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I. Nursing HistoryA. Past Health History

1.) Childhood illness The client had usual childhood illnesses such as mumps,measles, and chickenpox2.) Immunization The client has unrecalled immunizations

3.) Allergies The client has no known allergy4.) Accidents The client mentioned that she fell from their stairs and had carpalbone fracture 5 years from now; she was hospitalized for several weeks at thattime. Another was a motor accident and she had head trauma, it was 2 years fromnow. Earlier was snake bite, she was not hospitalized for that

5.) Hospitalizations Admitted at Jose Reyes 15-20 years from now from anunknown illness. She said she was experiencing headache at that time and lateron, alopecia. She said she couldnt remember the diagnosis.

6.) Medication used or currently taking aside from the drugs for ptb that shecompleted, she wasnt taking any medications in the past.7.) Foreign Travel No foreign travels yet

B. History of Present IllnessThe present Illness started 2 months prior to admission as the patient

experienced undocumented moderate fever occurring anytime of the day. Consultwas done at a private physician and diagnosis was unrecalled. Patient was givenunrecalled medications to be taken for 7 days, which afforded temporary relief.

1 month prior to admission, patient noticed swelling of her lowerextremities. This was associated with other symptoms like fever, cough, headache,nausea and vomiting, colds, loose stools and abdominal pain. No consultation wasdone and no medication was taken.

2 weeks prior to admission, patient again experienced fever,undocumented, moderate to high grade by touch. This condition is associated withchills, difficulty of breathing and swelling of the lower extremities. Consult was done

at a private physician and laboratory tests were done, but results were unrecalled.She was given unrecalled medications, to which she was adherent. Thesemedications afforded temporary relief.

Few hours prior to admission, still with the same signs and symptoms,patient sought consult at a private physician and she was advised admission;hence subsequently she was admitted in our institution.

C. Family HistoryThe clients mother and father are already dead, her mother died of giving

birth to her. She said she didnt know what the cause was and she couldntremember her age when she died and her father died at the age of 65 because offall that caused head trauma. Her mothers side have the history of anemia while

her fathers side have the history of hypertension, rheumatic heart diseases andpneumonia.

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Genogram

D. Maternal HistoryShe has had menarche at age 15, subsequent menses at 28 30 days

interval with 4 -5 days consuming 4 5 napkins/day, each napkin moderately soaked,with no associated dysmenorrheal and post coital bleeding. She is Gravida 9 Para 9 (9-0-0-7). All births were normal spontaneous delivery, assisted with midwife at home, withno feto-maternal complications. She had her menopause at 40 years old and this wasnot associated with any symptoms.

II. Patterns of Functioning

A. Psychological Health

The client shares that whenever she has problems she just talks it outand she is already eased, she also prefers to chat with her friends to relive heavyfeelings. She used to mingle with her children and grand children whenever shehas spare times. She has visual problems but and cannot read far texts anymoreshe didnt have consultation for that. She finds it difficult to hear low toned voices.She is a happy go lucky person who tends to forget problems whenever she ischatting with her children. They seldom encounter family problems.

ANALYSIS:Psychosexual Development (Sigmund Freud)Genital stage: Develops sexual maturity and learns to establish satisfactoryrelationships with the opposite sex.

(Pillitteri, Maternal and Child Health Nursing: Care of the Childbearing andChildrearing Family, 5th Edition page 815)Developmental Task (Erik Erikson)Generativity vs. Stagnation: People extend their concern from just themselves andtheir families to the community and to the world. They may become politicallyactive, work to solve environmental problems, or participate in far reachingcommunity or world based decisions.

P.A. xBirth toa child

J.S. x

Fall and

headtrauma

M.S. x

Pneumonia

Client

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**When a person makes a contribution during this period, perhaps by raising afamily or working toward the betterment of society, a sense of generativity- a senseof productivity and accomplishment- results.(Pillitteri, Maternal and Child Health Nursing: Care of the Childbearing andChildrearing Family, 5th Edition page 817)

Cognitive Development (Jean Piaget)Formal Operational ThoughtCan solve hypothetical problems with scientific reasoning; understands causalityand can deal with the past, present, and future. Adult or mature thought. Goodactivity for this period: talk time: to sort through attitudes and opinions.(Pillitteri, Maternal and Child Health Nursing: Care of the Childbearing andChildrearing Family, 5th Edition page 819)

INTERPRETATION:Psychosexual Development (Sigmund Freud)The client has developed close relationship with the opposite sex, it is not merelyestablishing a good intimate relationship.

Developmental Task (Erik Erikson)The client has developed generativity because she has established goodinterpersonal relationship with her family as well as the community.

Cognitive Development (Jean Piaget)The client had already developed Formal Operational thought; she uses logic insolving problems and understanding causality

B. Socio Cultural PatternThe patient has high regards with respect to elders, she obliges her

grandchildren to respect elders, in her province they dont have phrases like po

and opo but they still do some practices that give respect to elders like consultingthem before making a decision for the family. They celebrate some festivities intheir province and she is happy whenever that happens because she gets to seeher family together and her friends and relatives who live far away. She spends herleisure time cleaning the house and caring for her grandchildren. They have a ricefarm but she couldnt go there because her legs are cannot endure the walk, shelet her nieces and children to take of the rice fields.

