Far Eastern University

Institute of Nursing

I. BIOGRAPHIC DATA
Name: Ms. CRM
Address: 148 Livelihood Area C Talanay Batasan Hills
Sex: Female Age: 19 years old Birth Date: May 5, 1991 Room: 505K
Marital Status: Single Religious Affiliation: Roman Catholic
Chief complaint: Vomiting, Headache Occupation: Housemaid(10months)
Provisional: Acute Gastroenteritis (AGE)
Attending Physician: Dr. L. Uy/Dr. Madriaga

II. NURSING HISTORY

A. Past Health History

1. Childhood Illnesses

The client does not have history of childhood illnesses such as mumps, measles,
and chickenpox. He is a non-asthmatic, non-diabetic and non-hypertensive

2. Immunization

Immunizations received during childhood were completed as verbalized by the

client’s mother

3. Allergies

No known allergies to food and drugs.

4. Accidents

No history of accidents, trauma, or injuries.

5. Hospitalization

Has been hospitalized twice, when she was still twelve and the second confinement
was when she was still fourteen, both were due to abdominal pain.

6. Medications used or currently taken

 The client used paracetamol (Biogesic 500mg), and now taking prescribed
medications

7. Foreign Travel

The client doesn’t have any foreign travels yet.

B. History of Present Illness

The present illness started 3 days ago prior to admission when the client
experiences vomiting for 2 days accompanied by fever, abdominal pain and body
weakness. No other associate signs and symptoms such as, colds, cough, jaundice,
nausea, noted. She was self – medicated with paracetamol (Biogesic 500mg).

Due to the persistence of the above conditions, patient was rushed to FEU-
NRMF Hospital (Emergency Room) and was subsequently admitted.

C. Family History
III. PATTERNS OF FUNCTIONING
A. Psychological Health
The client’s usual way of coping is through laughing, and talking with other
people she verbalized, “Pag may problema ko sa trabaho, itinatawa ko na lang, pag
inisip ko yun, sasakit lang ang ulo ko,” but when it comes to family problem she said that
she tends to cry and hide inside her room. The client interacts well during the
conversation, she smiles every time we talk to her and answers politely and accurately.
She was able to finish high school in Leyte and decided to work in Manila as a
housemaid. When the client was asked about her self – concept the client answered that
she is contented with her appearance, and would not ask to change anything if she’s
given a chance, Ms. CRM verbalized, “Kung ano yung bigay ng Diyos, masaya na ko
dun, wala na kong gustong palitan kahit bigyan ako ng pagkakataon.” She aid she’s
attracted with the opposite sex and had established a relationship with a man 4 years
ago. The client has not been involved in any sexual activity. The client is able to decide
for herself, she narrated that she need not to call her mother’s attention whenever she
has to go with her friends. She told us that she thinks before she act, makes sure that
she’s sensitive for her not to hurt anybody.

ANALYSIS:
Psychosexual Development (Sigmund Freud)
Genital stage: Develops sexual maturity and learns to establish satisfactory relationships
with the opposite sex.
(Pillitteri, Maternal and Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th Edition page 815)
Developmental Task (Erik Erikson)
Intimacy vs. Isolation: The developmental crisis of the young adult is achieving a sense
of intimacy versus isolation. Intimacy is the ability to relate well with other people, not
only with the members of the opposite sex but also with one’s own sex to perform long –
lasting friendships.
(Pillitteri, Maternal and Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th Edition page 817)
Cognitive Development (Jean Piaget)
Formal Operational Thought: Can solve hypothetical problems with scientific reasoning;
understands causality and can deal with the past, present, and future. Adult or mature
thought. Good activity for this period: “talk time: to sort through attitudes and opinions.
(Pillitteri, Maternal and Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th Edition page 819)

INTERPRETATION:
Psychosexual Development (Sigmund Freud)
The client was able to establish a satiscfactorily relationship with the opposite sex, it is
not merely having an intimate relationship. It is an expression of feeling beyond genital
response.
Developmental Task (Erik Erikson)
The client was able to establish intimate relationship, spontaneous and was able to be
close with others
Cognitive Development (Jean Piaget)
The client is normal for she is able to decide for herself, and uses logical thinking when
making decisions.

