Introduction Rheumatic fever is caused by an untreated bacterial infection (usually streptococcus aureus in throat).

Luckily, the introduction of antibiotics to treat this infection has dramatically reduced the numbers of this infection. But when the treatment is not continuous, the heart valves become inflamed; the leaflets stick together and become scarred, rigid, thickened and shortened. This leads to valvular stenosis or valvular insufficiency. Valvular stenosis occurs when a valve opening is smaller than normal due to stiff or fused leaflets. The narrowed opening may make the heart work very hard to pump blood through it. This can lead to heart failure and other symptoms .All four valves can be stenotic (hardened, restricting blood flow); the conditions are called tricuspid stenosis, pulmonic stenosis, mitral stenosis or aortic stenosis. Valvular insufficiency also called regurgitation, incompetence or "leaky valve", this occurs when a valve does not close tightly. If the valves do not seal, some blood will leak backwards across the valve. As the leak worsens, the heart has to work harder to make up for the leaky valve, and less blood may flow to the rest of the body. Depending on which valve is affected, the conditioned is called tricuspid regurgitation, pulmonary regurgitation, mitral regurgitation or aortic regurgitation. These valvular abnormalities will lead to Congestive Heart Failure. Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to deliver oxygen rich blood to the body. Congestive heart failure can be caused by diseases that weaken the heart muscle, diseases that cause stiffening of the heart muscles, or diseases that increase oxygen demand by the body tissue beyond the capability of the heart to deliver adequate oxygen-rich blood. Many diseases can impair the pumping action of the ventricles. The diminished pumping ability of the ventricles due to muscle weakening is called systolic dysfunction. After each ventricular contraction (systole) the ventricle muscles need to relax to allow blood from the atria to fill the ventricles. This relaxation of the ventricles is called diastole.

The lungs may become congested with fluid (pulmonary edema) and the person's ability to exercise is decreased. Fluid may likewise accumulate in the liver, thereby impairing its ability to rid the body of toxins and produce essential proteins. The intestines may become less efficient in absorbing nutrients and medicines. Fluid also may accumulate in the extremities, resulting in edema (swelling) of the ankles and feet. Eventually, untreated, worsening congestive heart failure will affect virtually every organ in the body. Less common causes include viral infections of the stiffening of the heart muscle, thyroid disorders, disorders of the heart rhythm, and many others. It should also be noted that in patients with underlying heart disease, taking certain medications can lead to the development or worsening of congestive heart failure. This is especially true for those drugs that can cause sodium retention or affect the power of the heart muscle.

Functional Classification of Heart Disease In the management of patients with heart disease, it is important to quantify and monitor the severity of symptoms. A commonly used classification system is that of the New York Heart Association (NYHA), shown below.

Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.

Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.

Class III: marked limitation of any activity; the patient is comfortable only at rest.

Class IV: any physical activity brings on discomfort and symptoms occur at rest.

Recent recommendations propose that patients with heart failure be classified into four stages:

Stage A: Patients at high risk for developing HF in the future but no functional or structural heart disorder;

Stage B: a structural heart disorder but no symptoms at any stage;

2

Stage C: previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment;

Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care.

(Medical and Health Encyclopedia, by: Morris Fishbein, MD, pages 710-713; Maternal & Child Health Nursing, Vol. 2, by: Adele Pillitteri, pages 1214-1215; Brunner & Suddarths Medical-Surgical Nursing, by: Suzannes Smeltzer and Co., pages 798-800 and 825-826; Introduction to the Human Body, Anatomy & Physiology,7th ed., by: Gerard Tortora & Bryan Derrickson, page 371; and www.cts.usc.edu/zglossary-congestiveheartfailure.html -

I.

Biographic Data Name: Miss Heart Age: 28 y/o Address: Gordon Heights, Olongapo City Birth Date: 04/10/83 Birth Place: Leyte Religious Affiliation: Roman Catholic Civil Status: Single Nationality: Filipino Educational Background: High school Graduate. Chief Complaint: Swelling of Feet with difficulty of breathing Initial Diagnosis: Rheumatic Heart Disease Final Diagnosis: Congestive Heart Failure III-C Secondary to Valvular Heart Disease Attending Physician: Dr. Benjie Sugui.

II.

