Complete Initial Data Base

8/12/2019 Complete Initial Data Base

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FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

HEALTH HISTORY

A. BIOGRAPHIC DATA

Name:M.M

Age:22 years

Gender:Male

Date of Birth: November 18, 1990

Place of Birth:Mindoro City

Ethnic Group: None

Primary Language Spoken:Tagalog

Marital Status:Single

Educational Status:High School Graduate

Occupation:Salesman at Shoe Market

Religion:Roman Catholic

Health Care financing:Philhealth

B. PAST HEALTH HISTORYThe patient has Chicken Pox at the age of 7 years old. He described this

condition as water inside a balloon because of its vesicular- like appearance. Hismother brought him in Western Mindoro Hospital for consultation. In return, the doctor

advised him not to go to school for at least 7-14 days or until the crusts slough off.

Nonetheless, he was not able to recall the medications prescribed by his doctor during the

occurrence of this condition.


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Moreover, he had Urinary Tract Infection last December 2012.He took over-the-

counter Paracetamol because of his peaked fever (38oC). However, the fever persisted

and thus, he seek a doctors advised at Quirino Hospital. He was confined for two days,

for thorough observation and treatment. He was then discharged by his attending

physician with some medication prescription (medicines prescribed can no longer recall

by the patient). According to him, he took the medication regimen religiously asprescribed by his attending physician.

On the other hand, the client has no allergy to foods, drugs, and other substances

that can trigger allergic reactions.

Lastly, he could not also remember if he had complete immunization status. No

accident or inquiry concurred; no foreign travel has been noted.

C. FAMILY HISTORY OF ILLNESSThe father of the patient died at the age of 54 years old due to Hypertension.

However, no one in their family has reported nor diagnosed to have Hypertension.

Furthermore, he emphasized that faulty eating habit was the main culprit to his fathers

demise. Fortunately, his fathers death became an eye opener for them to be nutritiously

and actively conscious about their health, as well as, allowing themselves not to acquire

Hypertension. Moreover, no history of Diabetes Mellitus, and other familial incidence of

heart disease has been noted.

FUNCTIONAL HEALTH PATTERNS

D. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERNHe defined Health as a state of being able to perform and carry out essential tasks

and responsibilities given to him by his supervisor. However, due to his current

condition, he could not assume a 100% percent performance of his body in response to

his current workloads. In addition to this, he rated his health 8 out of 10 due to his

improving condition and alleviation of presenting complaints of weakness, loss of

appetite, and expectoration of sputum with strict of blood. Nonetheless, he was positive

to his continuing good prognosis as shared by his attending physician.

Continuing proper nutrition, daily exercise, adequate fluid intake, and sufficient

rest were his health goals. He emphasized, that he was able to routinely practice these

health goals by allocating sufficient time to perform such dynamic goals. Moreover, he

exclaimed that meeting these ideal health goals only requires self-discipline and healthy-

mind consciousness.


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Furthermore, he also stated that healthy-mind consciousness must be

scientifically sound and not merely supported by provincial folklores and old-age health

traditions. He believes that nurses and doctors are made to provide quality care to patients

with different medical problems. In response to this, he goes directly to consult a health

care provider when he has health complaints and problems. Needless to say, he was

compliant to the medical advices (medical advices as such: medication regimen, foodprecautions/restrictions)given to him by his attending physician.

Personal hygiene was also at his utmost priority to maintain his health. Daily

personal hygiene of bathing twice a day, tooth brushing every after meals, trimming of

finger nails at least once a week, wearing of slippers inside and outside house premises,

body powders, colognes, and deodorants after each bath, and hand washing before and

after meals, was mainly observed and inserted to his daily personal routine.

However, even with such maintenance of ideal personal hygiene and health goals

(health goals as stated above), he exclaimed of difficulty eradicating his cigarette

smoking habits. He was able to puff 10 cigarettes per day. Moreover, he also noteddrinking alcoholic beverages (2-3bottles of 500 ml Red Horse Beer) almost every night

after his long-day of work. Although, there were attempts of eradicating or utmost

lessening of such vices, he found it difficult to turn away from what he called daily

routine vices. However, his stated that his current condition may allow him to exert a

much greater effort of turning away from this form of vices.