ANALYSIS:Moral Development (Kohlberg)Post Conventional (Level III): Universal ethical principle orientation. Followsinternalized standards of conduct.

(Pillitteri, Maternal and Child Health Nursing: Care of the Childbearing andChildrearing Family, 5th Edition page 821)

INTERPRETATION:The client had already developed Post Conventional Moral development. Shedoesnt just follow simple rules or abides law imposed by the government but alsoapplies ethical principles just like the requirement consulting the elders beforemaking a decision.

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C. Spiritual PatternsThe client goes to church every day and prays the rosary every day; they

celebrate Christmas, New Year, fiesta and birthdays together. Shes a member ofWomens for Christ. She believes that God has the power of healing her and

making their family closer as possible.

ANALYSIS:Spiritual Development (Fowler)Stage 5: Paradoxical, Consolidative / Conjunctive Faith, awareness of truth fromvariety of viewpointsStage 6: Universalizing, becomes an incarnation of the principles of love and

justice. Person loves with Gods love (unconditional love)

INTERPRETATION:The client considers God as a Supreme being and the source of all blessings andprefers to consider her belief as the truth.

III. Activities of Daily Living

Activities ofDaily Living

BeforeHospitalization

DuringHospitalization

Interpretation and Analysis

Nutrition The client preferseating vegetables andfish, sweet potatoshoots, upo, stringbeans, papaya,nilagang baka,nilagang manok at

baboy.

Diet as tolerated butwith strict aspirationprecaution.

ANALYSIS: An individuals healthstatus greatly affects eating habits andnutritional status. Habits about eatingare influenced by many factors such asdevelopmental considerations, personapreferences, lifestyle, medications andtherapy. People develop likes and

dislikes based on associations with atypical food. Certain lifestyles are linkedto food-related behaviors. People whospend many hours at home may taketime to prepare more meals, Individualdifferences also influence lifestylepatterns. (REF: Fundamentals ofNursing 7th ed. By Kozier et. al., p.1176

INTERPRETATION: The client prefereating foods that can be helpful in hegeriatric years, healthy food preference

is a manifestation of a good health, Thclient was placed on NPO because thiis one of the measures should be donto resolve her pancreatitis.

Elimination The client defecateseveryday and variesfrom brown soft formedstools to slightly hardand sometimes watery.

The client has thesame pattern of elimination.

ANALYSIS: Normal defecation is oftenfacilitated in both well and ill clients byproviding privacy, teaching clients toattend to the defecation urges promptlyassisting clients to normal sitting

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But she doesnt haveproblem with her defecation. Excretesstraw colored urine atleast 4 times a day.She shared that she

attends promptly whenshe has the urge todefecate and tourinate.

positions whenever possible,encouraging appropriate food and fluidintake and scheduling regular exercise.(REF: Fundamentals of Nursing 7th ed.By Kozier et. al., p.1253)

INTERPRETATION:The client has normal eliminatiopattern before hospitalization and durinthe elimination.

Exercise The client considerswalking around theyard every morning asa form of exercise.

The client ambulatesaround the area whenshes bored. She saidshe do it withassistance or whileholding the edges ofthe beds and the wallsbecause her legs

cannot totally supporther.

ANALYSIS: Physical activity is animportant factor in an adults ability tomaintain health and independence.Regular exercise promotes appetite,improves mental health, and decreasesstress. (REF: Fundamentals of NursingSaunders p. 337)

INTERPRETATION:Even though the client has reducestrength and endurance at her loweextremities she still makes it to the pointhat her activities were totally absent.

Hygiene The client shared thatshe takes a bath oncea day but she quippedthat she doesnt brushher teeth morefrequently because shedoesnt have teeth

anymore.

The client takes a bathduring confinementonce a day and doesoral care.

ANALYSIS: Personal hygiene is theself-care by which people attend tosuch functions like bathing, toileting,general body hygiene and grooming.Hygiene is a highly personal matterdetermined by individual values andpractices. It involves care of the skin,

hair, nails, oral and nasal, eyes, earsand perineal genital areas. (REF:Fundamentals of Nursing by BarbaraKozier et., al page 106)

INTERPRETATION:The client can attend to her hygienneeds alone before hospitalization, anshe needs assistance during thhospitalization.

SubstanceAbuse

NONE NONE -

Sleep and Rest The client said that shesleeps for 4 hours; shesaid shes okay withthat. She said that shesleeps at 19 pm andwakes up at 3 ambecause she pray therosary. She said that

The client sleeps atabout 6 hours everyday, she sleeps at 10pm and wakes up atam. She also takes anap at the afternoon.

ANALYSIS: Just as activity is importanto the adult, so too is rest. According tothe National Sleep foundation (2001),adults need 8 hours of uninterrupted,quality sleep each night for optimumhealth, safety, and productivity. (REF:Fundamentals of Nursing, Saunders p.337)

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she take naps everyafternoon INTERPRETATION:

The client has normal sleeping patterduring hospitalization. It seems that hesleep was undisturbed during thhospitalization.