I.

Demographic Profile

Name A.M
Age 83 years old
Address San Vicente, Sto. Tomas.
Gender Male
Religion Roman Catholic
Occupation Farmer
Educational Attainment High School Graduate
Chief Complaint Shortness of Breath

II. Patient’s Health History

A. History of Present Illness

A.M is 83-year-old female with 8 children. He was having episodes of asthma when farming. And he’s
asthmatic since 2015. He's already old, so he'll have to look after his body. He should take care of his
body, because he easily gets tired of breathing when doing farm works. And he acquired hypertension last
2016. Lastly, he has an enlargement of prostate in year 2016.

Treatments/Medication:
1. OTC
a. Vitamin C

B. Past Medical History

2015 – Enlargement of Prostate
2015 - Asthma
2016 – Hypertension

C. Genogram
D. System Review: Gordon’s 11 Functional Health Patterns Assessment
1. HEALTH RECEPTION AND HEALTH MANAGEMENT PATTERN

a. Client’s rating of health:

Scale: 10-best, 1-worst
30 years ago: 10
Now: 7

The patient’s health is not good, he is asthmatic and high blood. Due to his disease, his goal now is to
avoid salty and fatty foods. The patient must also maintain normal his blood sugar and blood
pressure. Because of his episodes of asthma, he couldn’t breathe well. The patient was been
hospitalized and never had an enlargement of prostate before, apart from that. As of now, the patient
doesn’t have any physical examination routine. Aside from being high blood his health is normal, but
because of his age he easily gets tired. His only issue is the shortness of breath.

2. NUTRITIONAL AND METABOLIC PATTERN

The patient is a Filipino, and he eats the typical Filipino food. He eats bread for breakfast. He's
drinking coffee and water. He eats a cup of fried fish and a cup of vegetables for lunch. Sometimes
after lunch, he eats some fruits, such as banana. And for dinner: he eats a small cup of rice, with a cup
of vegetables at night. Usually the patient is not eating in the fast food chain. He prefers in the house
to eat local food. He takes 8 glasses of water once a day with Vitamin C. The patient says, his
appetite was good.

The patient don’t uses dentures, but he says he has no trouble swallowing his food and chewing it. In
his sore throat, tongue, and even tonsils, he has no problems. But after eating food, he easily feels
nausea and vomiting. It's due to his upper abdominal pain, I think.

3. ELIMINATION PATTERN

Bowel elimination pattern: According to the patient, his bowel removal is usually once a day, but
during his bowel movement he has no problems or discomfort. Stool is in shape of brown bowel.

Urine elimination pattern: Usually the urine of the patient is 6x / day every day. The patient said
during the urination he had no discomfort. And there are no current issues in his bladder. He said he
had no body odor and excess perspiration.

4. ACTIVITY-EXERCISE PATTERN

The usual activities in a day: He takes a morning bath, eats breakfast, and usually goes to the farm
and does his farm work afterwards. So, he's not actively engaged in physical activity, walking and
farming sometimes. But in doing house chores and watching tv, the patient uses his spare time.

5. SLEEP-REST PATTERN

Sleeping Pattern: Minimum of 7 - 8 hours of sleep, but usually 8 hours of day sleep. He goes to bed in
the evening from 9 pm to 10 pm and usually wakes up in the morning at 5 - 5:30, and goes to the
farm.
 The patient doesn’t have problem in falling asleep, his sleep is continuous and doesn’t feel tired when
waking up.

6. COGNITIVE-PERCEPTUAL PATTERN

The patient is able to write and read. He claims to be able to read and write, but not in small letter
appearance. No problem to speak, to read and to write. The way he speaks you can easily understand.
And clearly expresses ideas, feelings.

He doesn’t wear eye glasses. No learning difficulties, he can still read and understand.

7. SELF-PERCEPTION AND SELF-CONCEPT PATTERN

The patient is a person who is calm and not anxious. He can interact easily with others. As of now,
because of his shortness of breath, he doesn't feel good. That's body changes. The patient’s mood is
usually good and doesn’t have any problem in interacting with others.

8. ROLE-RELATIONSHIP PATTERN

He lives with his one son. The patient has 8 children, which has a good relation with each of the
family member, but sometime he had a simple argument with his wife. Every Sunday, the go to
church and eat outside in a restaurant or fast food. After that, they watch movie or sometimes they go
the mall.

9. SEXUALITY-REPRODUCTIVE PATTERN

Due to his age, he’s not engaged in any sexual practice and sexual relations. He’s not had a menstrual
every month, because he’s menopause already.

10. COPING - STRESS TOLERANCE PATTERN

In the situation of coping with stress, he watches television and uses time to spend time with his
family.

11. VALUE - BELIEF PATTERN

The patient is a religious person, usually their wife and children go to church almost severy Sunday.

SUMMARY OF PROBLEM LISTS identified with the patient

(Please follow the format in writing Nursing Diagnosis: PES format=Problem, Etiology, Signs and
Sympytoms)

 Risk factor for Chronic obstructive pulmonary diseease related to shortness of breath as
evidenced by air pollution
 Excessive fat intake related to high consumption of saturated fats as evidenced by high
cholesterol