In terms of their environmental condition at their home, he stated that they have

sufficient windows to provide them adequate ventilation (4 windows with at least x

yardin each measurement). Each house roomswere lighted by a 20 watts fluorescent bulb

with day-light illumination. At their back yard, a back light (20 watts fluorescent with

pale-yellow illumination) was set-up to provide lightings at night.

Environmental sanitation was also observed by their household. Foods and

portable water beverages were stored at their refrigerator. While, leftover foods were

usually covered by net-plastic covers.

Their main source of water was Manila Waters. They usually store water at two

covered water drums in cased of water cut off in their area or if typhoons may interrupt

such water supply.

Lastly, no vectors were also noted due to the household effort of having general

cleaning during Sundays. He also exclaimed that daily garbage pick-up to their

community helps allot to cut off possible time for vectors to proliferate on their

community.


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E. NUTRITIONAL AND METABOLIC PATTERNProper nutrition was one of the clients health goals to maintain his optimum

level of health. He defined nutrition as the ability to combine the three basic food groups

(grow, glow, go) within a meal. A larger portion of vegetables, fruits, fish, and a smaller

portion of meats and sweets was the key to maintain well-sound body nutrition.

Moreover, he usually prepares their food in the morning. He observes hand

washing before and after food preparation and cooking. Inherently, the client eats

breakfast and dinner mostly with his three brothers at home and eats with his co-workers

during their lunch breaks.

One thousand pesos was their food budget for the whole week. He and his

brothers contribute with the portion of this budget and other household miscellaneous

expenses.

Amidst of the good appetite and maintenance of his weight (68 kg), he

significantly loses weight upon his admission (current weight difference: please refer tothe physical examination section).

Furthermore, no eating discomforts noted. However, the doctor advised him not

to eat dark colored foods at the moment due to streak blood-tinged sputum. (No Doctors

Order to support such subject information given).

No skin lesions, dryness, and skin problems, and dental problems noted.

F. ELIMINATION PATTERNThe client usually defecates once a day, usually in the morning. He described his

stool as brown in color and formed-solid in consistency. No changes in usual defecation

pattern. Moreover, no difficulty, discomfort, or pain was noted during his defecation.

He pointed out that defecation was the bodys response to eliminate certain

garbage or wastes within a persons system. Furthermore, he noted that he drinks one

to two glasses of water (glass of water approximation: 240- 250 ml) before he defecate.

He stated that water washes away the waste from the body, and eventually eliminate it

through defecation.

In addition, he also exclaimed that food choices affect the consistency,frequency, color of his stool. In such instance, he noticed that (1) when he eats plenty of

banana, his stool will be formed-solid in consistency; (2) when he eats prunes, raisins,

and pineapples, the frequency of his defecation may become twice depending on the

amount he was able to consume. He also noticed that when hes eating fruits rich in fiber

(e.g raisins), his stool becomes semi-form to form in consistency.


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He was also observant if either his stool was sinking or floating. He laughed as

he exclaimed much eagerness on why such phenomena happen. In such cases, he noticed

that when he ate meat or meals reach in protein, his stool becomes a sinker, but when he

eats fat-rich foods, he noticed his stool becomes a floater. This gave him a notion that

food choices might have an effect with his defecation.

Moreover, he also added that stress affects his defecation pattern. In a flashback,

he remembered a situation way back his first day in job. He had mix emotions of

excitement and anxiety during his first day of work. He was then instructed to get a

product (client could not barely recall if the product was a shoe or a shirt).

Unfortunately, the product he took was not the product his supervisor wants him to

obtain. Immediately, his supervisor commented negatively with this test of following

instruction. He was frustrated and nervous up to the extent of even having an urge to

defecate. Nonetheless, the client exclaimed that stress might affect your defecation

patterns if these stressors would not be handled correctly and positively.

