PATIENTS PROFILE:

Name: P. R.
Birth date: January 15, 1950
Age: 88 years old
Se: !
Status: "ido#
Address: 0$ %on &atias North %on Antonio '(S )ue*on +ity
(ele,hone: 9-1--.-
Nationality: !ili,ino
Religion: Roman +atholi/
0anguage1diale/t s,o2en: 3nglish, (agalog
3du/ation attained: +ollege 4raduate
5//u,ation: Retired tea/her
Slee,ing 'a6its1,attern: 8710 hours
Slee,ing time: 8 ,m
"a2ing time: 8 am
'andedness: Right handed
3yeglasses: yes
+onta/t lenses: none
'earing Aide: none
%entures: none
%ietary 'a6its1,attern: regular diet
Parti/ular 9ood ,re9eren/es: renal diet
3er/ises: N1A
Al/ohol1+a99eine: /o99ee drin2er 1 /u, a day
+igarette: N1A
0i:ing en:ironment: daughter;s o#ner #ith 8 o//u,ants
Sour/e o9 in/ome: daughter;s and son;s in/ome
+urrent medi/ations: 0anoin, %io:an, %iami/ron, &et9ormin, Neium, Na'+5-
(reatment order: %iet ,res/ri,tion, Renal diet so9t 1800 /al -0g +'5N
%ate and time o9 Admission: 1178708 at 19:$5
+hie9 /om,laint: #ea2ness, ,oor a,,etite
Attending ,hysi/ian1s: %r. &endel, %r. 0o/nen, %r. Jimene*, %r. Al/antara
HEALTH HISTORY
A. History of Present Illness
5ne month ,rior to admission, ,atient #as noted to ha:e grade << 6i,edal
edema. 'er relati:es then ordered a B=N and +R3A to 6e done on the ,atient #hi/h sho#ed
normal results. No medi/ations #ere ta2en. (his ,ersisted until 1 #ee2 ,rior to admission,
still #ith 6i,edal edema. Patient had loss o9 a,,etite, in/rease slee,iness, nausea and
:omiting. (his #as also asso/iated #ith some e,isodes o9 6lood tinged stools. B=N and
+R3A #as again done #hi/h sho#ed ele:ated :alues, thus, see2ing admission.
B. Past Health History
(he /lient is already /om,lete immuni*ed. She #as a6le to re/ei:ed 1
dose o9 B+4, - doses o9 %P(, - doses o9 5P>, - doses o9 'e,a B and 1 dose 9or &easles. She
has allergies to 9ood li2e /ra6s, shrim,s and eggs and dia6eti/, #ith medi/ations, 1 year ago #ith
/hest ,ain, edema, /ardiologist #ith +hroni/ 'eart !ailure, atrial 9i6rillation. (he ,atient had
maste/tomy last ?000 in her right 6reast and /hole/yste/tomy last 1990;s.
C. Faily Health History