B. Socio – Cultural Patterns

Client CRM goes to church every Sunday and prays before eating, going to sleep
and upon waking up. She also celebrates New Year and Christmas. She’s a Roman
Catholic since birth and believes that Christ helps her in a lot of ways like in her work
and sometimes when there’s a family problem. She reads books whenever she has no
more house chores to do, but most of the time she spend her leisure time sleeping. She
stays with her bosses, and goes to her mother’s house every third week of the month.
She’s been living there for 10 months now. She earns 3,000 pesos monthly, she also
verbalized that she is earning enough money to sustain her needs and still able to save
some of it. When ask when she follows rules and regulation, the client answered that
she does, not only laws established by the government but also the rules made by her
parents and masters.
 ANALYSIS:
Moral Development (Kohlberg)
Post Conventional (Level III): Universal ethical principle orientation. Follows internalized
standards of conduct.
(Pillitteri, Maternal and Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th Edition page 821)

INTERPRETATION:
The client says that she follows rule which is normal for an early adult

C. Spiritual Patterns
The client attends Sunday Mass and prays most of the time. The client believes
that God answers her prayer and keeps her safe from harm, during her stay in Leyte she
campaigns for the Catholic Church and a member of the youth for Christ, she shared
that her family is an active member of the church. She also said, “Pag may problema
ako na hindi kayang lutasin ng pag – iyak o pag – tawa, idinadaan ko sa dasal,
naniniwala akong hindi tayo pababayaan ng Diyos.”

ANALYSIS:
Spiritual Development (Fowler)
Stage 4: Individuative – Reflective, focuses on reality. Asks philosophical questions
regarding spirituality and may be self – conscious about spiritual matters. Begins to see
the conflicting truths of her beliefs but does not get to see how they interrelate
Stage 5: Paradoxical, Consolidative / Conjunctive Faith, awareness of truth from variety
of viewpoints
Stage 6: Universalizing, becomes an incarnation of the principles of love and justice.
Person loves with God’s love (unconditional love)

INTERPRETATION:
The client does not question God existence anymore, she already has an established
idea that God exist this is normal for she has established her own viewpoint on what is true
when it comes to her chosen religion.
 IV. Activities f Daily Living

ADL Before During Interpretation and Analysis

Hospitalization Hospitalization

1.) Nutrition The client said She does not ANALYSIS: An individual’s health status
that they usually eat the BRAT greatly affects eating habits and
eat vegetables (Banana, Rice, nutritional status. Habits about eating are
and meat. She Apple Tea) influenced by many factors such as
cooks viand like preparation developmental considerations, personal
pakbet, menudo brought to her preferences, lifestyle, medications and
and sinigang. bed during our therapy. People develop likes and dislikes
She can shift. She based on associations with a typical food.
consume a cup prefers eating Certain lifestyles are linked to food-related
of rice and a foods bought behaviors. People who spend many hours
small serving of outside the at home may take time to prepare more
viand every hospital like meals, Individual differences also
meal chicken and influence lifestyle patterns. (REF:
rice. The client Fundamentals of Nursing 7th ed. By
verbalized, Kozier et. al., p.1176)
“Hindi ko
kinakain yung INTERPRETATION: During the
pagkain galing hospitalization the client is under Full Diet,
sa ospital, hindi her food preference affects her health
kasi masarap.” because including only chicken and rice in
the diet is not enough to reach her needs.
Being picky when in comes to food is
normal but the client should make sure
that she is having a healthy meal which
includes recommended foods on the food
pyramid.

