I. Health history
A. Demographic profile
? Name: R.G
? Gender: Male
? Age: 41 years old
? Birth date: September 23, 1967
? Birth place: Pasig , Metro Manila
? Marital status: Married
? Nationality: Filipino
? Religion: Born Again- Christian
? Address: Brgy. Pantihan 3, Maragondon, Cavite
? Educational background: High school graduate
? Occupation: Factory worker in Monterey
? Usual source of medical care: Doctor/Healthcare Professional
B. Source and reliability of information
? The patient R.G is the primary source of information. He is conscious and coherent, able to speak Tagalog fluently. His wife is also considered as source of information regarding patient status and condition.
C. Reasons for seeking care or chief complaint (Top 3)
? 1st – insufficient sleep at night
? 2nd – loss of his weight
? 3rd – scaly of skin
D. History of present illness
Patient R.G was handled during our duty at Brgy. Pantihan 3, Maragondon,,Cavite with the chief complaint of insufficient sleep at night, loss of his weight and scaly of skin. The laboratory test and special treatment for the patient are not applicable because this case is base on community setting.
E. PAST MEDICAL HISTORY OR PAST HEALTH
-Incomplete immunization- (-) serious illness on this stage
* Injuries or accidents
-1992, right leg accident due to mishandling of machine
* Serious or chronic illness
-December 2003, Diabetes Mellitus diagnosed clinically
-2x FBS result 300mg/dl
-2006 Pulmonary Tuberculosis, diagnosed clinically
-Chest X-ray and sputum AFB examination
-2007 Urinary Tract Infections
-1992, Water Rose General Hospital
Admitting diagnosis: Right leg machine accident
-December 2003, Rizal Medical Center, Pasig City, Metro Manila
Admitting diagnosis: Diabetes Mellitus Type 2
* Obstetric History
-incomplete immunization (unrecalled)
-No known allergies to food and medication
1 tab TID p.c.
1 tab OD a.c.
-Vitamin B Complex tablet
1 tab OD
-Alaxan 500mg/tab (Paracetamol + Ibuprofen)
1 tab PRN for fever and pain
* Last Examination Date
-July 2007 (OPD case), Philippine General Hospital, Taft Avenue, Manila
F. FAMILY HISTORY
G. SOCIO-ECONOMIC STATUS
Mr. R.G. lives in their own house at Pantihan 3, Maragondon, Cavite. His wife is selling and making barbeque sticks as the source of their income while his 16 years old son works as a vendor in a wet market at Dasmarinas, Cavite as additional source of income. They also received financial support from their relatives in Pasig. They can be measured up as to poor class family. The patient has no history of drinking alcohol and cigarette smoking.
H. DEVELOPMENTAL HISTORY
A person may experience midlife crisis between the ages of 35-45 years old, the “deadline decade”. This occurs when the individual recognizes that he has reached the halfway mark of life and according to Erik Erikson, the developmental task of the middle-aged adult is Generativity vs. Stagnation.
As to our patient, who belongs to a middle age group and is suffering from a life-threatening condition, he had experienced this developmental crisis, which led him to be non-productive.
Being non-productive led him to be stagnant after the occurrence and diagnosis of his disease which made him to be dependent with his family, he can’t attend, function and be able to accomplish his responsibilities as a father, a husband and as part of the community.
I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION
“Ito nangangayat na dahil sa sakit ko” as verbalized by the patient. Weight: 35 kg. (July 10, 2009)
87 kg. (December 2003)
(+) wt. loss 48kg.
