NURSING HEALTH HISTORY

BIOGRAPHIC DATA
Name: C.M Age: 39 years old Gender: Female Address: 384 Pangulang Bagumbayan Bulacan, Bulacan Birthday: March 18, 1975 Occupation: Housewife/Businesswoman Nationality: Filipino Source of Income: Our Store Source of medical health care: none Illness: HPN

HISTORY OF PAST ILLNESS

According to the client she is completely vaccinated , She didn`t experience any serious illness except for hypertension, She take medication drugs or over the counter drugs when she got sick. Her last hospitalization was when she gave birth to her last child.

HISTORY OF PRESENT ILLNESS

When asking the client about her condition now she stated Ayos naman ako ngayon, pabugso-bugso nalang minsan, kadalasan siya pagpagod

FUNCTIONAL HEALTH PATTERN

HEALTH PERCEPTION PATTERN
Healthy naman ako" she stated. Client CM perceive that she was healthy even though she is hypertensive. When we asked

her to rate her health from 1-10 (10 is the highest) she said 8.

NUTRITIONAL AND METABOLIC HEALTH PATTERN

The usual intake of CM composes of rice, vegetables and fish. She seldom eats meat. He usually drinks 4-6 glasses of water a day. With regards to her hypertension she said that she always have pineapple juice at their house. 3 DAY DIET RECALL BREAKFAST July 11,2012 4pcs. Sky flakes crackers 220cc hot milo 3pcs pandesal 220cc hot milo LUNCH 1cup rice (steamed) 1 saucer of chopsuey 220cc of water 1cup rice (steamed) 1pc of tilapia 220cc of water DINNER 1 cup rice (steamed) 1 saucer of chopsuey 260cc of water 1 cup rice (steamed) 1 saucer of menudo 260cc of water

July 12, 2012

July 13,2012

4pcs pandesal 220cc hot milo

Our client usually drinks 4-6 glasses of water a day.

ELIMINATION PATTERN
The client defecates regularly (once a day) with normal color (brownish) and semi solid shaped. She urinates 3-5 times a day approximately 600cc.

ACTIVITY AND EXERCISE PATTERN

Regarding to our client she does not exercise regularly, for her household chores is already exercise.

SEXUAL RELATIONSHIP PATTERN

According to our client her first menstrual period was when she turned 14 years old. They are not acceptor of family planning. They believe that natural is better than artificial.

SLEEP REST PATTERN

She usually sleeps at 10pm and awakens 6 in the morning. She usually takes a nap every afternoon from 2pm to 3:30pm.

COGNITIVE- PERCEPTUAL PATTERN

Client has no hearing and visual difficulties. She dont use eyeglasses. She hears voices clearly.

COPING- STRESS TOLERANCE

Client stated madali mag init ulo ko,madali din ako mapagod, pag ganyan hinihiga ko nalang. For her, lying in bed is one of her way to cope stress.

VALUE- BELIEF PATTERN

Generally, client doesnt always get the thing she likes; this is because of the financial restraints that would not permit them to do so. She said that for her GOD is their strength. And without her family she is nothing.

BULACAN STATE UNIVERSITY COLLEGE OF NURSING

City of Malolos Pangulang, Brgy. Bagumbayan, Bulakan, Bulacan

TEACHING PLAN
1st Sem S.Y. 2012-2013 Name of Student: Chavez, Kathleen C. Gumabon, Jerry Ann B. Section: BSN-4C

DATE/ TIME/ PLACE The health teaching will be done at Pangulang Bagumbayan Bulakan, Bulakan on July 20, 2012 at 9 in the morning.

OBJECTIVES

LEARNING CONTENT

STRATEGIES Discussion METHODS

TARGET Mrs. Mariano

RESOURCES pamphlets

EVALUATION After nursing intervent ion and discussio n regardin g hyperten sion, the client can help with self managin

OUTCOME After conducting the health teaching: T he client is able to do self managin g about her hyperten sion. The

After the This health nursing teaching contains: intervention, the client: Hypertension Will know and its the definition importan What are the ce of causes and everyday contributing nutrition factors for about hypertension foods that What are the they signs and needs symptoms of

and needs to avoid. Will know what factors that affects/ contribut es to her hypertens ion Will enumerat e ways how to manage and control her hypertens ion

hypertension Nutritional needs of client with hypertension The yes and no to food of a hypertensive client.

g of her hyperten sion. After nursing intervent ion and health discussio n; the client can identify what factors contribut e to her hyperten sion. After nursing intervent ion and health discussio n, the client could identify which food she needs to avoid and she

client is able to identify what factors are contribut ing to her hyperten sion. The client is able to identify which food she needs to avoid and have.

needs to have.

BULACAN STATE UNIVERSITY COLLEGE OF NURSING

City of Malolos Pangulang, Brgy. Bagumbayan, Bulakan, Bulacan

NURSING CARE PLAN

1st Sem S.Y. 2012-2013

ASSESSMENT Subjective:

NURSING DIAGNOSIS Activity intolerance related to fatigue

PLANNING Short term:

INTERVENTION a. Note presence of factors

RATIONALE Fatigue affects better

EVALUATION After 2 hours of Nursing

 nahihilo ako secondary to madalas pag pagod hypertension as evidenced by: BP 140/100 Sedentary lifestyle Age 39y/o female

After 2 hours of nursing intervention the client will: a. Identify negative factors affecting activity intolerance and eliminate or reduce their effects when possible. b. Use identified techniques to enhance activity tolerance. c. Demonstrate in decrease in physiological signs of intolerance, blood pressure remains within client normal range.

