Professional Documents
Culture Documents
Zarex
Zarex
SUBMITTED BY:
ZAREX JOHN B. BACCAY
BSN 2-E
SUBMITTED TO:
MS. SARAVON LEGASPI RN
MS. OLIVE BECKER RN
PHC INSTRUCTORS
Table of Contents
A. Client Profile
B. Client History
C. Physical Assessment
A. Client profile
B. Client History
IV. Appendix
A. Assessment tool
Client Profile
Name: M.C.G.
Address: (confidential)
Age: 16
Gender: Male
Contact Number: 09052640601
Birthday: November 28, 1992
Marital: Single
Religion: Roman Catholic
Health Care Financing:
Visual Source of Medication: Family Income
Nationality: Filipino
Occupation: Student
Client history
Client M.C.G experienced having measles during his childhood years. He receives
vaccinations like BCG vaccine, OPV, and Hepa-B vaccine, where it was the last vaccine that was
administered to him during his second year college. Client M.C.G doesn’t have any allergies.
Client M.C.G encountered motor was bump by a fast approaching car. He was treated by
bringing him to an “albularyo/manghihilot”. According to him there were no complications
regarding the treatment. He also verbalized that he was not confined to hospital.
Client M.C.G eats 3 times a day with a usual time of 7:00 am for breakfast, 12:00 noon
for lunch and 7:00 pm for dinner. The usual amount of his meal is 1 slice of meat, 1 cup of rice
and a bowl of vegetables. For client M.C.G, stress is the very primary factor that affect his
appetite where in he always encounter every time he got home after school. Client M.C.G does
not take any food supplements or vitamins. The client only defecates every morning before he
takes a bath. The usual characteristics of his feces are yellow/brown, with a not much foul odor
in small amount. He rarely feels difficulty in defecating every time he skips his bowel.
The client regularly has 4-5 hours of sleep and do not take naps. Client M.C.G has
difficulty in sleeping due to being a heavy coffee drinker, stress and environmental factors. He
improve his sleeping habit by reading a book before sleeping and having a room with complete
darkness
The usual activity he does is going to school. “I cannot find time to do exercise due to my
hectic schedule”, client verbalized. The client was circumcised when he was Grade 5 in summer
time.
For Client M.C.G., the physician is his source of medical care where in he verbalized,
They are very much available, accessible and effective for my medical care.”
Client M.C.G. verbalized that he has knowledge on self defense but not that much. They do
not have any first aid tools that are readily available. Client M.C.G. stated that he does not much
visit his physician for health check-up. He is now living with his parents and he stated that he is
very much safe with his family. The reason is that, they provide his needs and they show care on
him. Likewise, with his friends where in he feels relaxed if he is with them because for him, they
make him smile. Client M.C.G expressed that he feels safe in their community due to “baranggay
tanod” to maintain peacefulness. The clients owns the house where there are living now, wherein
the nearest establishment are the bank, school and cinema theater. According to him there are no
factories or dumpsites near their house.
Client M.C.G has a happy and close tied family. He get along with them through doing
household chores, watching TV and going to mass together. His family shows their support to
him through giving what he needs. In return, he shows love to his family by making them proud
of him and respecting them. His family is very important, because they are the reason why he
continuous to live. Client M.C.G verbalized that he prefers to be with his friends. He knows very
well his friend that makes him very much close with them. The client often goes out with his
friends when he is having free time and the usually activities they do chatting and eating
together. For the client, his friends show him how life lives to the fullest. The client is very
active in joining school organizations through the motivation of his friends and his talents that he
has. According to the client the usual problem he encounter to other people are insecurities and
misunderstanding. Client maintains his relationship with other people by respecting them and
time management. Client stated that he is accepted by other people by who he is. In return, he is
giving his service to others in his own capabilities.
Client described himself as a simple and a down to earth person. He verbalized that he is
contented for whom he is and what he had but do not close his self to any development.
According to him, he is more on a leader rather than a follower, because for him being a good
leader is a good follower. The client gain respect from others by respecting them also. To
finished studies and become a professional, and give a better future for his self, for his family,
and for his future family, is the clients goal and ambition. He also stated that in any
circumstances he can face everything with enough strength because he knows that his family, his
friends and BRO is there for him.
For client M.C.G, he is proud and very happy for every accomplishment he done.
According to him, being a student there are many things to accomplish and to achieve. The client
values much every past actions and decisions he make, because for him all those things
contributes for who he is now. He also forgive those people sinned against him through
accepting them again for who they are. According to the client, there are no things he hardly
accepted. He also verbalized that he does not yet gained the real wisdom. He values his wisdom
by sharing them to others like sharing his talent because he knows that is also GOD who gives it.
