NURSING HEALTH HISTORY

PRESENT HEALTH HISTORY In 2006, the patient first noticed two small palpable lumps like the size of a peanut in the right lower quadrant of her left breast which were immovable and painless. The patient never gave attention to the lumps because she assumed that the lumps would disappear later. Then by 2008, the lumps that she noticed seemed to increase in size like the size of a 1 peso coin, which urged her to seek consultation at Toran District Hospital. She was then admitted at the said hospital, and Lumpectomy was done at her left breast on March 21, 2008. The lumps that were removed were analyzed through Biopsy. The result of the latter showed Stage-2 Malignant cancer cells. The physician then advised the patient to undergo Chemotherapy; however, she did not comply because of financial constraints and fear of the procedure. Subsequently, two months prior to consultation at Christian Hospital in Aparri, she felt an itching sensation at the post operative site and noticed that she had worm infestation and foul smelling pus hence admission. The hospital refused to admit her due to insufficient medical supplies to handle her condition but they advised and reemphasized to her to undergo chemotherapy as what has been advised before. However, she did not once again adhere to the instructions given to her. Moreover, it was just her family who removed the infestations manually through unsterile manner. Some time after this, the patient suffered from fever for 2 days and managed it by taking Paracetamol (acetaminophen). Despite the removal of the infestations, the patient still had a constant foul smelling discharge-pus. Then 3 days before consultation at CVMC, the patient had body weakness and observed a continuous foul smelling lesion on the same post operative site, thus admission.

PAST HEALTH HISTORY Patient A.C. has known allergies on food such as eggplant, monggo beans and fish sauce. During her childhood years, she experienced having chicken pox, fever, colds and mumps. She takes over the counter drugs to treat common illnesses such as Neozep (phenylpropanolamine maleate) for colds and Paracetamol (acetaminophen) for fever. According to her she did not received any immunization during her childhood. Once in a while, she visits the Rural Health Unit for check-up and BP taking. At age 30, she started taking pills without doctors prescription and stopped taking it at the age of 40. Her first hospitalization was in 2008 at Toran District Hospital. Likewise, she had undergone her first operation which is Lumpectomy on her left breast. She had not experienced any other severe disease except for Breast Cancer.

FAMILY HISTORY Patient A.C. is the 2nd child among the 3 children. Her father, at age 70, died of a medical known disease which is Diabetes. Her mother had missed abortion during her 4 th pregnancy due to unknown cause and she also had breast cancer but did not undergo chemotherapy and died at the age of 72. Her younger sister had a history of breast cancer too, but she survived because the cancer was detected early and she adhered to the medications and chemotherapy.

SOCIAL HISTORY Patient A.C. is the 2nd child out of 3 children in their family. She is married and was gifted with 4 children, 2 males and 2 females. She graduated in College with a degree of Bachelor of Science in Fisheries at Cagayan State University, Aparri but she did not apply her college degree instead she choose to be a plain housewife. They reside at Allacapan, Cagayan. They are living in a bungalow type of house made mainly of concrete and wood. Her 3rd child verbalized that her mother had a harmonious relationship with her family, neighbours and fellow Born Again Christian. She serves as a pastor in their chapel at Allacapan.

OB History
The patient had her menarche when she was 14 years old. She had 3-5 days menstruation period and consumed 3-4 pads per day, fully soaked and sometimes experienced dysmenorrhea. She had her coitarche when she was 26 years old. She had her menopause at the age of 49. She rarely performs self breast examination. She has four children at present. She has an OB score of G4P4(T4P0A0L4M0).

GORDONS 11 FUNCTIONAL HEALTH PATTERN

FUNCTIONAL PATTERN BEFORE HOSPITALIZATION She perceives that she is well and rated her health as 8/10. She values health by treating common illnesses by taking over the counter drugs such as Paracetamol (acetaminophen) for fever, colds (phenylpropanolamine maleate) and Lagundi tablet for cough and seeks medical advice when an illness cannot be treated with over the counter drugs or when it endangers her health condition. The patient is 52 (162 cm) tall and weighs 50 kgs. (110 lbs.) Her BMI is 20.16 kg/m2(Normal weight). She eats at least 1 cup of rice every meal and she is the one who cooks their food. Her favourite dish is chicken adobo. She is also fond of eating grilled fish and meat. She does not have difficulty chewing and swallowing. She does not follow any certain type of diet and eats her breakfast at around 7-8 am, 12-1 pm for lunch, and 6-7 pm for dinner. She has food allergies such as monggo beans, eggplant and fish sauce. She drinks 6-8 glasses of water a day and does not drink coffee or alcohol. She eats bread and drinks soft drinks every snack time at their chapel. DURING HOSPITALIZATION She believes that she is no longer healthy because of her debilitating condition as she verbalized Haan nga mayat ti panagriknak gapu ti kundisyun ku ken panaka-ospital ku. The patient is aware about her medical diagnosis. She relies on the help of therapeutic personnel and follows prescribed medication as she verbalized ket tumarek dagiti ag-agas nga ireseta ti doctor. The patient is on DAT with SAP diet. This is to lessen the chance of aspiration. Her present IVF is PNSS x 8 hours regulated at 31 to 32 drops per minute hooked at her right arm, patent and infusing well. The patient eats 3 times a day but due to appetite loss she eats only spoonful of food prepared by the hospital. The patient has no difficulty swallowing. She drinks approximately 2 to 3 glasses of water a day. Her current weight is 44 kgs (96.8 lbs) and her height is 52. With these data, her BMI is 17.74 kg/m2 (underweight).

