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Biographic Data Name: GNH Age: 70 years old Birthday: December 24, 1940 Birth Place: Sorsogon Address: 40 Chevelle St. Fairview Quezon, City Gender: Female Civil Status: Widow Nationality: Filipino Religion: Catholic Admitting date / Time: August 7, 2011/ 1:24 AM Room No. : CCU 6 Case Number: 60326 Attending Physician: Dr. FloranteMu oz/ Dr. Lucas (cant read the surname ) Admitting Diagnosis: Acute Infarct Right Medulla

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Nursing History A. Past Health History According to the client, she has Hypertension and Diabetes Mellitus Type II. The client is hypertensive since 1978. It started when she was pregnant of her fifth child. She stated that it is her third time to be hospitalized due to hypertension, and it is her first time to be admitted in CCU. She is taking a medication for maintenance for hypertension which is Losartan ( mg) . And taking Metformin for diabetes, the client was not able remember the dose. There are no known allergies in foods and drugs. There are no local and foreign travels. B. History of present Illness As stated on her Past History, the client is Hypertensive and Diabetic. GNH complained of severe headache, dizziness and nausea. GNH was admitted due to hypertension with the admitting diagnosis of Acute Infarct Right Medulla. C. Family History The client has a family history of Hypertension on her maternal side. Aside from that.there are no other diseases noted.

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Patterns of Functioning A. Health Perception GNH was asked verbalize how she feels at the moment and she stated, Mahinanaako, kasi before very strong namanako. Napupuntalangakosa hospital pagmanganganak and never admitted saibangsakit. When the client was asked to rate her health from 1 to 10, she gave herself a score ranging from 3-4, Dati healthy ako. Hindi akoyongmahinangklase, di akosakitin.Kasingayon, kontinggalaw, may nakainnaakonghindi tama tataasnadugoko as verbalized by the client. The client takes a bath everyday. She brushes her teeth every morning and at night, she said that it is not that necessary to brush every after meal. During her stay in the hospital, bed bath and shampoo was done. She never get a chance to brush her teeth because her significant other was not able to bring her toothbrush. B. Nutritional and Metabolic Pattern The client s nutrition before she was admitted is fair according to her. GNH is not into carbohydrates specifically rice. She is fond of eating fish, vegetables and fruits. Ngayonlangnamanakowalanggana at nahihirapankumain at lumunokdahilsanasasamidakodahilna din saubosiguro. As verbalized by the client. And when asked if the client drinks plenty of water before, whe stated that she see to it she drinks 8 glasses of water a day. But during her hospitalization she only drinks when feels thirsty or when she is taking her meal and medications. She said that there is also difficulty in swallowing like mentioned a while ago. The client has fair apetite and on soft diet , low salt low fat DM diet with strict aspiration precaution during her stay in the hospital. C. Elimination Pattern GNH verbalized that she is experiencing difficulty when urinating , Masakitpagunanglabasngihi, mahapdiperopag nag flow nawalanarinnaman. It only started when she is already in the hospital. Before, she is not experiencing any pain when voiding, and more or less she voids 4 times. Moreover, the client s elimination prior to hospitalization, she already have an irregular elimination pattern. Sometimes it lasts for 2 weeks that she is not yet defecating, and in irregular pattern, it may be at night or day. Since admission, GNH was not able to defecate, ayokokasingtumaengnakahiga at sa diaper client verbalized. The client is not taking any laxative medication in order for her to defecate. She does not experience any pain when she urinates.

D. Activity and Exercise Pattern The client s routinely activity before hospitalization was, she walks every morning when going to church and does householdchores routinely. Hindikokasi kaya yongnauuponalang at walangnagagawa, I have to work. as verbalized by the client. And when asked why she

does not want to do nothing she mentioned that because before she is working as a sewer (mananahi ), and it is part of her system to work. Perongayonnamanpagmasamapaliramdamkouuponalangakoperopaghindinamantuloylang she added. She considers cleaning the house and walking as a form of exercise. E. Cognitive- Perceptual Pattern There are significant changes in the sense of the body. When asked if she is forgetful or not, she stated Very poor when it comes to memory. Minsankakilalako, nakalimutankona. The client has blurred vision and wearing eyeglasses but when asked the grade of her vision she cannot remember. And sometimes she is having a hard time to hear especially in a low tone of voice. However, she communicates well and answers the questions addressed to her. Her GCS is scored 15 (indicate Eye,Verbal and Motor).GNH is oriented to place and time during the interaction.

