CLIENTS PROFILE

A. DEMOGRAPHIC DATA Patient D is a 67-year-old Female, a Roman Catholic, Filipino, Married, and is residing at Serran Village, Wao. She is 145 centimeter in height and 35 kiolgrams in weight upon admission. Her primary language is Visayan. She is high school under graduate. Patient D was admitted last August 17, 2011 with, shortness of breath and chest pain as her chief complain. 5 days prior to admission (August 13, 2011) patient had facial edema but still, she can able to walk long distance. Upon laboratory findings, patient D was diagnosed with Congestive Heart Failure. B. VITAL SIGNS Patient D had the following vital signs during the series of assessment: Upon admission at Capitol University Medical City Emergency Room (August 17, 2011), the patient had the following vital signs: blood pressure of 160/90 mmHg, temperature of 36.4C, pulse rate of 84 bpm, and respiratory rate of 21 cpm was given oxygen supplementation via nasal cannula at a rate of 2LPM. Day 1 On the first day of duty (August 19, 2011): blood pressure= 130/90 mmHg, temperature= 36.8C, pulse rate= 80 bpm, respiratory rate= 20 cpm, with a pain scale of 8/10 at knee cap. (0 as no pain felt and 10 to worst possible pain). Day 2 On the second day of assessment (July 24, 2011): blood pressure= 130/90 mmHg, temperature= 36.6C, pulse rate= 72 bpm, respiratory rate= 20 cpm, with a pain scale of 4/10 at knee cap (0 as no pain felt and 10 to worst possible pain).

C. HISTORY OF PRESENT ILLNESS Three years prior to admission Patient M experienced on and off joint swelling and pain. Indeed without consultation patient M self-medicated with diclofenac 500mg and other NSAIDS drugs (twice to thrice a day when in pain) without Doctors prescription. Three months prior to his admission, he experienced scanty urination without fever and urine discomfort. Two months prior to admission, Patient M experienced vomiting every after meal, with generalized body weakness and consulted with a laboratory findings of Urea=11gm/dL and Uric acid = 9mg/dl. Patient M was advised to undergo hemodialysis but refuses so he was given home medications as follow: Ketosteril 600mg 2 tabs TID NaCO3 1 tab BID Lifezar 500mg OD Ferous sulfate OD Epoitin injection weekly

Upon laboratory findings patient M was diagnosed with Chronic Kidney Disease Secondary to Uric acid Nephropathy gouty arthritis and was then admitted. Patient was advised to undergo hemodialysis. Last July 24, 2011, patient M has undergone intrajugular catheter placement. Patient M is also hypertensive for 5 years. Other health problem he had is arthritis. Circumcision is the only surgery he had in the past. He used to manage health through self-medication first before consultation.

FUNCTONAL HEALTH PATTERNS

HEALTH PERCEPTION AND MANAGEMENT PATTERN (Pre-hospitalization) Patient M is a non-smoker and consumes alcoholic beverages occasionally. The patient has no known food and drug allergies, drinks cola and tea occasionally. He takes drugs like NSAIDS without doctors prescription and with no control whenever hes in pain. He even states, mag-inom rako ug tambal basta musakit akong tiil. Upon admission, patient weighs 126 lbs. but he stated that prior to his condition he weighs 140 lbs. NUTRITION AND METABOLIC PATTERN Pre-hospitalization The patient has no food preferences and on a regular diet. As he verbalized, wala koy pili sa pag-kaon, mukaon raku bisag unsay naa.

Day 1 (July 23, 2011) Patient M is on 40 grams protein, 4 grams sodium decrease purine diet, taking teraferon now as supplement. He eats 3 times a day of his share with fair appetite and without eating discomforts. He is also advised by his physician to decrease his fluid intake. Hooked to him is an intravenous fluid of D5W at 10cc/hr (micro set) plus side drip nicardipine 2 amps. Day 2 (July 24, 2011) The patient was still on 40 grams protein, 4 grams sodium decrease purine diet, taking teraferon now as supplement. He eats 3 times a day of his share with fair appetite and without eating discomforts. He is also advised by his physician to decrease his fluid intake. Hooked to him is an intravenous fluid of D5W at 10cc/hr (micro set) plus side drip nicardipine 2 amps.

ELIMINATION PATTERN Pre-hospitalization Patient M usual bowel pattern before admission is 3 times a day with small amount and yellowish brown in colored stool without discomfort. On the other hand, prior to his admission patient has scanty hazy yellow colored urine. Day 1 (July 23, 2011) Patients bowel pattern drop off once a day every morning with small amount and yellowish brown in colored stool without discomfort. On the other hand, his urinary

pattern was scanty, with hazy yellowish colored urine and with an average of 150 cc per shift without problem in controlling. Day 2 (July 24, 2011) Patient bowel pattern was still once a day every morning with small amount and yellowish brown in colored stool without discomfort and his urinary pattern was still scanty, with hazy yellowish colored and with an average of 160 cc per shift without problem in controlling.

ACTIVITY-EXERCISE PATTERN Pre-hospitalization The patient verbalized exercise pattern of walking and jogging. His leisure activities include texting and more often reading books. He is able to tolerate normal activities of daily living and mobility status. Day 1 (January 23, 2011) Patient M exhibited decreased tolerance to activity; the reason for mobility limitation is due to joint swelling and pain at right knee and has a positive pitting edema (Grade 2+) at both feet. The patient is independent in performing activities of daily living such as feeding, dressing and grooming (ADL-0). With the meal preparation, cleaning, and laundry, the patient is totally dependent (ADL-4). With the mobility status, in toilet transfer and ambulation, a cane was used to assist patient in ambulation (ADL-3)

Day 2 (July 24, 2011) Patient demonstrated gradual increase in mobility status in chair/toilet transfer and ambulation. He was totally independent with his feeding and grooming (ADL-0).

With the meal preparation, cleaning, and laundry, patient was totally dependent (ADL4). In his bathing, dressing, and toileting, He is assisted by significant others (ADL-2).

ADL LEGEND: 0 -total independence 1 -assist with device 2 -assist with person 3 -assist with device and person 4 -total dependence

COGNITIVE-PERCEPTUAL PATTERN The patient is conscious, oriented and conversant. He is worried and anxious

yet cooperative when asked and assessed. His primary language is Visayan and he has no speech deficit, no learning difficulties and no changes in memory.

SLEEP-REST PATTERN Patient Ms usual sleep pattern pre-hospitaliztion is about 6 to 8 hrs. Upon hospitalization he has sleep disturbance. According to patient M, he cannot sleep continuously and sleeps for a short period of time approximately 30 mins-1 hour. He considers his environment as a great factor and also he is so worried about his condition in which it affects his sleeps or rest pattern.

SELF-PERCEPTION AND SELF-CONCEPT PATTERN

Simple man lang ko, ug karon ga.adjust pa ko kay dili jud sayon magkasakit og ing-ani,as verbalized. ROLE-RELATIONSHIP PATTERN Patient M is single. The patient lives with his family. Ako pamilya ra jud akong masandigan sa mga panahon nga inani ug gakabalaka jud sila nako labi na akong ginikanan, as verbalized. Family medical history revealed positive hypertension to maternal side and diabetes mellitus to paternal side.

SEXUALITY REPRODUCTIVE PATTERN Patient M has no problem with sexual function. He is knowledgeable of the importance of having testicular examination thus he perform it monthly.

COPING-STRESS TOLERANCE PATTERN Wala man pud koy lain gakabalak-an karon aside sakong sakit, as verbalized.

VALUE BELIEF PATTERN Patients religion is Roman Catholic and he treats his religion an important piece to his life. Some of the religious practices he and his family performed. They are going to church and attending a mass and of course observed holy week. For him, his illness did not interfere with his faith.

NURSING SYSTEM REVIEW CHART

Day 1 (July 23, 2011)
EENT: pale conjunctiva; anicteric sclera; pallor mucosa; pallor lips; missing teeth Integumentary System: pallor skin; rough skin

IV: Cardiovascular System: Pale nail beds; capillary refill= not clear. BP=130/90 mmHg Urinary System: Scanty hazy yellow colored urine, 150cc within 8hrs Musculoskele tal System: Joint swelling (redness, warm skin noted) Pain- 8/10 D5W 250 @ 10 cc/hr

Pitting Edema Grade 2+

Day 2 (July 24, 2011)

Intrajugular catheter Integumentary System: pallor skin; rough skin

EENT: pale conjunctiva; anicteric sclera; pallor mucosa; pallor lips; missing teeth Cadiovascular System: pale nail beds; capillary refill= not clear;

IV: D5W 250 @ 10 cc/hr Musculoskel etal System: Decrease Joint swelling (redness, warm skin noted) Pain- 4/10 Pitting Edema Grade 2+

Urinary System: Scanty hazy yellow colored urine, 160cc within 8hrs

P H Y S I C AL AS S E S S M E N T (Head-to-toe appraisal) A . P h y s i c a l As s e s s m e n t Head Head Facial movements Fontanels Hair Scalp Eyes Lids Conjuctiva Sclera Pupils Reaction to light Reaction to accommodation Visual Acuity Peripheral vision Ears External pinnae Tympanic membrane Gross hearing Nose Mucosa Septum Patency - pale -midline - both patent - normoset - intact - normal - symmetrical - pale - anicteric - equal in size (2 mm) - Brisk both Left and Right - Uniform constriction - nearsighted (wears e yeglasses) - decreased normocephalic symmetrical closed fine clean

Gross smell Mouth Lips Mucosa Tongue Teeth Gums

- normal

Pallor and dry pallor midline missing teeth pallor

Pharynx Uvula Tonsils Neck Trachea Thyroids Others

- midline - not inflamed

- midline - non-palpable - normal ROM

Skin General color Turgor Temperature Moisture rough firm warm dry

Cardiovascular status Precordial area Heart sounds Point of maximal impulse Peripheral pulses Capillary refill

flat regular 5th ICS LMCL faint/weak cannot assess (pale nail beds)

Respiratory Anterior-Posterior-Lateral ratio Breathing pattern Lung expansion Percussion Breath sounds

-AP-2 L-1 - regular - symmetrical - resonant - vesicular

Abdomen

General Configuration Bowel sounds

- straie - symetrical/flat - normoactive

Back and Extremities Range of motion

Spine Gait

- decreased ROM at Right low er extremity - joint pain and swelling at right knee (redness, warm skin noted) - midline - uncoordinated