In terms of urination elimination per se. He usually urinates approximately six toseven times depending on the total amount of fluids he ingested. He stated that the more

fluid he consume, the more frequent he urinates. The client also added that the type of

fluid he consumes affects the color of his urine. In such instance, he noticed that when he

drinks plenty of water, his urine color was white. However, when he drinks a lot of plenty

of orange juice, his urine turns dark-concentrated yellow to amber yellow.

Approximately, the client urinates 700- 1200 ml per day (approximation was

based on the patients cup. Cup approximation: 240. Pointed level of approximation was

third portion of the cup). No difficulty, pain, or changes of usual urination pattern

noted. Moreover, the client could also hold his urine for about an hour whenever when

wants to urinate during his working hours.

Urination serves the purpose similar to defecation, removal of waste from our

body. He stated that urination was really necessary to remove excess fluids which our

body doesntneed anymore.

On the other hand, he develops eagerness towards the odor of his perspiration

especially after drinking alcoholic beverages (e.g Tanduay 350 ml, Red Horse 500 ml).

He noticed that his perspiration smells like the beer he consumed. Nonetheless, he

stressed that when he stops drinking beers for about a week, his perspiration became

odorless.

(Addition), the client had Urinary Tract Infection last December 2012. (Refer to

the Past Health History).


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G. ACTIVITY AND EXERCISE PATTERN

Cleaning the house every Sunday and walking to and from his work were

considered to be his only exercise since he could not go gymnasium to work out or play

sport activities (e.g. Basketball). This was because of his schedule of activities allthroughout the week (schedule of activities: refer to the table of activities). In such cases,

the client was satisfied of rigorously moving during their general house cleaning to let

him perspire. This gave him the notion of exercising without spending a penny from a

pocket. According to him, exercising was important to maintain muscle strength and

functioning. Even simple household chores could become a simple form of exercise.

No time should be wastedthat was the sole motto of the client. Moving,

working, walking, running errands was his diverse way of exercising. More importantly

is that he could sweat and perspire due to long-hours of work and responsibilities.

Despite of his work-loaded schedule, he makes sure to play his portable playstation for about 2 hours. According to him, that was his form of leisure activity since he

could not go to parks, stroll in malls, nor spend enormous time in amusement parks.

Playing of this portable playing devise also allows him to rest and relax from a fully-

loaded stress days.

Resting during his lunch breaks allows him to immediately regain some energy

and catch up from fast-phase nature of his occupation. He also exclaimed that even at the

advent of toxic work day, he was able to manage work-load efficiently (through

prioritization of instructions and proper time management) without tiring himself so

easily.

1 out of 10 was his scale of his stress level as of the interview. It was because he

was getting positive feedback of improving prognosis to his condition(positive feedbacks

of increasing appetite, regain of usual energy, and possible discharge from hospital

care). Moreover, he was also able to file his sick live to his supervisor, thus this reduce

him the anxiety from no-work-to-return-with mentality.

H. SLEEP AND REST PATTERNThe client usually sleeps 7-8 hours. He usually sleeps at 10 pm and wakes up by

6 in the morning. He noted a refreshing feeling everytime he complete a 7-8 hour of

sleep.

Sleeping in a close light was his preference when sleeping. It was because he

believes that close lights hasten him to sleep immediately. Moreover, their house is not

near a major road or highway. This gave them the opportunity of uninterrupted sleep and

noise-free environment for rest. In such cases, their neighbors were also sensitive and


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hesitant to make noise during sleeping hours. An electric fan was also used during

sleeping hours. Nonetheless, when he was already drowsy, he turns off the electric fan to

conserve electricity and avoid fires caused by overnight-overheat use fans.

In addition, when he cannot seem to get his sleep yet, he usually plays his

portable play station or watch movies in their television.

Taking a bath was his usual routine before going to bed. According to him, he

could not sleep whenever he didnt take a bath. It was because; not taking a bath lets him

felt dirty due to accumulated pollution to his body.