Nursing History

IIA. Past Health History Statement: The patient stated that Nagkakasakit ako pero di ko pinapansin kasi ordinaryong lagnat at ubo lang naman. Pinainom ako ng nanay ko ng kalamansi at umaayos naman ako. Isa pa wala naman kaming pera para magpadoctor Nagkaroon na ako ng chickenpox nung Grade 5 pa ako. Wala akong ininom na kahit na anong gamot. Kumpleto naman ako sa bakuna sabi ng nanay ko tulad ng BCG. Nang grade 3 ko naman umpisang naramdaman ang pananakit ng mga tuhod at balakang ko. naman. Wala naman akong ininom na gamot pero nawala

Pero taong 2005 ng nasa Leyte pa ako naospital na ako sa EVMRC Hospital at sabi ng doctor my Rheumatic Heart disease daw ako. Mga ilang linggo, umayos naman kalagayan ko kaya pinalabas na ako. At sabi sa akin

maintenance ko na daw na gamot ang Digoxin, 25 mg isang beses sa isang araw. Kaso taong 2009 itinigil ko ang paginom ng gamot kasi wala kaming pera. Pinagkakasya lang namin ang pera sa pangangailangan namin, as verbalized by the patient. Interpretation: Although vaccination is an important factor for prevention of different types of infections and diseases, it is not enough to ignore any kind of sickness most especially pain because it might be a symptomatic form of an illness. Maintenance of medicine should not be discontinued. It might only lead to more complex form of sickness. Financial stability is also necessary for continuous treatment of disease as well as having nutritious food.

Analysis: For many people, pain is expected and accepted as a normal aspect of illness. Clients and families may lack knowledge of the adverse effects of pain. Clients may not report pain because they expect nothing can be done, they think it is not severe enough. People with inadequate support networks sometimes allow themselves to become increasingly ill before confirming the illness and seeking therapy. Support people also provide the stimulus for an ill person to become well again. (Kozier & Erbs Fundamentals of Nursing, 8th ed., by: Kozier, Erb, Vol. 1, page 302 and Vol. 2, page 1205)

IIB. Present Health History Statement: The patient stated that Dalawang buwan bago ako napunta sa ospital nakakaramdam na ako ng madaling pagkapagod at pananakit ng tiyan pero binalewala ko lang kasi nawawala naman. Dalawang linggo bago ako dinala 6itto sumasakit na mga paa ko at naninilaw ang mga balat at mata ko. Mabait naman yung kapitbahay ko minamasahe nya mga paa ko. Nakaramdam naman ako ng ginhawa kaya di ko na pinansin. Isa pa wala akong trabaho. Umaasa lang ako sa ate ko. Nitong Hulyo 25 bigla nalang namaga mga paa ko at nahihirapan akong huminga. Dinala ako sa hospital ng kapatid ko at na chest x-ray ako. Binigyan din ako ng mga sumusunod na gamot: Furosemide. sumapen, Metoprolol tartrate, digoxin, at

Interpretation: The patient ignored the pain felt before. Often time, she tend to disregard pain only until such time that it is no longer tolerable or is already in a severe status without realizing the possible effects and complication that may happen. It may also be possible that it is already associated with congestive heart failure. Early detection is very important in avoiding possible complications. Patients health is dependent on their status in life.

Analysis: Classification of pain may be useful in determining the clients underlying problems or needs. Locus of control is a concept from social learning theory that nurses can use to determine whether clients are likely to take action regarding health, that is, whether clients believe that their health status is under their own or others control.

People who believe their health is largely controlled by outside forces like financial constraints are referred to as externals. The health status of a person is affected by many internal and external variables over which the person has varying degree of control. (Kozier & Erbs Fundamentals of Nursing, 8th ed., by: Kozier, Erb, Vol. 1, page 302, 308 and Vol. 2, page 1188)

IIC. Family History Statement: According to the patient, there are two of them in their family who had rheumatic heart disease. She was only diagnosed with congenital heart disease IIIC secondary to valvular heart disease upon confinement last July 25, 2011. Her family has history of hypertension and diabetes. Her mother Narita, 56 years old and father Ely, 65 years old both have high blood but alive. The mother of her grandmother on her mother side has history of rheumatic heart disease and so is her grandfather on her mother side has diabetes. Her grandfather in father side died due to high blood and grandfather on mother side died due to diabetes but both grandmothers on both sides are alive. She had three brothers and three sisters namely Allan 40 y/o, Lotlot 38 y/o, Liza 31 y/o Sheryl 26 y/o, Elias 21 y/o, and Jonas 18 y/o. Her sister Lotlot has also rheumatic heart disease.