HEALTH PERCEPTION/ HEALTH MANAGEMENT PATTERN

NUTRITIONAL/ METABOLIC PATTERN

ELIMINATION PATTERN

She had bowel movement every morning and has no difficulty eliminating. She does not use laxatives, enemas and suppositories. The color of her stool ranges from yellow to brown and is soft to hard in consistency

The patient cannot manage herself due to body weakness because of this she is being accompanied by her daughter to the C.R. The patient urinates once a day without difficulty. The color of her urine is yellow. Since

depending on what she eats. She urinates at least 5 times a day and without difficulty. The color of her urine was light yellow. She had no history of bowel and bladder surgery.

she was brought to the hospital she only defecated once with a soft yellow stool consistency and without difficulty.

She considers her daily Patient A.C. was confined in bed ACTIVITY / EXERCISE PATTERN household chores like washing most of the time and can no clothes and mopping as her form of exercise. She has no musculoskeletal impairment and has no difficulty in performing activities of daily living. She also considers her preaching as her form of exercise and leisure activity because she enjoys every time she preaches. She has no difficulty sleeping and manages to sleep 7-8 hours every night between 10:00 to 11:00 pm up to 05:00am. She reads the bible before sleeping and it takes 10 to 30 minutes long for her to fall asleep. According to the SO, the patient takes naps every afternoon for 15-30 minutes.

longer manage to move on her own because of body weakness. She is being assisted by her daughter in performing ADLs. At times, she talks to her husband and daughter.

SLEEP-REST PATTERN

According to the SO, the patient has difficulty sleeping at night due to anxiety and pain but manages to sleep at least 2 to 3 hours. Her sleep is being disturbed also by the rounds of the physician and nurses management. She sleeps every morning for 2 to 3 hours. She said that her sleep is not enough.

SEXUALITY / REPRODUCTIVE PATTERN

According to the patient, she had her menarche when she was 14 years old. She had her menstrual cycle at regular intervals of 28 days. She also experiences dysmenorrhea and takes Mefenamic acid to relieve the pain. She got married when she was 26 years old and had her coitarche to Mr. R.C. without difficulty. She had her menopausal period when she was 49 years old. Rarely, she performs breast selfexamination even before she knew about her condition.

She expresses her familiarity by using appropriate clothes to her gender. She satisfies her sexual desires by means of holding hands with her husband.

Patient expresses The patient feels weak due to her SELF-PERCEPTION / SELF-CONCEPT responsibility on being a wife and a illness. She is ashamed and not mother. She is kind, loving and comfortable because of

her

PATTERN

caring person to her family. She condition. She has low selfconsiders her family and friends as esteem due to disturbed body her strength. image. Although she is quite bothered about her condition, she still looks at the brighter side regarding her condition. The patient speaks Ilocano, as well as Filipino and English. Patient is able to read and write and does not use eyeglasses when reading. She graduated in college at CSU Aparri with Bachelor of Science in Fisheries. She has no sensory deficits. She has no difficulty expressing herself or explaining matters to others. Watching television is her way of learning new information. Patient A.C is a good wife to her husband and a responsible mother to her children. She believes that her major role to her family is to care, protect and love them. She is a typical Filipino housewife and preaches the word of God every Sunday at their chapel as part of her obligation as a Born Again Christian. She has a harmonious relationship with her fellow preachers and Born Again Christian. She seldom participates to any social group or neighbourhood activities. She is kind to her relatives and to her neighbours as well. The patient cannot understand questions easily and is unable to answer it immediately because of her condition. Due to her body weakness, the patient is unable to handle long conversation.

COGNITIVE / PERCEPTUAL PATTERN

ROLES / RELATIONSHIP

Her husband and daughter accompany her in the hospital and assists in positioning her. Her family and relatives stays or visits in the hospital to render love, care and to give her strength and support for her fast recovery. She wants her family to be always with her. She is able to participate with the treatment plan given by the health care providers.

COPING / STRESS PATTERN

Whenever the patient experiences obstacles in life, she tries to solve it by herself first before telling it to her husband. She solves it patiently and asks God for guidance. She reads the bible to relieve her from stress and sometimes watches television. She does not take medicine to relieve her from stress.

The patient believes that the illness is just a trial that she can surpass with the help of our Almighty God. She consults her husband about her problem. She stays strong for her family. The SO verbalized that the patient has difficulty sleeping at night and frequently takes a nap at daytime.

VALUE / BELIEF PATTERN

She considers her family and her faith to God as the most important things in her life. The major influencing factor that helps her in making decisions is her love to her family. She makes sure that every decision she makes is for the betterment of her family. They are Born Again Christian and she devotedly serves to their church by worshipping and preaching the word of God. Certain practices are important to her like praying and reading bibles. She does not believe in quack doctors and superstitious beliefs.

She trusts in God and believes that this is just a challenge for her to surpass. She prays for her fast recovery.