No medication use to induce sleeping; Difficulty getting sleep, interruption of

sleep, sleep walking, and sleep talking, and sleep terror were also no accounts noted.

I. COGNITIVE-PERCEPTUAL PATTERNThe client can read (noting subjective statement of having normal 20/20 vision) ,

write legibly, and respond to question with relevance and coherence to the topic being

asked or discussed.

According to the client, he has 20/20 vision (assessment for visual acquity is an

available during interview. Subjective primary data obtained). No hearing, smelling,

tasting, touch perception changes noted/reported. Moreover, he could also recall

immediate memory (e.g inventory list of products available at stock room), intermediate

memory (e.g. Job start at 2009), and as well as his retrospective memory (e.g death of his

father while he was still 7 years old). However, recently, the client complaints of pain in

his back, right lower quadrant, lumbar region. According to the patient, the doctor

verbalized to him that it may be because of his condition or it could be because of hisforced expectoration of sputum (noting no Doctors Notes supporting this cue. However,

subjective-primary hand information relating to the Doctors verbalization during

doctors round was noted by the patient).

In terms of his performance during his school years, he was very active during

recitation. According to him, active class participation was his way of learning lessons

more easily. In such instance, providing a silent and non-stimulating environment (e.g

noise free, distractive light/stimuli free environment) could help him focus on his subject

lessons. He also stated that he had good grades during his school days. However, he stops

going to school (stop to entry level to college) because of financial instability of their

family during those periods. Stopping with his education was hard according to him.However, it didnt stop him to gain more knowledge through reading books and daily

news sheets. Up until then, he was able to land a Job, in a hope to continue his interrupted

education.


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J. SELF-PERCEPTION AND SELF-CONCEPT PATTERNThe client described himself as hardworking employee, a loving brother to his

brothers/sisters, and most of all, a respectful son to his parents. He often times connoted

as the most responsible and hardworking among the family.

However, due to his current condition and series of complains (e.g expectoration

of blood-streak sputum, lower back pain); this gave him sometimes a notation of not

being productive and helpful to his family. He exclaimed that this condition almost alters

the usual activities and daily routine of his brothers and sistereven to an extent of being

a financial burden to his siblings. In such instances, his current condition gave him

some reluctance of seeking financial help to his brothers and sister. Nevertheless, he was

transparent and open to share information about his current condition to his family.

Nonetheless, he was positive of becoming fruitful and productive once again as soon as

he recovers and heals from his current medical condition.

Being positive towards the course of his condition, he has then developed apositive outlook and goals after he recovered from this medical condition. According to

him, he will build his own merchandise store as soon as he repaid from his financial debts

to his family. He added that this merchandise store may also give him physical rest, far

cry from his dynamic and energy-exhausting work as a salesman.

The client described himself as calm individual in times of emissary and stress-

point conditions (e.g misunderstanding and miscommunication within the family, work

overload). However, when he reach the point of being angry and irritated, he usually

withdraw himself from the situation to give himself a breather and think on how to deal

with the presenting situation. Whenever the situation now becomes a more collaborative

and negotiative in atmosphere, the client talks and reconciliate to the person involve with

the problem.

On the other hand, the client noted himself as a person with high self-esteem and

confidence. He noted that having confidence and self-esteem were the main characteristic

of a salesman should be. Unless you have not development such characteristics, you can

never talk and address the concerns and wants his clients. These characteristics gave him

also the notion of putting self-confidence in whatever decision, activity, and judgment

who would make in life. According to him, acquiring such and applying such principle of

confidence and heightened esteem would give ones decision a firm and unwavering

principle.


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K. ROLE-RELATIONSHIP PATTERNThe client lives with his 3 brothers in an apartment. They usually share

household expenses (e.g electricity and water bills, food budget). Their parents were

already gone (client prefers to address the loss of their parents as gone (wala na), than

being dead, patay na), and some of his brothers and sister had already their ownfamily. However, in such occasion, the familys eldest brother usually organizes a family

reunion during the holiday season. This reunion allows them to communicate and share

life experiences and recent update to their success or problems in life.

