HEALTH PERCEPTION/ HEALTH MANAGEMENT: The client is aware and understands his medical diagnosis, stated that Alam

ko lahat ng nangyari sa akin, nung dinala ako dito sa ospital, ang hindi ko lang alam ay nung inoperahan na ako , as well as the procedure done to him stating Inoperahan ako kasi pumasok ang bala sa katawan ko, at inayos nila ang buto na natamaan sa akin . According to Mr. V, he had no previous hospitalization.; simple cough and colds are treated with herbal medicines like pito-pito, oregano leaves and calamansi. He cut his left thumb nail accidentally with an axe when he was 14 years old. He was sent to the hospital but was not admitted. NUTRITION AND METABOLIC PATTERN: Mr. V is on soft diet as of November 17, 2010. According to him he misses eating rice. His usual meal consists of 3 to 4 cups of rice, meat and vegetables. He also said that he likes eggs and coffee for breakfast. He has no allergies with food rather he eats everything that is served to him. ELIMINATION PATTERN: According to Mr. V, usually he has no problem with voiding and defecating. He defecates 3-4 times a week. Since he was hospitalized, his urinary frequency and bowel movements decreased. His usual stool is soft and firm and yellowish color urine. Reports no pin in voing and defecating. ACTIVITY AND EXERCISE PATTERN: Mr. V stated that Sa tuwing nagkakaoras ako nag babasketball ako. Pag umaga naman nag sestretching ako sa labas ng bahay namin, tapos nagluluto na ako ng umagahan. According to him he sleeps at 8pm without any difficulty and sleeping devices needed for him to fall asleep. He wakes up early to cook and to work. Due to his accident, his left arm s range or motion is limited and is currently covered with casting. According to his doctor the bones in his arms are completely fractured and repairing it now will not be successful, they still have to wait until the wounds have fully recovered. COGNITIVE AND PERCEPTUAL PATTERN: Mr. V responds to questions without difficulty in remembering previous health problems and medical needs. He is aware about his needs of medical assistance and of complying with medical regimens. He usually reports pain on his left upper limb especially when coughing. ROLES AND RELATIONSHIP PATTERN: Mr. V is the bread winner of his family and works as a tricycle driver in their community. According to him he just got home (March 2010) from his work in Riyadh. He said kailangan kong maging matatag para sa pamillya ko. He lives with his wife, an 8 month old daughter and his mother.

COPING AND STRESS PATTERN: Mr V. is concerned about work and child care. He smokes and drinks alcohol once in a while. SELF PERCEPTION PATTERN According to Mr. V, he thought he was going to die when he was shot. He said that he was fearing about the result of his death to his family. VALUES AND BELIEF PATTERN Mr V s religious preference is Roman Catholic; admits he believes in quack doctors and superstitious beliefs. He puts a handkerchief with the prayer of El Shaddai on top of his abdomen and goes to church together with family on his day off. ROXANNE VENICE C. DAVIS

ASSESSMENT: EYE No redness, discharge, or crusting noted; eye lids in normal position. Conjunctiva and sclera appear moist and smooth; Sclera white with no lesions or redness over lacrimal glands; Irises are round, flat and evenly colored; Pupils are equal in size and reactive to light and accommodation. EAR Equal in size bilaterally, auricle aligned with the corner of each eye. Skin smooth, no lumps, lesions, nodules and discharge. Non tender on palpation MOUTH Lips are dry, no cracks; gums are pink with no swelling or redness. Buccal mucosa pink, wrist and without exudates. NOSE Nose are somewhat large, smooth and symmetrical; markings of tape from NGT are present. No purulent drainage. THORACIC AND LUNG ASSESSMENT Presence of CTT on the left thorax; Experience pain when breathing and coughing; Tattoo on the left side of the chest. PERIPHERAL VAASCULAR ASSEESSMENT Left arm fractured with casting, right arm with full range of motion. Legs are equal in size, no swelling; brown in color, normal distribution of hair, no presence of edema. ABDOMINAL ASSESSMENT Abdomen is flat, symmetric no bulges or lumps. Jackson Pratt is present on the uppr left side of the abdomen, no bleeding around the site. No persistaltic wave seen. NEUROLOGIC ASSESSMENT

Using Glaskow??? DATE Nov. 11 Nov. 12 Nov. 13 Nov. 14 Nov.15

EYE OPENING Spontaneous To speech To pain No response BEST MOTOR RESPONSE Obey Localizes Withdraws Abdominal flexion

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