Interpretation: The patient has related risk factors of the congestive heart disease. And her congestive heart disease is secondary to her rheumatic heart disease. The client inherited her heart disease from her ancestors particularly from her mother side. She is already the third generation as shown in the genogram below.

Analysis: The most common causes of mitral regurgitation in developing countries are rheumatic heart disease. And one of the most common causes of congestive heart failure is rheumatic heart disease. Other factors that may influence cardiovascular function also include environmental factors such as heat and cold, previous health status, stress and coping, dietary factors, alcohol intake and an elevated homocysteine level. (Brunner and Suddarths Medical and Surgical Nursing 10th edition, Volume 1, pages 799 and Kozier & Erbs Fundamentals of Nursing, 8th ed., Vol. 2, by: Kozier, Erb, page 1409).

GENOGRAM
Grand mother RHD

Grand father Diabetes

Aa

Grand mother

Grand father HPN.

Grand mother A/W

CARRIER A/W

Grand father Diabetes

Aa
Mother High Blood A&W

Father High Blood

A/W

Allan 40 y/o A/W

Lotlot 38 y/o RHD A/W

Liza 31 y/o A&W

Ruby 28 y/o CHF A&W

Sheryl 26 y/o A&W

Elias 21 y/o A& W

Jonas 18 y/o A& W

A& W

Patient Affected Unaffected(female) Unaffected (male) Deceased

9

III. Patterns of Functioning A. Health Perception/ Health Management Statement: Para sa akin importante ang kalusugan at masasabi kong healthy ang isang tao kapag malakas siya, walang sakit, at nagagawa niya lahat ng gusto niyang gawin at walang ipinagbabawal. (ilagay ung rate )Kung irarate ko ang sarili ko kung gaano ako kahealthy ngayon ay 3 lang kasi dahil sa sakit ko at hirap akong huminga at mabilis rin akong mapagod. Siguro ang dahilan ng sakit ko ngayon ay dahil barado ang puso ko at dahil sa barado ang puso ko nahihirapan akong gawin ang lahat, maglakad lang ako na konti ay napapagod na ako at hirap rin akong huminga. Sa magulang ko at kapatid ko unang sinabi na may masakit sa akin. Hindi naman ako umiinom ng gamut agad depende kapag sinabi ng mama kong uminom ako agad ng gamut, kahit sakit lang ng ulo hindi ko agad iniinuman ng gamot. Hindi rin ako nagpapacheck-up agad sa center. Hindi rin naman ako umiinom ng alak at hindi rin ako naninigarilyo. As verbalized by the patient. Personal hygiene? Interpretation: Health for her is very important factor in life but shes not totally aware of what is a healthy person. She is not also totally aware of what kind of disease she has now, she only knows that she have a heart disease w/c she experience difficulty of breathing and body weakness. There were noncompliance of medication and ignorance of seeking medical provides that will going assists her upon illness or disease. Being a high school graduate affects how the patient perceive health and how the knowledge about her disease will be absorbed or catch up on mind to be able to understand. Analysis: Health is a highly individual perception. Health is perceived depends on how health is defined. Health is a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity.
10

Health education can help to prevent crisis situations and reduce the potential for re-hospitalization resulting from inadequate information about self-care. The goal of health education is to teach people to live life to its healthiest-that is to strive toward achieving their maximum health potential. Health is highly individual perception. Many factors affect individual

definitions of health. Definitions vary according to an individuals previous experiences, expectations of self, age, and sociocultural influences. (Brunner and Suddarths textbook of medical-surgical nursing , vol.1, pg.6,pg.49 ) (Kozier & Erbs Fundamentals of Nursing, 8th ed., by: Kozier & Erb, pages 295-296)

