I.

HEALTH HISTORY
A. DEMOGRAPHIC DATA

Patient L.R., is a 78 years old female, born on February 1940, housewife, a widow for 5 years, a
Filipino citizen and Roman Catholic in religion, who lives in Makati City. She is an elementary
undergraduate; the usual source of medical care is remained private and was admitted last 16th of
October 2018.

E. PAST MEDICAL HISTORY

Patient L.R. did not have any kind of injuries or accidents before as well as any serious of
chronic diseases. She hasn’t had any operations done and she does not have any known allergies.
As per her obstetric history, she gave birth to 3 children, all of them are term. She did not have
any abortion but one of her children died at 19 years old. Her medications include Losartan
100mg per tab per orem taken only once a day every morning. She is also taking Co-trimoxazole,
160mg per tab, taken twice a day. Her last medication is Cefuroxime 500mg per tab taken every
12 hours. She was hospitalized on October 15, 2018 and her last examination date was on
October 19, 2018

Gordons

1. Health Perception/ Health Management Pattern

Before Hospitalization:
Prior to admission, patient L.R. only goes to the hospital to have a check-up if
she experiences any discomfort that she cannot tolerate. She verbalized
“Pumupunta lang ako sa doctor pag masama lang ang pakiramdam ko.” She
does not smoke cigarettes nor drink alcoholic beverages. She also has a
maintenance medications for her hypertension to which she takes daily.
During hospitalization:

During her confinement, patient L.R. was able to follow the advice that was
given to her by the doctor and was able to take the medications prescribed to
her by the physician.

2. Nutritional

Before hospitalization:

Prior to confinement, patient L.R. has poor appetite and does not like drinking
enough water. She prefers drinking something that has taste like juice but she
was contented to drink only a couple of glasses.

During hospitalization:

During her confinement, patient L.R.s appetite improved and she was eating the
food provided by the hospital and was drinking the recommended amount of
water by the physician

3. Elimination

Before hospitalization:

Prior to confinement, patient L.R. the patient feels radiating pain in her lower
back epigastric area with pain scale of 10. The patient also was suffering from
constipation for four days prior to confinement.
During hospitalization:

4. Activity and exercise

Before hospitalization:

Prior to confinement, the patient likes to walk around their garden for at least
15-30 minutes as a form of her exercise routine. She also does the household
chores as a form of exercise.

During hospitalization:

During confinement, patient L.R. could not do any exercise because she was
feeling dizzy and muscle weakness due to her illness.

5. Cognitive – Perceptual

Before hospitalization:

Prior to confinement, patient L.R.’s speech was slow and limited due to her
Benign Paroxysmal Positional Vertigo. She always feels dizzy and nauseous.
Patient does not have any hearing aid and she does not have any memory
problems.

During hospitalization:

During confinement, patient L.R. knows where she is and why she was there.
She was also able to respond as we asked her if she could hear us clearly. The
patient responded by nodding her head as a sign of agreeing. She also speaks
with a very low voice that we have to ask her if she could repeat it again.

6. Sleep/Rest

Before hospitalization:

Prior to confinement, patient L.R. experiences adequate sleep and rest. She
usually sleeps at around ten o’clock in the evening and wakes up at five o’clock
in the morning. She also takes a nap sometimes in the afternoon as her “siesta”
time. According to her, she does not experience any sleep disturbance like
insomnia and she does not experience nightmares either.

During hospitalization:

During confinement, patient L.R. experiences short periods of sleep because of

her illness. She will have some short sleep but then she wakes up easily also
because she is not used to being hospitalized.

7. Self-Perception

Before hospitalization:

Prior to confinement, the patient does not really care about her appearance as
she was too old to be self-conscious. She just mentioned that compared to her
younger days, her joints and muscles are now weaker.
During hospitalization:

During the hospitalization, as we assessed patient L.R., we observed that she was
anxious and suddenly cries. Her voice is also low and very soft that we had to ask
her to repeat her answers. She does not also make eye contact and frequently closes
her eyes.

8. Role Relationship

Before Hospitalization:

Prior to confinement, the patient lives with her children and her children’s
family. According to the patient, she likes taking care of her grandchildren and
helping with the household chores because she does not want to be a burden to
her children. Patient L.R. is part of a catechesis group to which she attends
every Sunday.

During hospitalization:

During hospitalization, the one who stayed with the patient was her daughter-
in-law and her granddaughter. They would take turns in taking care of the
patient. Whenever the patient has visitors, she would smile and would talk
more.
9. Sexuality/Reproductive

Before hospitalization:

According to the patient, she did not take any contraceptives or any form of
family planning prior to her menopausal age. She said she did not encounter
any problem in conceiving and she gave birth to three term children with no
miscarriage or abortion.

During hospitalization:

During patient L.R.’s confinement, there was no problem regarding her

reproductive system.

10. Coping stress

Before hospitalization:

According to patient L.R., whenever she encounters problem in her life, she just
take a walk in her garden like the usual routine and watches the television
because it relaxes her in some way.

During hospitalization:

During hospitalization, the patient was put on bed rest and was having some
small talk with her watcher to keep herself entertained.
11. Value / Belief

Before hospitalization:

Prior to confinement, patient L.R. is active in attending the mass every Sunday
and is a part of a religious group in their community church. Whenever she
encounters a problem, she prays silently before she goes to sleep and that is her
bedtime routine.

During hospitalization:

During confinement, patient L.R. said she still continues to pray before she goes
to sleep at night and she keeps a rosary displayed on her side rail. According to
the patient, being confined in the hospital does not affect her faith in God.