(+) numbness at times(lower extremities)
(+)excessive sweats, axilla
BP- 130/80 Temp. – 36.5 °C
“Hindi makati sa binti, pero ang braso, nangangati” as verbalized by the patient. (+)itchiness (upper extremities)
(-)history of skin disease
“Dati malago ang buhok ko” as verbalized by the patient. Thinning of hair, evenly distributed
(+)itchy scalp (scratching)
“Ito matigas na ang kuko ko kumpara dati” as verbalized by the patient. (+)clubbing of nails (long nails)
(+)Yellowish nail beds
Amount of sun exposure: Exposure to sunlight every morning
“Sumasakit ang ulo ko na parang tinutusok” as verbalized by the patient. (+)frequent headache
“Malabo na ang paningin ko” as verbalized by the patient. (+)blurry vision
“Malinaw pa naman ang pandinig ko, pero may sumasakit minsan” as verbalized by the patient. Both ears hears well when the examiner is 3 feet away
Mouth and Throat:
“Medyo hirap akong lumunok” as verbalized by the patient. (+)difficulty in swallowing
(+)lesions on tongue
(+)hoarseness of voice
(+) gag reflex
“Wala naming problema sa leeg ko” as verbalized by the patient. (-)stiffness
(+)palpable bilateral lymphs
Breasts and Axillae:
“Pawisin ang kilikili ko” as verbalized by the patient. (+)excessive sweating, axilla
“Medyo nahihirapan akong huminga” as verbalized by the patient. RR – 28 bpm
(+)difficulty of breathing
(+)wheezes on both lungs
History of lung disease: pneumonia, PTB, 2006
Last chest x-ray: 2007
“Paminsan- minsan sumasakit ang dibdib ko” as verbalized by the patient. (+)chest pain
(+)dyspnea on exertion (bed to chair)
(+)pallor in hands
(+)clubbing of nails
(+)tingling (sole of feet)
0-1 second, capillary refill
“Eto madalas magan ako kumain” as verbalized by the patient. (+)good appetite
Food intake tolerated
Frequency of BM: 3x a week
Characteristic of stool: yellowish- brown in color, formed in consistency
(+)constipation (arch and formed stool)
“Ihi ako ng ihi” as verbalized by the patient. (+)polyuria
Dark Yellow in color
History of urinary disease: UTI(2006)
“Kumikirot ang kasukasuan at buto-buto ko” as verbalized by the patient. (+)minimal pain, knee area and ankle
(+)pain, calf area
(+)lower back pain, radiating
(+)weakness, leg muscles
“Alam ko pa naman ang mga sinasabi ko ngayon” as verbalized by the patient. (-)history of seizure, stroke, fainting
Self-pity and crying
Oriented to time, person and place
“Pagkakaalam ko,wala naman akong sakit sa dugo” as verbalized by the patient. (-)bruises
(+)palpable lymph nodes
(+)bleeding tendency of skin (scaly skin)
(-)history of Blood Transfusion
“Sa pamilya naming may Diabetes, kaya ako merong Diabetes” as verbalized by the patient. (+)DM, type II
(+)change in skin texture, scaly skin
(+)excessive sweating, axilla
J. FUNCTIONAL ASSESSMENT
I. Health Perception/Health Management Pattern
Mr. R.G. is a 41 yrs old, male and seriously ill person. Once he felt something wrong about his condition, he seeks for medical advice. Occasionally, he also had colds in the past. Last December 2003, after a consultation from a physician and with accompanying lab result of blood sugar level (2x done, result is increased 300mg/dl) he was diagnosed of DM type 2. The client believes that he acquired his illness from his grandfather who also had Diabetes Mellitus. According to Mr. R.G., eating nutritious food, exercise and religiously taking of prescribed medication or what nurse’s and Doctor’s advise/suggest will keep him healthy. Due to financial incapacity, this regimen was not taken into consideration.
II. Self Esteem, Self Concept/Self Perception Pattern
Before he was diagnosed with DM type 2, Mr. R.G. is a responsible husband and father to his wife and kids. He was able to provide the needs of his family. The client possessed a jolly and fun loving type of personality.
Since his illness started, most of the time, he felt self-pity and worthless. He is always irritable and angry when he thinks that he was ignored. Because of his condition he became more depress and the only thing that gave him hope and strength is through prayer.
III. Activity-Exercise Pattern
Perceived ability for: (Refer to Functional Level Code)
Feeding Level II Grooming Level II Bathing Level II General Mobility Level II Toileting Level II Cooking Level IV Bed Mobility Level II House Maintenance Level IV Dressing Level II Shopping Level IV Functional Level Code
Level 0 Full Self Care Level I Requires Use of Equipment or Device Level II Requires Assistance or Supervision from Another Person Level III Requires Assistance or Supervision from Another Person and device Level IV Is Dependent and Does Not Participate
IV. Sleep/Rest Pattern
The patient had altered sleep pattern. Each day he only had a maximum of 2 hours of sleep and despite of that he still fells god upon waking up. He said sometimes the pain he felt put him into sleep.