B. Nutritional Metabolic Pattern Statement: Madalas (gaano kadalas) kong kainin dati kanin at ang ulam ko laging pritong isda na may kasamang sinabawang gulay (tulad ng ) paborito ko kasi ang prito, kahit anu basta prito siya at marami rin nakakain. Pero ngayon konti na lang ang nakakain ko din a ako nakakakain ng marami kung dati 1 cup na kanin at 2 pirasong piniritong malaking isda ang nakakain ko ngayon cup na kanin na lang at 1 pirasong piniritong isda na lang ang nakakain ko. Tatlong beses naman akong kumakain sa isang araw(Umaga, tanghali at gabi) at dalawang beses naman akong nagmemeryenda (umaga at hapon). Ang timbang ko dati ay 50kg. Kapag kumakain ako nahihirapan akong lumunok masakit sa lalamunan pero dati naman hindi ako nahihirapan. Wala naman akong herbal at vitamins na iniinom kahit bago pa ako naospital. Ngayon marami akong iniinom na gamot tulad nito (phenoxymethyl penicillin, potassium, furosemide, metoprolol tartrate, kalium durule, lanoxin, Coumadin). Tubig lang ang iniinom ko nakaka isang 1.5 liter akong tubig sa isang buong araw. Ngayon bawal na sa akin ang mga pagkaing maalat, matataba at maasim. As verbalized by the patient. Present Weight: 40 kg Ht.: 155 cm
11

BMI: 40 kg/(1.55 m)2 Remarks: Underweight

16.6 or 17

Three Day Meal Recall 07/30/11 Morning: 2 pirasong tinapay at 2 basong tubig as verbalized by the patient. Snack: 2 pirasong tinapay at 2 basong tubig as verbalized by the patient. Lunch: 1/2 cup na kanin at pritong isda at 2 basong tubig as verbalized by the patient. Snack: 2 pirasong tinapay parin ganun parin ang meryenda ko as verbalized by the patient. Dinner: Ganun parin sa tanghalian ko, pritong isda at 1 pirasong saging as verbalized by the patient.

07/31/11 Morning: 2 pirasong tinapay parin at kape ang agahan ko as verbalized by the patient Snack: 2 pirasong tinapay at 2 basong tubig as verbalized by the patient. Lunch: 1/2 cup na kanin at 1 pirasong pritong isda sinabawang gulay at saging at 2 basong tubig as verbalized by the patient.

08/01/11 Morning: 2 pirasong tinapay at kape as verbalized by the patient. Snack: 2 pirasong tinapay at 2 basong tubig as verbalized by the patient. Lunch: 1/2 cup na kanin at miswa at 2 basong tubigas verbalized by the patient.

Snack: 2 pirasong tinapay at 2 basong tubig as Snack: verbalized by the 2 pirasong tinapay at 2 patient. basong tubig as verbalized by the Dinner: patient. 1/2 cup na kanin, giniling na karne at 2 Dinner: basong tubig at 1 Ganun parin ang pirasong saging as hapunan ko, cup na verbalized by the kanin, ulam ko patient. sinabawang gulay at 1 pirasong pritong isda at 1 pirasong saging, at 2 basong tubig as verbalized by the patient.

12

Interpretation: The patient has a regular eating pattern in each day but the foods that she is eating is not appropriate (how come) because she still eats foods which is high in fats and sodium containing foods which is fried fish that she always ate in lunch and in dinner that can affect her health thats why she experience difficulty of breathing and body weakness. The patients weight is 40kg and height is 155 cm, based on her BMI she is underweight and it is affected by her diet. Analysis: Increasing age alters nutrients requirements; the elderly require fewer calories and more nutrient-rich, healthy diet in response to alterations in body mass and a more sedentary lifestyle. Recommendations include reducing fat intake while getting enough protein, vitamins, minerals and dietary fiber for health and disease prevention. Sodium is an essential nutrient for body function, helping to regulate water balance and blood pressure. High intakes of sodium can lead to the body retaining large amounts of salt and water. This increases the volume of your blood which can cause pressure on major organs. A diet high in salt has been linked to high blood pressure, heart disease, and strokes. As the pressure in your body increases, it makes it more difficult for the heart to pump blood through your body. Thus, the heart must beat harder and faster to move the blood to your vital organs. This leads to a rapid heart rate and a higher blood pressure. (Brunner and Suddarths textbook of medical-surgical nursing , vol.1, pg.234) ( Jamie Wise, Rapid Heart Rate & Salty Foods, Live strong article)

C. Elimination Pattern Statement: Dalawang beses akong umiihi sa isang araw. Mga ganito lang ang iniihi ko ???(23.1cc) pero marami naman ang iniinom ko yung iba pinapawis ko, nakakalimang beses akong palit ng damit dahil sa pagpapawis ko. Limang beses naman akong dumudumi sa isang araw pero konti lang ang dinudumi ko at ang kulay nito ay black na may konting dugo as verbalized by the patient
13

Characteristics of urine Characteristics of stool?

difficulty

of

urinating

and

defecating?

