2.

FIRST AND SECOND LEVEL ASSESSMENT

First Level Assessment
Px: Illness State: Hypertension
Cues: Objectives:
Temperature: 37.3 C
Highest result of BP: 200/100
PR: 110 bpm
RR: 22 cpm
Height: 53
Weight: 63

Second Level Assessment

Inability to make decisions with respect to
taking appropriate health action due to:
a.Failure to comprehend the
nature/magnitude of the problem.
b. Lack of adequate knowledge as to
alternative courses of action open to them

Subjectives:
Masakit ang ulo at batok ko.
Nahihirapan akong huminga minsan
As verbalized by the client.
Px: Illness State: Myocardial Ischemia
Cues: Objectives:
2D ECHO Result: Diagnosis: Myocardial Ischemia
Electrocardiogram (ECG) changes reflecting ischemia; dysrhythmias

Inability to recognize the presence of the

condition or problem due to: Lack
of/inadequate knowledge regarding the
existing problem and its severity

Subjectives:
Sumisikip ang paghinga ko kahit wala naman akong ginagawa. As
verbalized by the client.
Px: Health Maintenance
Cues:
Objectives:
Presence of several healthcare workers contact information
Presence of several medicines in the medicine container

Potential for Enhanced Capability for the

health management

Subjectives:
Simula nang nahihirapan na akong huminga, nagpacheck-up na ako kasi
baka kung ano na yun.
Px: Unhealthy Lifestyle and Personal Habits/Practices:
Self-medication
Cues:
Objectives:
Presence of several medicines in the medicine container
Subjectives:
Walang time para magpacheck-up e.
Kapag nagpacheck-up naman, kamamahal ng gamut na binibigay.
Px: Unhealthy Lifestyle and Personal Habits/Practices:
Lack of/inadequate exercise/physical activity
Cues: Objectives:

Inability to make decisions with respect to

taking appropriate health action due to:
Inability to decide which action to take
from among a list of alternatives

Inability to make decisions with respect to

taking appropriate health action due to:
Fear of consequences of action, specially

Busy doing household chores

Subjectives:
Verbalizes pain under the heels
Verbalizes no desire and/or lack of interest in activity
Verbal report of fatigue or weakness
Tinatamad din kasi akong lumabas ng bahay kasi gastos lang yan.
As verbalized by the client.
Px: Unhealthy Lifestyle and Personal Habits/Practices:
Inadequate rest or sleep
Cues:
Objectives:
Irritability
Yawning
Presence of eye bags
Subjectives:
Kapag madami akong iniisip, nahihirapan akong matulog.
Normal lang daw ito kapag tumatanda na.
Hindi rin ako makatulog kasi minsan nahihirapan akong huminga.
Lagi nalang maaga akonagigising atlatenakakatulog.
As verbalized by the client.

physical consequences

Inability to recognize the presence of the

condition or problem due to:
Attitude/Philosophy in life , which hinders
recognition/acceptance of a problem