Client M.C.G view death as another step for a new life with GOD but now he is still not ready to
accept death because there are still things to accomplish here on earth.
PHYSICAL ASSESSMENT
EARS
Elasticity Palpation Pinna recoils after it is folded Pinna recoils after it is folded
NOSE
Lips
Color Inspection Pinkish Pinkish
Symmetry Inspection Symmetrical Symmetrical
Texture Palpation Soft, moist, smooth Soft, moist, smooth
Gums
Color Inspection Pinkish Pinkish
Teeth
Color Inspection Ivory/yellowish Yellowish
Tongue
Color Inspection Pinkish Pinkish
Symmetry Inspection Symmetrical Symmetrical
Mobility Inspection Moves freely Moves freely
NECK
Posterior thorax
Anterior Thorax
Breathing pattern Inspection Breathing is automatic and effortless Breathing is automatic and effortless
1. Place of Residence:
2. Type of Family:
Nuclear___ Extended___
-Mother
4. Significant others
C. Home Environment
1. House
Sleeping Arrangement
__Sleep Together
__Sleep In Separate Room
C. Presence of accident hazards
__River
__Field
__Highway
__Factory
d. Food Storage and Cooking Facilities
1. Food Storage
__Refrigerator
__Plastic Containers
2. Cooking Facilities
__Gas stove
__”Kalan”
e. Water Supply
1. Source:
__Open Wall
__Pump well
__River
__piped Water
__Spring
__Refilling Station
2. Ownership:
__Personal Property
__Public Property
3. Is it safe to drink? Why?
__Yes
__No
If No: ________________________________________
f. Toilet Facility
1. Type:
__Flush Type
__Water Sealed
__If none of this,
Specify: ______________________________________
2. Ownership:
__Private Property
__Public Property
3. Sanitary Condition:
__Clean and Safe
__Dirty and Not Conductive to Health
g. Garbage Disposal:
__Communal Pit
__Individual Pit
__Burning Pit
__Open Dumping
__”Wrap and throw”
h. Drainage System:
__Open
__Blind
__None
a. Sanitary Condition:
__Well Sealed
__Clogged Drainage
__Sometimes Overflows
2. Kinds of Neighborhood
__Congested
__Not congested
__News paper
__TV
__telephone service
__Radio
__Word of mouth
__Cell phone
__Others, specify
b. Transportation
__Car
__Tricycle
__Pedicab
__Bus
__Kalesa
__Use of domestic animals
1.
A. What are your beliefs and practices and that are conductive in terms of or illness?
-Cure the Family Members as soon as possible.
2.
Food Amount
__vegetable
__Meats
__Fruits
__Fish
__Canned goods
__Noodles
__Other please
specify
C. Do you eat on time?
- Sometimes no because of busy schedule
4. Physical Assessment
(If Present)
Present Absent
Zaldy C. Baccay Sr.
Carmelita B. Baccay
Zharmaine B. Baccay
Zarex John B. Baccay
Zaldy B. Baccay Jr.
Corazon N. Briones
Adelyn B. Cudal
5. Did any of the family members undergo laboratory examinations or diagnostic procedure? (If yes, answer the table below)
9. What are the factors that help you attain a good sleep?
-read books before sleeping and a completely dark room.
15. What are the existing recreational activities in your community which your family participates in?
-None
17. How do your stress management activities affect your family life?
- Easily become hot tempered if I’m in stress condition
Fncp
LFD
PHYSIOLOGIC NEEDS:
Oxygenation:
1. How’s your breathing?
Fluids:
1. Describe your fluid intake.
Color:
Odor:
Amount:
Others:
(Blood stained, etch.)
Food:
- Components:
- Amount:
• How often?
Color:
Odor:
Amount:
Others:
(Blood stained,
etch.)
Sleep:
Procreation:
Male
Female
1. How old are you when you had your first pregnancy?
To yourself:
3. How often do you visit your physician for your health check up?
To your family:
To your community:
Family:
Friends:
Society:
SELF ESTEEM
2. If there is one thing you want to change or develop what would that be?
• In what circumstances?
• To what extent?
SELF ACTUALIZATION
1. What have you achieve so far?
6. Have you forgiven those people who sinned against you? How?
Temperature:
Pulse Rate:
Respiratory Rate:
Blood Pressure:
Pain (depends on the client):
Remarks: