II.

NURSING PROCESS
A. Assessment
1. Personal Data
Name: Patient T.S
Age: 52-year-old
Address: San Isidro, Tarlac City, Philippines.
Gender: Female
Date of Birth: April 20, 1969
Birthplace: San Isidro, Tarlac City, Philippines.
Civil status: Widow
Occupation: Retired Teacher
Position/role in the family: Wife, Mother of three
Nationality: Filipino
Chief Complaint: Severe Back Pain
Date of admitted; Time of admitted: May, 17 2021 10:00 am
Admitting diagnosis: POST-MENOPAUSAL OSTEOPOROSIS

Environmental Status: 
Patient T.S is currently living in San Isidro, Tarlac City, Philippines. She lives alone in a
one-story house far along the highway. She has three children and one grandchild. Their house is
made of cement with 3 doors and 6 windows. Her house has a good ventilation. They use pump
to get water; their garbage is collected by the truck of garbage. She uses tricycle as his means of
transportation.
Lifestyle:
Patient T.S is working at a car plant; she is taking care of her 3-year-old grandchild occasionally.
According to her she is experiencing diffuse bone pain over the past several years after
menopause. She cannot be able to sleep at night comfortably for the past 3 months because of
severe back pain. She stated that “the pain is becoming worse, and it is keeping me from doing
my daily activities” as verbalized by the patient. She reports having a “hot spell” at different
times throughout the day, she also complains of some vaginal dryness. According to her, she has
no exercise routine and admits having a somewhat sedentary lifestyle, she also said she does not
smoke or use alcohol but admits to eating a vitamin-poor diet.
Family History of Health Illness
GENOGRAM
Maternal Paternal

Grandmother Grandfather Grandmother Grandfather

Uncle Mother Aunt Father Uncle

Sister Patient T.S Brother Sister

Patient T.S Husband

Daughter Son Son

Female: Osteoporosis

Male: Hypertension:

Deceased:

Unknown:

Patient T.S was diagnosed with Osteoporosis among her 4 siblings, she is the second child. Her
Paternal and Maternal Grandfather and Grandmother passed away a long time ago due to
unknown causes. Her sisters, daughter and sons are still alive and continue to support her. Her
Mother who was diagnosed with osteoporosis, and His brother who was diagnosed with
hypertension were reported having health problems in their family.