Amidst of living separately with his other siblings, the family never failed to

communicate and greet each other good morning or goodnight through text messaging.

He claimed that a good communication within family members entice them to become a

much stronger and united family amidst of their geographical separations.

The he has few friends according to him. It was because he doesnt want to go

with any socialites and social gatherings because this triggers his eagerness to drink muchbeer (even exceeding his usual 2-3bottled-beer limit).Nevertheless, he has friends within

their work whom he manages to eat with and share stories with during working breaks.

He pointed out that having few friends doesnt contradict his interpersonal nature.

Nevertheless, he was interpersonal but still figures to who would he befriend with. It was

because he believes that the type of friends you have also describes on who and what you

are.

L. SEXUALITY AND REPRODUCTIVE PATTERNSexuality

The client was very grateful of being a man because of: (1) physical strength was

far-cry from the physical strength of females, (2) no menstruation (because according to

the client, buying menstrual pads was an added expense) , (3) men doesnt give painful

birth. However, he never belittles the capacity of women to compete with men in terms of

strength, knowledge, skills, and technical intellect.

He has no problem communicating with females (as he says, he has much

confidence in himself). Nonetheless, if the female he was talking with was irritated and

hot-tempered, he usually assumes that the female whom he was talking with has monthly

cycle, or a relative problem.

Amongst the females surrounding his life, he stated that his sisters were the most

important women for him right now. They usually text each others with greeting about

life quotations and trivia. Sometimes, the client takes with his nephews and nieces during

his work-free periods.

Overall, the client has no stated difficulty addressing any concern or problem

with the opposite gender.


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Reproductive

The client had undergone circumcision at the age of 12 years old. According to

him, he was forced to go in such minor surgery because of the social stigma and bully of

not being circumcised before going to high school.

Furthermore, the client noted no pain or growing unusual mass in his

reproductive organ as he was usually palpating it (referring to reproductive genitalia)

during showers (usually in the advent of applying soap to such genital areas).

M. COPING-STRESS TOLERANCE PATTERNThe client defined stress as a significant situation or condition by which your

body might respond to it positively or negatively (positively: you got challenged or

motivated to break your performance limit, negatively: you got sick, urge to defecate at

the instant moment). Nonetheless, he managed stress by using his time wisely andprioritizes such situation depending to the level and need of attention. Most of the time,

this techniques (referring to time management and prioritization)were helpful for him to

accomplish task and responsibilities given at hand.

Although, sometimes, he stated that this technique may not be applicable to the

situation being address. In such instances, he needs to get a breather of himself and

withdraw from the current situation, up until he has lowered his temper and devise a

solution on how to address the problem. He exclaimed that talking with anger and

irritation may even escalate the situation to get worst and unmanageable.

More importantly, the family plays a role in handling his stress. Noted that hisbrothers and sisters usually give him advices and insights on how he will address such

stressful problems. This gave him the notion of a bonded family can solve untimely stress

and adversities.

N. VALUE AND BELIEF PATTERNThe client noted that certain values and belief may affect an individuals health.

In such instance, if you are a roman catholic, you could eat almost all foods available in

the market, without realizing that this can harm ones body (client is referring to sea

shells, pork, beef fats and chicken skin). Nonetheless, the client doesnt deny that he eat

such foods in moderation. Nevertheless, he believes that the parents of each familyshould already teach their sons and daughters the right food choices to eat.

His family was the utmost valuable for him. According to him, anyone could

abandon you except your family. This gave him the notion on how important and

valuable a family is. He also noted that the family is the main breeding ground on how an

individual could grow up. It was because he believes that the family was one the

responsible to the upbringing, values, and believe-beliefs of an individual.


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Lastly, because of the values his parents inculcated to him (values such as being

respectful to others, humble, hardworking, and responsible), he sees himself as a

valuable and productive individual in the society; Productive in a sense that he was

paying his taxes on time and helping his costumers on their concerns with their products.

Documents

Complete Initial Data Base