0egend: ! de/eased
&ale !emale
&rs. P. R., 88 y1o, is a #ido# in the 9amily #ith - /hildren and - grand/hildren.
She is ,ositi:e o9 hy,ertension, and %ia6etes &illetus. (he granddaughter o9 ,atient :er6ali*ed:
@hindi 2o na rin 2asi alam yung sa mommy ng lola 2o 2ung ano sa2it nila.A All o9 her /hildren
and grand/hildren are healthy. 'er hus6and died o9 ha:ing em,hysema last 199..
". "e#elo$ental an% So&ial History
(he /lient is in the old7old age. A//ording to Piaget;s /ogniti:e de:elo,ment, o:erall the
older adult maintains intelligen/e, ,ro6lem sol:ing, Budgment, /reati:ity 6ut intelle/tual loss
generally re9le/ts a disease ,ro/ess su/h as atheros/lerosis. (he /lient /an identi9y and re/ogni*e
#ho she is tal2ing to. She also s,ends time #ith her /hildren at home, #at/hing tele:ision at
night. (he /lient is a non7smo2er and a non7al/oholi/ drin2er.
em,hysema
Patient
CDE'y,ertens
ion
CDE%&
'OR"ONS F(NCTIONAL HEALTH PATTERN
A. Health $er&e$tion ) health ana*eent $attern
S F Patient :er6ali*ed: @Ayos lang naman ang 2alusugan 2o. 'indi a2o naninigarilyo at
umiinom, ,ero nag2a2a,e a2o. <sang 6aso sa isang ara#. Gum,leto a2o sa 6a2una. Retired
na a2o 2asi matanda na rin a2o at ayos naman ang tinitirhan 2o 2asama ang ,amilya 2o.
'indi ,a naman a2o na aa2sidente dati. 'indi rin a2o nageeer/ise.A
5 F (he ,atient loo2s dro#sy and lethargi/ 6ut /oo,erati:e during /on:ersation. She is
oriented a6out the time, ,la/e and ,erson #hen as2ed, #ell7groomed. &o:ement #as limited.
4eneral a,,earan/e: hair distri6ution is eHual, /olor gray, s2in is dry, 9ingernails and toenails
are thi/2ened and 6rittle. No 9oul 6ody odor.
>ital signs: BP: 1$01 80 mm'g
(: -5.9I+
PR: 88 6,m
RR: ?8 /,m
'eight: $;10A
%B": 98l6s
A F Readiness 9or enhan/ed health management
B. N+tritional ) eta,oli& $attern
SF Patient :er6ali*es: @Bumigat ata a2o ngaun. 4inaganahan naman a2o 2umain 2a,ag
gutom. Pa2iramdam 2o ,agod a2o at nanghihina 2ata#an 2o. &ay mga ,ag2ain a2ong da,at
at hindi da,at 2ainin. Na2a2a J a2ong ,aginom ng tu6ig . 4usto 2ong ,ag2ain ay yung may
2asamang sou,. &insan nahihilo a2o ,ero hindi nagsusu2a. Gonti lang naiihi 2o ngayon.A
5F Patient has a dry s2in, #ithout lesions and rash, s2in turgor is 9ragile, /yanoti/.
&u/ous mem6ranes o9 mouth is moist, no lesions, /olor is ,ale, has 9alse teeth, no dentures,
gums are ,ale. 'a:e moist eyes, ,ale /onBun/ti:a, no lesions. 'a:e edema in arms and legs.
Patient /annot turn #ithout assistan/e. %ia,er #eighs: &onday7-80, (uesday7 -55.
AF !luid :olume e/ess r1t retention o9 Na and #ater as mani9ested 6y edema, and
de/reased urine out,ut
C. Eliination $attern
SF Patient :er6ali*es: @&insan isang 6eses o dala#ang 6eses a2o dumudumi sa isang
ara#. Basta minsan mag2ai6a. Pero minsan nahihira,an a2o dumumi. Ga,ag hindi a2o
dumudumi ng a,at na ara#, umiinom a2o ng gamot. 'indi 2o na na2i2ita 2ung anong 2ulay
ng dumi 2o. %ati nag2aroon na a2o ng diarrhea. Ang 2ulay naman ng ihi 2o ay dila# ,ero
minsan nahihira,an din a2o umihi. 'indi 2o nararamdaman minsan 2ung umiihi na 2o sa
dia,er 2o.A

