PATIENT’S PROFILE

NAME : Mrs. C

AGE : 63 y/o

GENDER : Female

ADDRESS : Pasig City

DATE OF BIRTH : June 6, 1947

PLACE OF BIRTH : Pangasinan

OCCUPATION : Cook

NATIONALITY : Filipino

CIVIL STATUS : Single Parent

RELIGION : Roman Catholic

CHIEF COMPLAINT : Increased BP

ADMITTING DIAGNOSIS : TIA, HPN

DATE ADMITTED : February 3, 2011

TIME ADMITTED : 2:00pm

ADMITTING INSTITUTION: Pasig City General Hospital

PHYSICIAN: Dr. Lim/ Duro

 Nursing Health History

Biographic Data

Client X is a 63 year old female, single parent, Roman Catholic. A cook, whose finance
is supported by her own, the client is residing at Pasig City

Chief complaint:

The patient has body weakness, slurring of speech, and having icteric sclera for 5 days.

A. History of Present Condition:

B. The patient was diagnosed with hypertension for 10 years. He was diagnosed with diabetes
mellitus type 2 for five years. One week prior to admission the patient has body weakness
slurring of speech. Five days prior to admission the patient has icteric sclera. Few hours prior
to admission the patient has increase body weakness and dizziness.

Past history of illness:

He has no known existing and past allergy to any foods, drugs, animals, insects and other
environmental factors nor accidents and injury. He had no previous hospitalization.
C. Family Health History:
Mother Father
Hypertension Liver disease
Diabetes
mellitus

patient

Lege
nd

Son

Daught
er

D. PAIN ASSESSMENT

The patient rated the pain he feels on his right upper quadrant 8 out of 10 that started last April
17, 2011. He stated that pain was stabbing pain. The pain was minimized whenever he does sleep
but the pain continues after he woke up. And also, he stated that pain becomes worsen when he is
eating.

GORDON’S 11 FUNCTIONAL

1. HEALTH PATTERN-HEALTH PERCEPTION-HEALTH MANAGEMENT

PATTERN

Before hospitalization: The patient perceived his health in the state of good condition. He
perceives health as wealth and he values her health a lot. She manages her health by practicing
proper hygiene and eating nutritious food.

During hospitalization: The patient perceived that she is not healthy because of her condition.
She was more inclined to bed rest due to easy fatigability but engages in ROM exercises. She
eats hospital meals and fruits. She closely listens to the doctor’s and nurse’s health advices.
NUTRITIONAL-METABOLIC PATTERN

Before hospitalization: The patient eats 3 times a day and with afternoon snacks after coming
from work. According to the SO of the patient, she eats meat, fish and also vegetables. She
doesn’t have any allergies on foods and drugs. Her appetite is moderate and usually depends on
the food being served. She didn’t complain any difficulty in swallowing.

During hospitalization: Upon admission, the patient was ordered with PNSS 1liter to run for 8
hours. The diet has loss his appetite and hasn’t eaten a lot. She is on a LSLF (Low Salt and Low
Fat)

ELIMINATION PATTERN

Before hospitalization: The patient does not have any problem on her elimination pattern. She
usually urinates 5-7 times a day without any difficulty. She added that the color of her urine is
light yellow. She didn’t feel any pain in urination. The patient defecates once a day usually early
in the morning before going to work with yellow to brown color. She verbalized that sometimes
however, it is hard in consistency with dark color, which generally depends on what he eats.

During hospitalization: The patient urinates 2-3 times a day. The color of her urine is yellow.
The patient hasn’t defecates since she was admitted in the hospital.

ACTIVITY-EXERCISE PATTERN

Before hospitalization: She could perform activities of her daily living. According to her, she
always does brisk walking as a form of exercise.

Feeding-0; Bathing/hygiene-; Dressing/grooming-0; Toileting-0; Ambulation-0; Care of home-0;

Shopping-0; Meal preparation-0; Laundry-0; Transportation-0

During hospitalization: Her activity was limited lying on bed but the patient is given her
bathroom privileges.

Feeding-2; Bathing/hygiene-2; Dressing/grooming-2; Toileting-2; Ambulation-2;

SLEEP-REST PATTERN

Before hospitalization: She has the normal 6-8 hours’ sleep. She also has her nap time for 1-2
hours a day. Sleeping and watching the television are her form of rest.

During hospitalization: She doesn’t have the adequate time of sleep since she is disturbed with
the nurses that enter the room every now and then, and because of the environmental changes of
her surroundings. She also has inadequate time to rest since she doesn’t have enough time to
sleep.

COGNITIVE-PERCEPTUAL PATTERN
Before hospitalization: She has good memory and reasoning skills. She can easily comprehend
on things. In terms of his perceptual pattern, she has no problems with her senses except for her
visual acuity. She has an own reading glass.

During hospitalization: She responds clearly and well understood. She responds appropriately
to verbal and physical stimuli and obeys simple commands.

SELF-PERCEPTION – SELF-CONCEPT PATTERN

Before hospitalization: She sees herself as a person with a good personality. She has been a
good friend and mother. She said she has to be a good person in order not to hurt others. She also
describes herself as a typical type of mother.

During hospitalization: She verbalizes satisfaction with her abilities and talents. She also
describes herself as a very jolly person though she is sad during the interview because of her
current condition. With the help of her mother she was able to answer most of my questions. She
was able
to maintain eye contact upon interview.

ROLE-RELATIONSHIP PATTERN

Before hospitalization: She has a close relationship with her family. She is a single parent and
also a responsible mother and knows all his duties as a friend.

During hospitalization: She had more time to bond with his family. She said that it was a nice
feeling to know that your family is so supportive to her. She learned to appreciate the beauty of
having a family that gives you strength and support no matter what.

SEXUALITY-REPRODUCTIVE PATTERN

Before and during hospitalization: According to her, she he was already menopause at age of
58. Also she doesn’t have a history of sexually transmitted disease.

COPING-STRESS TOLERANCE PATTERN

Before hospitalization: She does not fully identify his situations having stress but she always
tells to her children when something is wrong.

During hospitalization: She shares her problems to her family. She verbalizes her feelings.
VALUE-BELIEF PATTERN

Before hospitalization: She is a Roman Catholic devotee. She always goes with her family
every Sunday to go to mass. She was taught by her family to believe and have fear to GOD.
They usually believe in quack doctors.

During hospitalization: The client is a catholic and she state that being polite to the elders and
following them is an important value for her. She usually prays at night before she goes to sleep.
She believed that God is always with her and would never leave her no matter what happens.