2.) The client The client was ANALYSIS: Normal defecation is often
Elimination defecates once able to defecate facilitated in both well and ill clients by
a day regularly, once a day and providing privacy, teaching clients to
characteristics: urinate 6 times attend to the defecation urges promptly,
soft formed a day. The client assisting clients to normal sitting positions
stool. Usually verbalized, “Mas whenever possible, encouraging
urinates once a marami ang appropriate food and fluid intake and
day and naihi ko scheduling regular exercise. (REF:
sometimes ngayonkesa Fundamentals of Nursing 7th ed. By
none. The client nung nasa Kozier et. al., p.1253)
described her bahay ko,
 urine as clear pinipilit kasi ako INTERPRETATION: The client was able
yellow in color ditto uminom ng to facilitate defecation during her stay in
and slightly tubig, hindi ako the hospital, her fluid intake was
aromatic. mahilig a tubig. increased to promote urination which she
Minsan nakaka tends to disregard at home.
2 baso lang ako
sa isang araw.”

3.) Exercise The client The client does ANALYSIS: Physical activity is an
considers her not exercise important factor in an adult’s ability to
work as her inside the maintain health and independence.
exercise, “All hospital, Regular exercise promotes appetite,
around kasi ako, “Siyempre hindi improves mental health, and decreases
laba, luto, na ko stress. (REF: Fundamentals of Nursing,
plantsa, linis. nakakapag – Saunders p. 337)
Iyon na yung exercise dito,
exercise ko”, nakahiga lang INTERPRETATION: The client does not
verbalized by ako, minsan perform exercise before and during
the client. natayo pag iihi.” hospitalization, which is abnormal.

4.) Hygiene She takes a Takes a bath ANALYSIS: Personal hygiene is the self-
bath once a once, and still care by which people attend to such
day, brushes brushes her functions like bathing, toileting, general
her teeth thrice, teeth thrice. body hygiene and grooming. Hygiene is a
uses deodorant. highly personal matter determined by
individual values and practices. It involves
care of the skin, hair, nails, oral and
nasal, eyes, ears and perineal – genital
areas. (REF: Fundamentals of Nursing by
Barbara Kozier et., al page 106)

INTERPRETATION: Despite being

hospitalized the client is still able to
perform self – care regimen which is
necessary to promote better health
through cleanliness

5.) Non – smoker Non – smoker ANALYSIS: The client encourages a

Substance and non – and non – healthy living by avoiding cigarette
use drinker drinker smoking and alcohol drinking among ll
ages.

INTERPRETATIO: Normal, the client is

having a healthy living

6.) Sleep and The client The client was ANALYSIS: Just as activity is important to
rest sleeps 10 pm – able to sleep 8 the adult, so too is rest. According to the
4 am (6 hours of hours, but feels National Sleep foundation (2001), adults
sleep) and takes uncontented, need 8 hours of uninterrupted, quality
nap 3pm – 4/6 the client sleep each night for optimum health,
pm. The client verbalized, safety, and productivity. (REF:
feels satisfied “Nakatulog ako Fundamentals of Nursing, Saunders p.
with her sleep. ng 8 hours, pero 337)
putol putol yun,
kasi nagigising INTERPRETATION: The client was able
ako sa ubo ko, to reach her 8 hours need of sleep before
saka medyo hospitalization, but due to her cough
mainit.” during hospitalization even though she
was able to sleep in the span of 8 hours,
interrupted sleep is not good for the client
to reach optimum health.

7.) Sexual The client has The client has ANALYSIS: Adult sexuality issues are
Activity not yet been not yet been multifaceted and complex. Being sensitive
involved in any involved in any and responding to specific physical,
sexual activity, sexual activity psychosocial, and relationship issues may
has been help clients sort out areas in which they
invi\olved in a lack information, need treatment or
man – woman counseling, or desire enhancement of a
relationship 4 relationship or sexual intimacy.
years ago Knowledge about methods of birth control
and safer sex may be a need for adults
who wish to delay or prevent pregnancy.
(REF: Fundamentals of Nursing,
Saunders p. 1138)

INTERPRETATION: The client is open to

discuss sexual activity which is normal
among early adults