5F Patient has dia,er and urine out,ut o9 -80 during morning shi9t o9 monday. A6domen
is so9t, no masses. No stool in re/tum during ,erineal /are.
AF +onsti,ation r1t ,oor eating ha6its
". A&ti#ity ) e-er&ise $attern
SF Patient :er6ali*es: @Gelangan 2o ng 2asama na mag,a,a2ain, mag,a,aligo, at
magaalaga sa a2in. Ngaun isa lang gamit 2ong unan. Na2a2aramdam a2o ng ,agod ngaun
lalo na yung ,arang ,agiling giling a2o. 'indi na a2o na2a2ala2ad at na2a2atayo lalo na
2a,ag #alang may ha#a2 sa a2in. Retired na 2o. 2a,ag nanunuod a2o ng t: ay minsan
na2au,o, 2ahiga. &a6igat yung 2anan 2ong 6raso.A
5F Radial and tem,oral ,ulse is easily ,al,a6le. &oist eyes, dry and so9t s2in, #ith /old
and /lammy s2in. 3tremities are /old to tou/h 6e/ause o9 the ,resen/e o9 air7/onditioner.
+a,illary re9ill is delayed, nails are #hitish in /olor. Res,iratory rate is ?8, shallo#. 0imited
mo6ility that needs assistan/e in turning and ,ositioning. A%0s assisted K 9eeding, 6athing,
grooming.
AF A/ti:ity intoleran/e r1t 6ed rest or immo6ility as mani9ested 6y #ea2ness
E. Se-+ality ) re$ro%+&tion $attern
SF Patient :er6ali*es: @&eno,ause na a2o nung 50 years old a2o. Na2alimutan 2o na
2ung 2alian huling regla 2o. (atlong 6eses a2ong nangana2 at nag6untis. 'indi rin a2o
na2unan nung nag6u6untis a2o. (inanggalan a2o ng 2anang di6di6 dati at ayos ,a rin naman
ang 2alagayan 2o ngayon.A
5F (he ,atient #as a6le to dis/uss her seual /on/erns /om9orta6ly. No symmetry o9
6reast #ith ,ositi:e maste/tomy in the right 6reast. Presen/e o9 s/ars a9ter the
remo:al o9 6reast.
AF Seual dys9un/tion r1t altered 6ody stru/ture or 9un/tion as mani9ested 6y
maste/tomy o9 the right 6reast
F. Slee$ ) rest $attern
SF Patient :er6ali*es: @"ala naman a2ong ,ro6lema sa ,agtulog 2o. A,at na oras a2ong
natutulog sa ga6e. (a,os 1 oras na tulog sa ha,on. Nagigising a2o sa ga6i minsan ,ero
na2ahiga lang a2o, hindi a2o tumatayo. Nagigising a2o ng 878:-0 ng umaga.A
5F (here is ,resen/e o9 dar2ening a6out the ,erior6ital area. (he /lient demonstrates a
slou/hed ,osture and lethargy through her 9a/ial gestures and she 9reHuently ya#ns and
/loses her eyes. A,,ears to 6e :ery slee,y 6ut still sho#s alertness.
AF Slee, de,ri:ation r1t aging7related slee, stage shi9ts as mani9ested 6y ,resen/e o9
dar2ening on the ,erior6ital area.
'. Sensory ) &o*niti#e ) $er&e$t+al $attern
SF Patient :er6ali*es: @ &ala6o na ang ,aningin 2o 2aya gumagamit a2o ng salamin.
&ahina na rin ang ,andinig 2o dahil nga siguro matanda na 2o. Sumasa2it yung leeg 2o 2asi
nanganga#it. Na2a2a,agdesisyon ,a naman a2o.@
5F Patient is oriented to time, ,la/e and ,erson. Patient;s s,ee/h is understanda6le.
+onBun/ti:a is ,ale in /olor. Right and le9t auri/les are aligned #ith outer /anthus o9 the
eyes. (here is no ,resen/e o9 lesions on 6oth eternal ears. 'er nose is symmetri/ and
straight #ith no ,resen/e o9 lesions.
AF %istur6ed sensory ,er/e,tion: :isual and auditory r1t en:ironmental stimuli as
mani9ested 6y aging
H. Role relationshi$ $attern
SFPatient :er6ali*es: @&aayos naman ang ,a2i2itungo 2o sa mga ana2 2o. 'indi naman
a2o nag2a2aroon ng ,ro6lema sa 2anila. (umitira a2o 2asama ang ,amilya 2o. Namatay na
ang asa#a 2o. 4inaga#a 2o na lang nung nasa 6ahay ,a a2o ay manuod ng t:, humiga,
matulog. &atanda na rin a2o, 2aya #ala a2ong masyadong ginaga#a na ma6igat at
na2a2a,agod.A
5F Patient /ommuni/ates #ith 9amily mem6ers #ith understanda6le s,ee/h ,attern.
Smiling #hen tal2ing to her daughter. Sho#s a /heer9ul 9a/e during the inter:ie#. No
dys9un/tional 9amily intera/tions. 3hi6its /loseness to her /hild and granddaughter.
AF (hera,euti/ regimen: Readiness 9or enhan/ed 9amily ,ro/ess.
I. Self.$er&e$tion $attern
SF Patient :er6ali*es: @<niisi, 2o na lang sa ngayon ang mga ana2 2o at mga a,o 2o.
(ingin 2o naman ma2a2a6uti ang ,agtagal 2o dito 2ung ,ara din sa 2alusugan 2o. 4anun ,a
rin naman ang tingin 2o sa a2ing sarili. 'indi 2o na lang masyado iniisi, ang ,ro6lema.A
5F Patient is /om9orta6le lying on the 6ed. A,,ears /alm, so9t :oi/e and /lear s,ee/h
,attern, no negati:e emotions o6ser:ed. Patient is not irritated during intera/tions.
AF (hera,euti/ regimen: @Readiness 9or enhan/ed sel9t7/on/e,t.

/. Co$in* ) stress $attern
SF Patient :er6ali*es: @&asaya na 2o 2a,ag na2a2asama 2o ang ,amilya 2o. Ga,ag
na2a2ausa, 2o sila. Bina6antayan nila a2o. &asaya na a2o sa ,agaalagang ginaga#a ng mga
ana2 2o at a,o 2o. &adalas din a2ong manuod ng t: sa ga6i ng teleserye. %itto sa os,ital,
natutu#a a2o 2a,ag 2asama 2o ang ana2 2o.A

5FPatient has no o6ser:ed altered 6eha:iors and thought ,ro/esses. No o:ert signs o9
/rying, #ringing o9 hands.
AF (hera,euti/ regimen: Readiness 9or enhan/ed /o,ing7stress ,attern
I. 0al+e.Belief $attern
SF Patient :er6ali*es: @Na#a#ala na ,agod 2o 2a,ag nandyan ang ana2 at a,o 2o. 'indi
naman a2o masyadong ,ro6lemado 2a,ag may mga naiisi, na 6agay. Sa,at na sa a2in ang
,agaalagang 6ini6igay sa a2in ng ,amilya 2o. &as na2a2a6uti talaga sa 2alusugan 2o 2a,ag
alam 2ong andyan sila ,ara alagaan a2o.A

5FPatient is +atholi/. (here is no ,resen/e o9 religious o6Be/ts in the ,atient;s room. (he
,atient did not sho# any religious a/tions or routines during assessment, does not sho# any
signs o9 alterations li2e anger or /rying.
AF Readiness 9or enhan/ed s,iritual #ell7 6eing