F. Sleep and Rest Before hospitalization GNH sleeps early at night. She usually sleeps 6-8 hours a day and 30mins-45mins nap every afternoon after doing the chores. During her stay in the hospital she always feel sleepy it also due to the side effects of her medications. The client has interrupted sleep. Sometimes she will be awakened to take her meds, for vital signs monitoring or during meal time.

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Coping-Stress GNH is stressed due to her present condition, she worries but she manages it by praying. And whenever she was stressed, based on her experiences, she is diverting her activities like watching a television, she even prays and asked to call her grandchildren. Kasipag mag iisip pa akotataaslang blood pressure ko.

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Role-Relationship

GNH is a mother of 5 children. As a mother she sets rules on their home. She treated her children equally. Just like any other family, they also have their financial worries, health problems. But whenever they are experiencing circumstances in life, they try to resolve it as soon as possible. The family is very close and each of them if they have any concerns within their circle is that they are free to voice out.

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Value-Belief When asked about her present condition, where does she get her positive outlook in life. Sometimes I worry, but I believe in God as verbalized by the client. It never came a time nahindiako nag worry, sometimes I doubt, pero mas lumalakas pa yongpananampalatayakosakanya. GNH is a Roman Catholic and she mentioned that she always pray at night and in the morning. She even hear mass everyday.

Activities of Daily Living Before Hospitalization Nutrition During Hospitalization Interpretation and Analysis Interpretation: During the hospitalization the client is following her diet regimen. Analysis: Nutrition is a basic human need that changes those changes throughout the life cycle and among the illnesswellness continuum. Tissue growth and repair helps regulate fluid balance component of body framework are the functions of protein in our body system. (Fundamentals of Nursing by Kozier 8th edition) Interpretation: The client s elimination pattern is being closely monitored.

GNH eats twice a day. The client maintains a soft She is fond of eating diet, LSLF DM diet with strict fish, vegetables and aspiration precaution. fruits.

Elimination

The client usually voids more or less 4 times a day and defecates every other day.She is not

The client normal urine output as being monitored. Since admission, GNH was not able to defecate, ayokokasingtumaengnakahiga

Exercise

Analysis: A proper functioning of urinary system is essential to the body s physical wellbeing to life itself and to a person s wellbeing. Elimination of waste products of digestion is a natural process, critical for human functioning. Although most people experienced minor acute bouts of diarrhea or constipation, some patients experience severe or chronic alterations in bowel elimination that affect their fluid and electrolyte balance, hydration, nutritional stat, skin integrity, comfort . (FON, Page 918-920) She walks every The patient s activity is very Interpretation: morning when going limited due to her illness. Very Activity is limited due to church and does limited movement is advised. to her present illness. household chores routinely. She Analysis: considers cleaning the Active exertion of house and walking as muscles involving the a form of exercise. contractions and relaxations of muscle groups is termed exercise. The human body was designed for motion, regular exercise is necessary for healthy functioning individuals who choose inactive lifestyles or inactivity by illness. (Fundamentals of

experiencing any pain at sa diaper client verbalized. when voiding and defecating.

Hygiene

The client takes a bath everyday. She brushes her teeth every morning and at night, she said that it is not that necessary to brush every after meal.

CognitivePerceptual Pattern

She is forgetful or not, she stated Very poor when it comes to memory. Minsankakilalako, nakalimutankona.

Nursing by Kozier 6th edition, page 345) Bed bath and bed shampoo Interpretation: was done. However the client The patient has a was not able to brush her limited movement. teeth. Analysis: Personal Hygiene promotes physical and psychological well-being. Various studies have confirmed that improved personal hygiene practice reduces illness. (FON, page 117) She communicates well and answers the questions addressed to her. Her GCS is scored 15 (indicate Eye,Verbal and Motor) .GNH is oriented to place and time during the interaction. She always feel sleepy it also due to the side effects of her medications. The client has interrupted sleep. Sometimes she will be awakened to take her meds, for vital signs monitoring or during meal time. Interpretation: The patient has a disturbed sleep & rest pattern related to illness. Analysis: Rest connotes a condition in which the body is in decreased state of activity with the consequent feeling of being refreshed. Illness that causes physical distress can result in sleep problems. People who are ill require more sleep than the normal and the normal rhythm of

Sleep and Rest

She usually sleeps 6-8 hours a day and 30mins-45mins nap every afternoon after doing the chores.

sleep and wakefulness if often disturbed. (FON, 6th edition page 998)