I.

Biographic Data

Name: M.C.
Address: Tatalon, quezon city
Educational Attainment: n/a
Gender: Female
Civil Status: Single - child
Religion: Catholic
Date of Birth: July 17, 2009
Age: 1 y/o
Birthplace: Bicol
Nationality: Filipino
Admission Date: January 8, 2010
Physician: Dr. E. Fullido
Chief Complaint: Seizure
Diagnosis: seizure disorder; AURI

II. Nursing History

A. Past Health History

The patient never had childhood diseases like measles, chicken pox
and mumps but her mother said that she tends to have cough,
colds and fever. She has not yet completed the immunizations for
she is not yet vaccinated with DPT 2 and 3. She has no known
allergies to any kinds of drugs or food. She was hospitalized last
December 2010 because of loose bowel movement and
dehydration. She was not involved in any accidents. The patient
previously lived in Bicol where she was born. They transferred to
Tatalon, Quezon City last September 20, 2010.

B. History of Present Illness

Couple of hours prior to admission the patient experienced

difficulty of breathing and seizure like symptoms, hence the father
decided to seek consultation.

The patient was admitted last January 8, 2010 with a provisional

diagnosis of seizure disorder; AURI.
 c. Family History

The patient’s mother is hypertensive but other than that the patient
has no family history of diabetes, ashtma and other genetic diseases or
disorders.

III. Patterns of Functioning

A. Psychological Health
1. Coping Patterns
The patient is a toddler; she is talkative but the words are not
that clear and easy to understand. She is close to her parents, siblings
and aunts. The mother said, “hindi naman sakitin yung mga anak ko
nung nasa probinsya pa kami, ngayon lang sila naging sakitin nung
lumuwas kami sa maynila.”

2. Interaction Pattern

The mother said that she usually doesn’t allow her children to go
outside and play. She verbalized, “Hindi ko sila madalas pinalalabas ng
bahay kasi, madumi sa labas baka magkasakit lang sila. Paano ba
naman, pag labas ng bahay may dumi ng pusa at aso. Paglalalaruin ko
lang sila pag sigurado na akong malinis yung paligid.” She also said
that her daughter doesn’t have many playmates because she is not
often exposed outside and interact with others. On other times she
invites her daughter’s playmates to their house and play.
3. Cognitive Patterns

The patient is just 1 year old, so her words are not easily
recognizable. She likes to express her disagreement or dissatisfaction
with a cry or a shout. She likes to explore and discover things that are
new to her eyes. She is not yet toilet trained.

4. Self-Concept

The patient is shy and uncomfortable to new people around her.

The mother said, “medyo mahiyain tapos hindi siya nagpapakarga sa
mga taong hindi niya kilala pero pag-gusto ka niya sasama yan sayo.”

5. Sexuality
The patient is female; she loves to play with dolls and other
things which are for girls. Her mother makes her wear dresses and
skirts; and the mother also combs and ties her hair.
 6. Family Coping Pattern

Her mother said that their family is strongly bonded along with
her nieces who also stays with them. In every problem that arises, they
talk it through to solve it quickly and to avoid complications. They are
supportive, with each other. The mother said, “Nag-uusap kaming
magasawa kung ano yung problema, tapos kung sino at ano yung
tama ayun yung susundin. Wala sa amin yung dominante, pantay lang
kami. Hind porke’t siya yung nagtratrabaho siya lang nasusunod.”

B. Socio-Cultural Patterns

Cultural Pattern
The patient’s mother said that they believe in shaman, hilot and
tawas especially when they are still residing in the province. She
first seeks consultation to a shaman when they contract any kind of
illness, she observes if it’s effective; if not, they will ask for a help of
a doctor. She said, “ Naniniwala ako sa mga abularyo, pinatitingin
ko sila sa kanya, tapos oobserbahan ko kung gagaling sila, kung
hindi naman ipapagamot ko na sila. Minsan kasi hindi mo kasi
sigurado baka na usog o kaya nabati sila eh.”

The mother said that she typically uses oregano as a remedy for
cough and colds for their children. She said, “pinapakuluan ko yung
dahon tapos kukunin ko yung katas at papainom ko sa mga anak
kong may ubo.” She believes in reliability of it.

Significant Relationships
The patient is 3rd of the 4 siblings. Her mother stays in the house to
take care of them and cooks for them. While her father works as a
“mekaniko”. He often works from 8am up to 6pm. Her 2 nieces stay with
them to help her in taking care of the children and do house chores. They
also hire a helper to laundry and iron for them.

Her youngest sister which is 6 moths old is also confined in the

hospital. she was first hospitalized and diagnosed with Pneumonia and
after a couple of days M.C. was also hospitalized and diagnosed also with
Pneumonia. Because of that her mother is often at the hospital to take
care to the two of them.
 Recreation Patterns
The patient loves to play with her siblings; they often play dolls.
She also loves to watch cartoons and dance. Her mother said,
“mahilig yan maiikot-ikot sa bahay, manood ng tv tapos gagayahin
yung napapanood niya.