Interpretation: The patient excreting insufficient urine output even there was an increase intake of fluid per day that indicate an decrease oxygen supply in the tissue will decrease the renal perfusion causing a decrease urine output.

Analysis: Ineffective renal perfusion is a decrease of oxygen distributed from the left atrium to the left ventricle resulting in the failure to nourish the renal tissues at capillary level. Blood in stool is caused by harmless conditions such as stress, oily foods, and medicines to some serious conditions like hemorrhoids and rectal cancer which can vary in colour from terry black, red, brown or even may go unnoticed to naked eye (Dr. David K. Blood(MD),Causes of blood in the stool,healthcare magic articles)

D. Activity- Exercise Pattern Statement: Bago ako maospital ang madalas kong ginagawa ay magluto, maglinis ng bahay, ginagawa ko yung mga gawaing bahay. (araw-araw?) Nagtrabaho rin ako bilang isang sales lady noong 2005. Pero ngayong nandito ako sa ospital, madalas lang akong nakahiga, minsan naglalakadlakad pero di ako nagtatagal maglakad kasi agad akong napapagod at nagbabasa rin ako as verbalized by the patient Interpretation: The activity modify as the patient experienced the present heart problem wherein the distribution of oxygen along the body decreases needed for the body function that affect his activity pattern.

14

Analysis: The patient is advised to avoid physical exertion as it increases cardiac output and pulmonary pressure increases. (Brunner & Suddarth,Medical Surgical Nursing,12TH Edition,Vol. 1,p.918-919)

E. Sleep-Rest Pattern Statement: Hindii ako nakakatulog nang maayos , natutulog ako nang 9pm at nagigising ako nang 5am pero putol-putol yun. Pag nakatulog ako ng 1 hanggang 2 oras nagigising agad ako kasi nahihirapan akong huminga. Natutulog rin ako sa tanghali pero kalahating oras hanggang 1 oras lang ganun rin sa hapon. Nagigising ako kaagad dahil sa ingay at hirap akong huminga as verbalized by the patient Rituals? Interpretation: The patient has a sleep disturbance due to the environment and she is experiencing of difficulty of breathing.

Analysis: Many factors can affect sleep, including illness, environment and emotional stress (Kozier and Erbs, Fundamentals of nursing, eight edition, vol.2, pg.1183)

F. Cognitive Perceptual Pattern Statement: Alam ko naman kung anong araw ngayon(lunes) at kung kelan ako dinala dito sa ospital pero di ko na matandaan kung anung araw yun. Kilala ko naman kung sino ang pangulo natin ngayon si Noynoy Aquino. Alam kung
15

nasa ospital ako ng James Olongapo ngayon. Pero meron rin akong ilang bagay na hindi ko na matandaan, medyo mabilis rin kasi akong makalimot. Pito kaming magkakapatid at ako ang bunso. Ang mga kapatid ko ay sila Allan, Lotlot, Liza, Sheryl, Elias at Jonas. Ang birthday ko ay April 10, 1983. Maayos naman ang pandama at panlasa ko. Nalalasahan ko pa naman yung mga kinakain ko. Sa paningin ko naman kadalasan Malabo pero kadalasan hindi Malabo. Sa pandinig ko naman ganun din kadalasan mahina ang pandinig ko pero kadalasan malinaw naman at maayos ang pandinig ko as verbalized by the patient Interpretation: The patient is not completely oriented because there are things were answered but there were things that she cant remember upon interview. She can distinguish persons and date correctly but the patient perception were altered may be due to insufficient supply of oxygen in the brain for its function. Analysis: Any disorder that impairs cognitive functioning may affects clients ability to use and understand language. These clients may develop total loss of speech, impaired articulation, or the inability to find or name words. Certain medications such as sedatives, antidepressants, and neuroleptics may also impair speech, causing the client to use incomplete sentences. (Kozier, Fundamentals of Nursing 7th edition,pg.438) III.G.Self-Concept/Self-perception Pattern Statement: Parang naaawa ako sa sarili ko. Wala ako maitulong sa ate ko ngayon. Hindi naman ako dating ganito. ewan ko ba

Interpretation: Change in physical appearance, declining mental, physical or sensory ability. Inability to achieve goal, relationship concern & unrealistic ideal self are some of the factor that affect self concept & self perception.