V. Nutritional/ Elimination
The patient usually takes a glass of milk in his breakfast and he takes heavy meals more frequently but after eating he usually felt stomach ache. He has supplements of vitamin B-complex. He typically drinks more than an 8 glasses of water per day. Patient stated that prior to his illness he weighted 87kgs but at present he weighs 39kgs.
We noticed that the patient skin is scaly all over his body. He also have lesion in his tongue and positive dental carries.
The patient usually had 3x bowel movement per week with a dark yellowish brown color stool, with hard formed in consistency. On the other hand he noted that he frequently void with dark yellow in color urine and felt some discomfort when urinating.
During the day patient is experiencing excessive sweating in his armpit.
VI. Sexually- Reproductive Pattern
The patient is inactive in sexual intercourse due to present condition
VII. Interpersonal Relationship / Resources
Patient can speak and understand English and Tagalog. He can clearly express himself. He has 6 children and they were close to each other.
Before patient is very active and usually socializes with his neighbors.
Patient R.G’s family was very supportive and understanding, now that he is battling with his disease.
The patient is dependent due to his illness.
VIII. Coping and Stress Tolerance
Before when patient R.G is anxious he wants to be alone, when he is stressed, he prefers to drink liquor and involved himself in gambling.
When he was diagnosed of DM Type 2 there have been many changes occurred that made difficult for him to adjust. He cannot perform the usual activities that he had before. When patient R.G is stressed, he prefers to cry until he falls asleep. When it comes to problem, he tried to calm himself through prayers.
IX. Values-Belief Pattern
Patient R.G is a Born Again Christian, before according to the client he always hears mass every Sunday with his family.
Due to his illness he wasn’t able to go to mass. According to the patient there are many practices affects his illness.
He wasn’t able to follow therapeutic regimen due to financial problem and a strong faith to God helps him to get through all the suffering he has.
After what happened, patient R.G is still not seeking for medical assistance due to financial problem. Religious effort is still a part of patient R.G.’s life.
X. Personal Habits
Before, patient R.G. used to maintain a good personal hygiene and had a diet without restriction. He used to work as a factory worker 6 days per week and was able to help in doing household chores when he got home. He had a good sleep pattern of almost 8 hours at night. Every Sunday he goes to mass with his family and occasionally at his free time he drinks and smoke with his friends.
At present, due to his illness, patient R.G wasn’t able to perform his usual routine. He had to stopped from working in able to attend his health needs and become dependent to his family.
II. PROBLEM LIST
1. Imbalanced Nutrition Less than body requirements
2. Disturbed Sleep Pattern
3. Impaired Skin Integrity
4. Activity Intolerance
5. Risk for Infection
6. Risk for Falls
7. Risk for Security
A.) ACTUAL OR ACTIVE PROBLEM
Problem No. Problem Date Identified Date Resolved Remarks
Imbalanced Nutrition Less than body requirements July 09, 2009 July 16, 2009 Client appetite was increase. 2
Disturbed Sleep Pattern July 09, 2009 July 16, 2009 The client can sleep now from 4-8 hours unlike before.
3 Impaired Skin Integrity July 09, 2009 July 16, 2009 The wound is clean and dry.
4 Activity Intolerance July 09, 2009 July 16, 2009 The client able to perform some minimal ADL
B.) High Risk or Potential
Problem Date Identified 1 Risk for infection July 09, 2009 2 Risk for Falls July 16, 2009 3 Risk for Security July 16, 2009
IV. NURSING CARE PLAN
V. ANATOMY AND PHYSIOLOGY
VII. MEDICAL MANAGEMENT
VIII. PROGRESS NOTES
IX. DISCHARGE HEALTH TEACHING PLANS
X. SUMMARY OF CLIENT STATUS OR CONDITION AS OF LAST DAY OR CONTACT