she lost consciousness on February 24, 2019. After this
incident, she was brought immediately to the hospital for admission.
C. NURSING HISTORY: HISTORY OF PRESENT ILLNESS

a. Childhood Illness
-Common colds, cough and fever
b. Immunization
-BCG, measles, OPV,DPT, Hepa B
c. Allergies
-No known allergies to food and drugs
d. Hospitalizations
- Quezon Medical Center
e. Domestic Travel
- The usual route of travel is within Quezon area only

D. FAMILY HISTORY:

 Patient’s mother has a history of heart failure, as verbalized by the wife of the
patient.
 No other history of medical illness.
E. SOCIAL HISTORY

ACCORDING TO ERIK ERIKSON

STAGE AGE CENTRAL INDICATORS INDICATORS
TASK OF NEGATIVE
POSITIVE OF
RESOLUTION RESOLUTION
MIDDLE 40-65 YEARS GENERATIVITY To have and An individual must
ADULTHOOD OLD VS nurture children deal with issues
STAGNATION and/or become they are concerned
involved with with or it can lead
future to stagnation in
generations later life.

According to this theory, the middle adulthood stage correlates to the patient’s age
because he established his

F. ENVIRONMENT/ LIVING CONDITION

 The environment where he lives and works can be found near in the center. Prior
to the incident the patient was in her house.

G. PHYSICAL ASSESMENT

PHYSICAL NORMAL ACTUAL INTERPRETATION

ASSESMENT FINDINGS FINDINGS
GENERAL -clean in appearance -not clean in -due to unilateral
APPEARANCE and well groomed appearance not well neglect as a symptom
-cooperative groomed of post-
- uncooperative cerebrovascular
accident

SKIN -with good skin turgor -with dry skin -poor skin turgor
-poor skin turgor common with old age
(65 y/o)
HAIR -evenly distributed - evenly distributed
hair - thin hair
-thick hair
NAILS -with good capillary -with capillary refill - personal hygiene not
refill of 1-2 seconds of 2-3 seconds cared for
-with pinkish nail -with pale nail bed
beds -with dirty and short
-with clean and short nails
nails
SKULL AND FACE -mouth uniform -mouth uniform
consistency absence consistency absence
of nodules and masses of nodules and masses
 -rounded and smooth -rounded and smooth
skull contour skull contour -facial muscles of the
-symmetrical facial -with right right side of the face;
movement asymmetrical facial signifies damage done
movement and from stroke
response
EYES -no eye discharges -no eye discharges
-with pinkish -with pale conjunctiva
conjunctiva and white and yellowish sclera
sclera -eyebrows hair not
-eyebrows hair evenly evenly distributed
distributed/skin intact -skin intact
-symmetrical facial
movement
EARS -Auricle color same -Auricle color same
as facial skin as facial skin
-Auricle are mobile -Auricle are mobile
firm and not tender firm and not tender
-no edema and -no edema and
discharges discharges
MOUTH -pinkish lips -dark lips
-without missing teeth -with false teeth
-with pink gums (upper)
-no foul odor -with dark gums
-with symmetrical -no foul odor
contour -with symmetrical
contour
-difficulty in -risk for aspiration
swallowing
MUSCULOSKETAL -symmetrical -not symmetrical; -right hemiparesis and
(UPPER AND -with full range of right upper and lower hemiplegia as a
LOWER motion extremities unable to consequence of stroke
EXTREMETIES) be moved -gait disturbance from
-stiffness noted on uneven control of
both right and left extremities
upper and lower -ensure safety of
extremities patient

ABDOMEN -No abdominal - no abdominal

distension distension
-Flat rounded - no surgical incision
abdomen
-Symmetrical contour
-No surgical incision
H. PATTERNS OF FUNCTIONING

FUNCTIONAL BEFORE DURING INTERPRETATION

HEALTH PATTERN HOSPITALIZATION HOSPITALIZATION
Health management  Self medication  5x in the
pattern hospital

Nutritional / Metabolic
 Number of  3x a day  Renal diet The patient was
meals per day  Good appetite placed to semi
 Appetite  10x a day fowlers position to
 Glass of water avoid aspiration.
per day

 Height and
weight
Elimination
 Frequency of  8x a day  With diaper Incontinence and
urination  1500ml per  800ml per day lack of control of
 Amount of  Every other  Lack of bowel movement
urine per day day control of due to brain damage
 Frequency of bowel as a consequence of
bowel movement stroke
movement
Activity and exercise  Jogging and  Bed rest The patient was
walking moderately active
 Exercise  Easily fatigue before being
 Fatigability confined and
 Activities of experiences altered
Daily Living states of
 consciousness
throughout the
duration of her
hospital stay.
Cognitive/ Perceptual  Oriented to  Patient was Patient is usually
 Orientation time place conscious and conscious but
 Responsiveness and person oriented to experiences times of
 Responds time, place altered states of
appropriately and person consciousness.
to verbal and  Patient
physical responds to The paralyzed part
stimuli verbal stimuli of the patient’s body
but right side no longer responds
of the body to either verbal or
does not physical stimuli due
respond to to damage from
physical stroke.
stimuli.

Roles/ Relationship  Jolly and kind  Patient is Unilateral neglect

overall a good apathetic is a common part
 As a father father to his about her of post-CVA
offspring. condition but patients.
cooperative.

Values/Beliefs  Patient Patient  Patient is

believes in believes in religious and
god and god and worships
always pray. always pray god.
Self Perception / Self  Have a high  Have a high She still has high
Concept self worth / self worth / self worth in
importance importance spite of her
condition. This is
evidenced by her
refusal of
catheterization
and nasogastric
tube insertion.
She still wants to
be independent.
Coping / stress  Even though,  She is always Even from before
he seeks for accompanied the experience of
some advice by either her stroke and after the
to his wife son or her stroke, the patient is
when he has husband and still always
problems, is able to accompanied by
burdens and confide in family members.
stresses. them with her
burdens,
stresses and
concerns.