Analysis:
16

Self concept & health related behavior are intertwined, illness and trauma can also affect self concept. Identity stressors, body image stressors, self-esteem stressors & role stressor contribute to decline self concept & self perception. (Fundamentals of Nursing by Kozier and Erbs, Eight Edition, Vol. 2 Pg. 1008)

III.H.Role Relationship Pattern Statement: Pang apat ako sa pitong magkakapatid, si ate Elizabette pati pamilya nya na lang ang kasama ko, may mga kaibigan ako dati pero ngayon si ate na lang ang kaibigan ko. hindi kasi ako lumalabas ng bahay. Binabantayan ko na lang ang mga pamangkin ko noon. Interpretation: Patient condition affects her role & relationship to others. She spends her time taking care of her nephew. Some factors such as loss of parent, relatives or closed friend, changes or loss of ability to work, illness & inability to meet role expectation affects persons role & relationship to others. Analysis: A role is a set of expectations about how the person occupying one positions behave. Relationship can be supportive and growth producing or, at the opposite extreme & highly stressful of role stressor is presence. (Fundamentals of Nursing by Kozier and Erbs, Eight Edition, Vol. 2 Pg. 1007-1009)

III.I.Coping Stress Pattern Statement: Recent illness ( extreme ) Finance ( extreme ) Health ( extreme ) Recent hospitalization ( extreme ) Nalulungkot ako kasi di ko na magawa yung mga dati ko ginagawa. Madali ako mapagod at nahihirapan ako huminga. Problema din yung gagastusin ni ate ko dito sa ospital. Interpretation: Patients stress focuses on her health & financial status. Stress is rated 1(minor) 9 (extreme) when assessing the patient stressors. This stress contributes
17

to aggravate patients conditions. She is trying to forget all those stress as her coping mechanism. Analysis: Stress is a condition in which the person experiences changes in normal balanced state. There are many sources of stress. They can be broadly classified as internal or external stressors, or developmental or situational stressors. Coping may described as dealing with change successfully or unsuccessfully. (Fundamentals of Nursing by Kozier and Erbs, Eight Edition, Vol. 2 Pg. 1061-1068)

IIII.J. Value Belief Pattern Statement: Katoliko ako pero si ate naman ay Born Again. Wala naman kami di pinagkakasunduan pagdating sa relihiyon. Di na din ako nakakapagsimba ngayon, madalas naman sinasama ako ni ate sa church nila. Okay lang sa akin ang pamamaraan ng pang gagamot nila basta mahalaga ay gumaling ako. Interpretation: Patients values and beliefs dont affect treatment and laboratories procedures. Her religion doesnt conflict with the religion of her sister. She stated that her religion is Catholic but she doesnt go to church regularly. Analysis: Values are enduring beliefs or attitudes about the worth of a person, object, idea or action. Values are important because they influence decision making and actions. Beliefs are interpretations or conclusions that people accept as true. (Fundamentals of Nursing by Kozier and Erbs, Eight Edition, Vol. 2 Pg. 80)

III.K.SEXUALITY-REPRODUCTIVE PATTERN Statement 16 years old ako nung una ako nagkaregla, regular naman dati ang regal ko pero irregular na siya ngayon. Uminom ako ng ferrous sulfate noon pero hindi din naging regular ang regla ko. Hindi ko pa nasubukan magpatingin sa doctor. Interpretation: Patients menarche occurs in her normal age ranged. Less knowledge regarding menstrual process and not consulting to doctor can be dangerous.

18

Analysis: Adolescene (12 18 y.o) usually menarches take place. Sexual health is an individual and constantly changing phenomenon falling within the wide range of human and sexual thoughts, feelings, needs & desire. (Fundamentals of Nursing by Kozier and Erbs, Eight Edition, Vol. 2 Pg. 1023)

IV.

Activities of Daily Living

19