FAR EASTERN UNIVERSITY

Institute of Nursing

CASE PRESENTATION
Presented by:

Vidallo, Kenneth
Vigilia, Angelie Mariz
Villacorte, Robert Francis
Villamayor, Rachell Ann
Villanueva, Donna Rose
Villanueva, Jeness Jeanne

BSN 136A
Biographical Data
Our client’s name is K.P, 2 years old
and 3 months, male and lives at San Juan
City. He was born on April 6,2007 at
Bulacan. He is a natural born Filipino who
speaks Tagalog. His marital status is n/a.
Her religion was Roman Catholic. His father
has PhilHealth card. Their monthly income is
Php 10,000.
Past Health History
 During these past few years, the client had
experienced few diseases and asthma attacks. He
usually experience colds and cough especially when
the weather is bad. The client is given self-prescribed
medicines when able he is sick. He was vaccinated
with BCG, anti- polio, anti- tetanus, measles, hepatitis
B . According to the secondary source of information,
“Tuwing umuubo at sinisipon siya, pinapainum ko
lang sya ng maraming tubig kaya nawawala din agad.”
FUNCTIONAL HEALTH PATTERN:
HEALTH PERCEPTION AND HEALTH MANAGEMENT
PATTERN
 According to the secondary source of information, which is the client’s
grandmother, being healthy is merely the absence of diseases. She
verbalizes, “Para sa akin, healthy ang tao kapag hindi nagkakasakit.
Healthy kasi hindi bugnutin tsaka hindi matamlay.” She rates her
grandson 6 out of 10, 10 being the highest and 1 being the lowest. She
mentioned, “Madali kasi siyang (the client) madapuan ng sakit eh,
hindi ko nga maintindihan kung bakit?”

 She believes that taking vitamins regularly and eating nutritious food
prevent his grandson from acquiring any diseases. The client has no
routine check- ups, secondary source of information expressed that she
brings her grandson to a health care provider only when he complains
about pain or any abnormalities in his body. “Hindi ko rin naman kasi
madalas i-pa check-up ang bata.”
 “Madalas ko mapansin sa bata na ayaw niya uminom ng gamot, dahil na
din siguro hindi niya magustuhan ang lasa o kaya naman minsan kapag
tableta ang ipapainom nahihirapan syang lunukin ito.” Verbalized by the
grandmother.
 He had asthma attacks especially when I’m smoking inside the house
and there is climate change.
 He has good hygienic practices. He takes a bath once a day (every
morning). He washes his hands frequently before and after meals and if
his hands are visibly soiled. He brushes his teeth regularly.
 (-) dental carries
 (-) oral lesions
 (-) breath odor
 (-) body odor
 He has short nails.
 He is neat; well- kept and has proper grooming.
 NUTRITIONAL AND METABOLIC PATTERN
 The client usually eat three times a day. According to the secondary
source of information, which is the client’s grandmother,, “Madami
siyang iniinom ng tubig. May pito hanggang walong baso siyang naiinom
sa isang araw.”
 According to them, proper nutrition is eating the right food. The
secondary source of information verbalized, “Ang tamang nutrisyon ay
yung pagkain mo ng masusustansyang pagkain, tatlong beses sa isang
araw.”
 Weight – 11kg
 Height: 78cm
 BMI: 18.08kg/m2
 She has brown skin with
 uniformity.
 It has normal temperature.
 (-) edema
 (-) abrasions
 (+) lesions
ELIMINATION PATTERN
 He defecates twice a day early in the morning and before he
goes to sleep. The secondary source of information said that
his stool is normal because there are no inconsistencies on
her feces. His feces are brown and aromatic. He doesn’t feel
any pain when defecating. “Kapag nahihirapan siyang
tumae, pinapainom ko lang siya ng maraming tubig tapos
pinapakaen ko siya ng papaya kapag nahihirapan tumae .”

 He only urinates 4 to 6 times a day. It is sometimes yellowish

and aromatic. He doesn’t feel any discomforts when
urinating and sometimes he experiences problem in
controlling urine elimination.
ACTIVITY- EXERCISE PATTERN
 According to the secondary source of information,
which is the client’s grandmother, “Matulog,
kumaen, maglakad lakad o mamasyal sa labas kapag
walang magawa.” She noted that the client became
lazy and uninterested in doing his normal activities
when he is sick. “Yung pakiramdam ng pagkatamad
maglaro pag may sakit eh, normal lang sa bata.”
 There is presence of resistance. Both left and right
side of the head give equal strength in resisting the
force
 He has signs of distress on his face. Difficulty in
breathing due to cough and colds.