Environment
The family lives in Tatalon city, their house is located in city
streets so their environment is noisy, dirty and polluted. The mother
said, “ Madumi yung lugar naming, makalat sa labas may mga dumi
ng hayop sa kalye. Kaya hindi ko pinalalabas yung mga anak ko eh.
Hindi marunong maglinis ng bakuran yung mga kapitbahay namin.”
She said that their environment is probably the reason why her
children have illnesses. She also stated. “dikit – dikit yung mga
bahay dun kaya nga naisip naming na lumipat kami sa iba
pagkatapos gumaling nga mga anak ko. Pati naisip nami na malas
yung bahay kasi naging sakin yung mga anak ko pagkatapos
naming lumipat dun.”
Their house has one only bedroom in which they all sleep
together. The mother added. “Katabi ko yung dalawa, si M.C. pati
yung bunso tapos yung asawa ko katabi yung dalawa ko pang
anak.” Their house has only one medium sized window.

Economic
The mother describes their living as: middle class. Her
husband’s salary is sufficient to their needs and sometimes if theirs
excess, she kept it, for emergency. They give most priority to food
while they give least priority to clothes and material things. The
mother said, “Pagkain yung talagang pinalalagahan naming tapos
yung mga gamot ng mga bata huli na yung mga damit mga luho
pagsobra lang yung pera.”

C. Spiritual Patterns

1. Religious Beliefs and Practices

The patient and her family are Roman Catholic. They used to
attend Sunday mass regularly but as their children grow up, they
slowly stop to attend mass. The mother reasoned, “Makukulit kasi sa
simbahan yung mga bata pati maiingay pa, ndi tuloy kami
makapagsimba ng maayos.” The mother doesn’t like to leave their
children in the house while they go to the church; she likes to attend
mass together. She said, “Gusto ko pagnagsisimba kami sam-sama,
kung hindi rin wag nalang kami magsisismba.” They just make sure
that they pray everyday in their house together. She also teaches her
children how to pray and thank the Lord in every blessing that comes
in their way.

2. Value and Valuing

The patient’s mother gives importance to the values, good manner

and right conduct. She teaches her children how to be courteous,
kind to others, respectful, modest and spiritual. She also teaches the
value of sharing your blessings with other and don’t be a greedy and
war freak. It is important to her that their family is intact and has
harmonious relationship. Furthermore, she believes that their
children will be successful someday.

ACTIVITIES OF DAILY LIVING

ADL Before During Interpretation

Hospitalization Hospitalization and Analysis

1. Nutrition “Magana “Wala namang

naman , siyang nagbago sa gana
kumain, hindi niyakain niya.
siya mapili sa Malakas pa din
pagkain” siya kumain.”

“Palaging bagong “Malakas pa din

luto yung siya magdede ng
pinapakain ko sa gatas, wala
kanya, hindi ko naman nagbago”
siya pinapakain
ng mga ininit
lang”

“Kadalasang
kumakain siya ng
gulaymga
dalawang
kutsara, pati isda
mga tatlong
 kutsara, tapos
mga ½ cup ng
rice pati mahilig
din siya sa
sabaw”

“Malakas siya sa
gatas, mga
nakaka 8 bote
siya sa isang
araw (1760ml).
Yung gatas niya
bear brand ayaw
niya kasi yung
iba”

“Sa tubig mga

nakaka isang
baso lng siya
(240ml)”

“Pinaiinom ko lng
siya ng mineral,
hindi ko siya
pinapainom ng
galing sa
nawasa”

2. Elimination “Mga nakaka- “Ganun pa ri

apat palit siya ng yung dami ng
diaper siya sa iniihi niya pati
isang araw” yung sa pagdumi
niya wala pa ring
“Kadalasang pinagbago”
dalawang beses
siya dumudumi
sa isang araw”

3. Exercise “Palalaro naman “Ngayon medyo

siya, mahilig matamlay siya,
siyang nakahiga lang sa
magtatakbo pati kama o kaya
 talagang malikot nakaupo. Hindi
siya, paikot – siya nagkakasat”
ikot”

4. Hygiene “Araw – araw ko “Ngayon nasa

naman siyang ospital siya, hindi
pinaliliguan ko siya nililigo,
paghindi masakit pinupunasan ko
yugn ngipin niya. lang siya. Mga
Pagmasakit yugn tatlong beses”
ngipin niya
pinupunasan ko “Ngayong hindi
nalang siya” ko siya
natotoothbrush”
“Araw- araw
naman siyang
nagsisipilyo”

5. Sleep and Rest “Nakakatulog “Maganda naman

naman siya ng yugn tulog niya
sapat sa isang dito, hindi naman
araw. Pagtanghali siya nahihirapan”
natutulog naman
siya mga “Paghapon
dalawang beses, natutulog siya ng
tig-iisang oras” mga 1pm tapos
magigising siya
“Mga natutulog ng mga 4pm”
siya ng 7pm
tapos magigising
siya ng mga alas
dose, magdedede
lang siya tapos
makakatulog siya
ulit. Tapos
gigising ulit siya
ng mga alas
kwatro para
magdede ulit
tapos tutulog uli
siya. Ang gising
niya mga alas
syete ng umaga”