Objectives: BP 140/100mmhg Age: 39 Sedentary lifestyle

contributing to fatigue. b. Monitor vital signs and cognitive signs, watching for changes in blood pressure, heart rate and respiratory rate. c. Reduce intensity level or discontinue an activity that causes undesired physiological changes. d. Instruct client in monitoring responses to activity and in recognizing signs and symptoms.

the clients Intervention: actual and perceived ability to participate in activities. The client is To be able to able to see when is identify the client negative having factors changes in the affecting vital signs activity tolerance To avoid over exertion The client was identified technique to enhance activity tolerance. The client demonstrated a decrease in physiological signs of intolerance, blood pressure within clients normal range.

Indicates need to alter activity level

 Goal Met as evidenced by: BP = 130/90

HEALTH TEACHING
(Hypertension/ altapresyon)

Ano nga presyon ng dugo?

Tinatawag na presyon ng dugo ang pagtulak ng dugo palabas ng puso upang mabigayan ang buong katawan upang itoy makagalaw

Ano ang altapresyon?

Systolic: gaano kalakas ang pagtulak ng puso sa dugo palabas nito.

Diastolic: gaano kalakas ang pagtulak ng puso sa dugo palabas nito habang nakapahinga ang atrium ng heart. Halimbawa: 120/80 *ang 120 ay ang systolic at 80 ay ang diastolic.

Paano malalaman kung may altapresyon ka?

Kategorya Normal Prehypertens ion hypertensio n Stage 1 Stage 2 140159 160 or higher 90-99 100 or higher systolic 120 120139 diastolic Less than 80 80-89

Uri ng altapresyon: Primary hypertension

Hindi katulad ng secondary hypertension, hindi malaman ang sanhi nito. Maraming nagiging sanhi nito. Maaring bunga ng ito ay namamana o dahil na rin sa kapaligiran lalo na kapag mainit ang panahon.

Secondary hypertension
Merong malinaw na dahilan kung bakit nagkakaroon nito. Napakaraming dahilan ang nagdudulot na ganitong sitwasyon kagaya ng problema sa bato, kung ikay nagdadalang tao at maaring epekto ng mga iniinom na gamut.

Ano nga ba ang nagdudulot ng altapresyon?

Sobra sa timbang Pag inom ng sobrang alak Mayroon ang kahit na sinong myembro ng pamilya Pagkain ng sobrang maaalat na pagkain Pagkain ng sobrang matatabang pagkain Pagtanda Kulang sa calcium at potassium Kulang sa ehersisyo

Ano ang sintomas nito?

Ang taong mayroon nito ay karaniwang makakaranas ng: Pananakit ng ulo Pananakit ng batok Panlalabo ng paningin Pagkahilo at pagsusuka Paninikip ng dibdib

Paano ito maiiwasan?

Ang taong may altapresyon ay lagi ng may mataas na pagbasa ng presyon ng dugo ngunit maaaring mapanatili sa normal na lebel sa pamamagitan ng mga sumusunod: Sundin ang payo ng doctor Inumin sa tamang oras ang lahat ng mga inerekomendang gamut ng doctor Bawasa ang paakain ng sobrang alat at matabang pagkain Panatilihin ang maayos na timbang

Tigilan ang paninigarilyo Iwasan ang sobrang pag-inom ng alak Laging mag ehersisyo

Pag iwas sa altapresyon sa 6 na madaling paraan

Step Step Step Step Step Step 1: 2: 3: 4: 5: 6: magkaroon ng plano ng masustansiyang bawasan ang pagkain ng maaalat panatilihin ang tamang timbang mag ehersisyo araw-araw bawasan ang pagkonsumo ng sobrang alak itigil ang paninigarilyo pagkain

Alternatibong solusyon: Bawang:

Mainam sa puso Tumutulong para mapababa ang bad cholesterol(LDL) Nakapagpapababa ng presyon sa dugo. Nakakatulong sa paglunas sa sakit na arteriosclerosis Pang-iwas sa Cancer Pinapalakas ang resistensya Ito ay isang anti-oxidant. Maaring gamut sa ubo at sipon Nakakaalis ng pamamaga ng lalamunan at sakit sa ngipin Nakatutulong sa paggamot sa sakit na TB o tuberculosis. Nakakaalis sa pananakit ng mga kasukasuan dulot ng rayuma. *maaring kainin ang bawang ng hilaw para mas makakuha ng mga sustansya at ugaliing isahog sa mga pagkain araw-araw.

Ampalaya:

Nakatutulong upang pagalingin ang gout o piyo at mga sakit sa atay at pali. Nakapagpapababa ng asukal at presyon sa dugo Nakakawala ng sakit sa ulo Mainam sa pagpapagaling ng sugat. Maaring igamot sa ubo at lagnat. Magaling sa pagpurga ng mga bulate o lunas sa pagtatae. Nakakaiwas sa impeksyon dahil pinapalakas ang resistensya. Nakakiwas sa Cancer.

BULACAN STATE UNIVERSITY COLLEGE OF NURSING

City of Malolos

COMMUNITY OUTPUT
(Pangulang, Brgy. Bagumbayan, Bulakan, Bulacan)
Prepared by:
Chavez, Kathleen C. Gumabon, Jerry Ann B. BSN 4C/Group 1

Clinical Instructors:
David Bote, RN Elmer De Guzman, RN