 He appears to be stresses and weak.

 He feels tired easily.

SLEEP AND REST PATTERN
 The client noted that he regularly sleeps at 7:30pm and wakes up at 8:00
in the morning.
 Client sleeping environment is somehow comfortable, though
sometimes he gets annoyed because of their poor ventilation in their
bedroom. “Minsan naiistorbo siya dahil narin siguro mainit sa bahay.”
According to the secondary source of income, he turns her light off
whenever the client is sleeping so that the client could fall fast asleep.
“Pinapatay ko talaga ang ilaw para makatulog siya kaagad, nakasanayan
narin niya. Umiinom din siya ng gatas sa gabi.” She also stated that the
client usually takes his naps between 12:30pm to 3:00. For sometimes,
he experiences mood swings during his sick days. “Madali mairita yan
lalo na pag bagong gising sa umaga, umiiyak.”
 He also stressed out that his exhaustion affects his
concentration in everything he does and at times, he
lacks interest and feel lazy. “Kapag napagod na siya,
kusa nay an titigil, mahihiga tapos maya maya tulog
na.”
 He is tired and sleepy
 Presence of eye bags.
COGNITIVE- PERCEPTUAL PATTERN
 According to the secondary source of information,
which is the client’s grandmother, “Wala naman
siyang problema sa mata at sa tenga.” He doesn’t
experience changes in his sense of smell, taste and
touch. She added, “Wala naman siyang nararanasan na
pagbabago o problema tungkol sa pang amoy,
pandinig, at yung iba pang senses niya.”
 The client’s responds correctly to normal voice tone.
 The client is able to smell not that comfortable in both
nasal cavities and blow with some discharges due to
colds.
SELF- PERCEPTION AND SELF-
CONCEPT PATTERN
 “Bibong bata yan, masayahin, malikut at makulit. pero
ganun siguro talaga.” The secondary source of
information verbalized. She also added that the client
has no problem in expressing her thoughts to others
 She also noted that the client is a cheerful child. The
client is also calm in handling things.
 The secondary source of information noted that she
doesn’t feel any stressful events lately.“Madalang naim
siyang mapagalitan dahil mabait na bata naman siya.”
ROLE- RELATIONSHIP PATTERN
 The client doesn’t play any major role in their family
because he is still a toddler.
 The client lives with his parents and other relatives in
their house. They are close with each other as the
secondary source of information said. They doesn’t
have any family problem as of now, and because he is
still a toddler they don’t expect a lot of thing in him,
except for his to grow up and finish his study.
SEXUALITY- REPRODUCTIVE
PATTERN
 “Wala pa naman kaming nakikitang kakaiba sa
pagkalalaki niya.” He is comfortable with his gender
and doesn’t experience difficulty regarding it.
Presently, he doesn’t experience any hard times in
dealing with the opposite sex. He prefers to go out with
both sexes and is enjoying playing with them.
 He enjoys his childhood with his other friends.
COPING- STRESS TOLERANCE
PATTERN
 According to the secondary source of information, the
client haven’t experienced any stressful event in her
life.“Ang pinakanakakapagod na nangyayari eh kapag
pinagagalitan naming siya, iniiyak nya lang lahat
hanggat hindi niya nararamdamang hindi na siya
nasaktan.”
 “Hindi pala away na bata yan, kapag may nang away sa
kanya, umiiyak at isinusumbong lang sa amin.”
According to the secondary source of information.
VALUE- BELIEF PATTERN
 According to the secondary source of information, Their
family is the most significant people in the client’s life but
she added “ Kahit ngayong bata pa lang siya,
napakalambing na bata niyan. Mahal na mahal niya mga
magulang niya.”
 Respect and honesty are the some of the social norms the
client is taught.“Kung ako ang tatanungin kapag sinabing
healthy, yun yung wala kang nararamdaman sakit o hindi
masama ang pakiramdam mo. Importante ang kalusugan.
Mas pag-iigihin ko pa ang pag aalaga sa bata para mas
maintindihan ko ang kahalagahan ng kalusugan.”